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Disclaimer:
Medicine and respiratory therapy are continuously changing
practices. The author and publisher have reviewed all information
in this report with resources believed to be reliable and accurate
and have made every effort to provide information that is up to
date with the best practices at the time of publication. Despite
our best efforts we cannot disregard the possibility of human
error and continual changes in best practices the author,
publisher, and any other party involved in the production of this
work can warrant that the information contained herein is
complete or fully accurate. The author, publisher, and all other
parties involved in this work disclaim all responsibility from any
errors contained within this work and from the results from the
use of this information. Readers are encouraged to check all
information in this publication with institutional guidelines, other
sources, and up to date information. Respiratory Therapy Zone is
not affiliated with the NBRC®, AARC®, or any other group at the
time of this publication.

Copyright ã Respiratory Therapy Zone

2
Table of Contents
Introduction ………………………………………………………………………………………………………..4
Section 1 …………………………………………………………………………………………………………….…..5
Section 2 ………………………..………………………………….………………………………………………..59
References ………………………..…………………………………………………………………….….……..191

Copyright ã Respiratory Therapy Zone

3
Introduction

Welcome to Module 1 of the TMC Test Bank!

I’m super-excited about how much knowledge you’re going to

gain after going through our practice questions.

Before you begin, I want to give you a quick run-through of how

the information is laid out for you here.

Each Module is Broken Up into (2) Sections:

ð Section 1 is for Testing Your Knowledge

It includes the questions only. This way, you can do a self-

assessment to see how much you already know.

ð Section 2 is for Practicing and Checking Your Work

In this section, you will find the same questions. Only this time,
each question will also include the correct answer and a detailed
rationale explanation.

This is where you’ll be able to check your answers and learn

exactly why it’s either correct or incorrect.

Going through the rationale and breaking down the question is

what can help your brain learn and retain the information that
you are required to know in order to pass the exam.

So without further ado, you’re now ready to get started going

through the practice questions. Good luck! J

4
Section 1

1. During the assessment of 60-year-old female patient, you note

the following signs: dyspnea, hypotension, reduced chest
expansion on the left side, hyperresonant percussion note and
tactile fremitus on the left side, absent breath sounds on the
left side, and a tracheal shift to the right. These findings
suggest which of the following?
A. A pleural effusion on the left side
B. A pneumothorax on the left side
C. Atelectasis on the left side
D. Consolidation on the left side

2. A 39-year-old male patient was admitted to the emergency

department with a fever and an SpO2 of 87% on room air.
Upon auscultation, rhonchi is heard and the patient has a
productive cough. Which of the following would you
recommend?
A. Intubate and provide mechanical ventilation with 40%
oxygen
B. Provide noninvasive positive pressure ventilation using a
full face mask
C. Implement postural drainage and percussion with
directed coughing
D. Provide oxygen therapy and obtain a sputum sample for
culture and sensitivity

3. A 50-year-old male patient is intubated with a size 8

endotracheal tube and is receiving volume-controlled A/C
ventilation. Upon assessment, you note that the patient’s cuff
pressure is measured at 38 cm H2O. Which of the following
would you recommend?

5
A. Withdraw the tube 1-2 cm and reassess the patient’s
breath sounds
B. Recommend reintubation with a smaller endotracheal
tube
C. Lower the cuff pressure to < 30 cm H2O
D. Recommend ventilation via a tracheostomy instead

4. During the assessment of a 52-year-old female patient that is

receiving oxygen via nasal cannula at 4 L/min, you hear the
bubble humidifier making a whistling noise. Which of the
following is the most likely cause of this finding?
A. There is an obstruction in the delivery tube
B. The patient’s ventilation has increased
C. There is a clogged system diffuser
D. The flowmeter pressure is set too high

5. A pre and post bronchodilator test was ordered on a 48-year-

old female patient. The forced expiratory measurement that
was obtained after the bronchodilator was given shows an
increase in the patient’s FEV1 from 60% to 80% of the
predicted value. This finding suggests which of the following?
A. A fixed airway obstruction
B. A reversible airway obstruction
C. A normal diffusion capacity
D. A restrictive process

6. A 58-year-old female patient is intubated and appears to be

breathing asynchronously with the ventilator. Her breath
sounds are absent on the left side and the trachea appears to

6
be shifted to the left. The patient has a dull percussion note on
the left side as well. Which of the following is the most likely
explanation of these findings?
A. A tracheoesophageal fistula has developed
B. A tension pneumothorax has developed on the left side
C. The endotracheal tube is in the right mainstem bronchus
D. The patient is experiencing diffuse bronchospasm

7. A 63-year-old female patient is intubated and receiving

mechanical ventilation in the pressure controlled A/C mode. If
the patient’s compliance were to decrease, which of the
following would you expect to occur?
A. Her delivered volume will decrease
B. Her peak pressure will increase
C. Her inspiratory time will increase
D. Her PEEP level will decrease

8. A 70-year-old male patient is intubated and receiving

mechanical ventilation in the volume controlled A/C mode.
After performing endotracheal suctioning, which of the
following would indicate the effective clearance of retained
secretions?
A. An increased tidal volume
B. A decreased inspiratory time
C. A decreased plateau pressure
D. A decreased peak pressure

9. An adult patient who is receiving mechanical ventilation

suddenly started showing signs of tachypnea. Upon

7
assessment, you note tracheal deviation to the right and
decreased breath sounds and hyperresonance on the left.
Which of the following would you recommend?
A. The patient needs suctioning
B. The patient needs a bronchoscopy
C. The insertion of a chest tube
D. The patient needs a thoracentesis

10. A 57-year-old female patient with acute pulmonary edema is

dyspneic and appears to be wheezing. The resident physician
has ordered an albuterol breathing treatment via SVN.
Which of the following would you recommend?
A. Recommend acetylcysteine instead of albuterol
B. Perform the therapy with supplemental oxygen
C. Perform the treatment as ordered
D. Recommend a diuretic and oxygen therapy

11. A 39-year-old female patient who is intubate was admitted

to the emergency department and the nurse was unable to
start an intravenous line during CPR. It is believed that the
patient is suffering from a narcotic overdose and the
physician wants to administer Naloxone. Which of the
following is an alternative route that can be used to deliver
this medication?
A. Through the feeding tube
B. Aerosolized via SVN
C. Through the nasogastric tube
D. Through the endotracheal tube

8
12. A 176 lb male patient is intubated and receiving volume
control A/C ventilation with the following settings: FiO2 of
40%, Rate of 12/min, and Tidal Volume of 550 mL. An ABG was
analyzed and the following results were obtained:

ABG Results Ventilator Settings

pH 7.39 Spontaneous Tidal Volume 180 mL
PaCO2 37 mmHg Spontaneous Rate 37/min
HCO3- 23 mEq/L Vital Capacity 550 mL
PaO2 107 mmHg MIP/NIF -12 cm H2O

Which of the following would you recommend?

A. Place the patient on a 40% T-piece and monitor closely
B. Switch the patient to SIMV at a rate of 5/minute
C. Place the patient CPAP and monitor closely
D. Maintain the current ventilator settings and re-evaluate
later

13. An adult patient was admitted to the emergency

department after involvement in a motor vehicle accident.
The patient is hyperventilating and appears to have a flail
chest. Which of the following ABG results would you expect
for this patient?
A. Increased pH and decreased SaO2
B. Increased pH and increased SaO2
C. Decreased pH and decreased SaO2
D. Decreased pH and increased SaO2

14. A 51-year-old female patient with a history of asthma is

receiving mechanical ventilation in the assist-control mode.
Upon assessment, you note that she is struggling to initiate
inspiration. Which of the following settings would you check
first in order to resolve this problem?

9
A. Tidal volume
B. Pressure limit
C. Sensitivity
D. PEEP

15. The physician has requested the insertion of a

nasopharyngeal airway on an adult patient. This type of
airway is useful in supporting which of the following?
A. Mechanical ventilation
B. Frequent suctioning
C. Incentive spirometry
D. Aerosol drug therapy

16. You would expect there to be difficultly establishing a patent

airway for a patient with which of the following conditions?
A. A patient with ARDS
B. A patient that is morbidly obese
C. A patient with a pleural effusion
D. A patient with ventilator-associated pneumonia

17. A premature infant who is receiving positive pressure

ventilation appears to be in acute respiratory distress with
signs of hypotension and asymmetrical chest movement.
Which of the following would you recommend first?
A. An arterial blood gas
B. A chest radiograph
C. A capillary heal stick
D. Chest transillumination

10
18. During the assessment of an adult patient who is receiving
mechanical ventilation, you suddenly notice the
simultaneous sounding of both the high pressure and low
volume alarms. What is the most likely cause of this finding?
A. There is a disconnection in the ventilator circuit
B. There is a leak in the ET tube cuff
C. There is a mucous plug in the ET tube
D. The patient has developed pneumonia

19. A 16-year-old male patient has been admitted to the

emergency department and shows signs of poor body
development. Upon assessment, you also note digital
clubbing, hyperresonance to percussion, and a productive
cough. It has also been reported that the patient has foul-
smelling stools. These findings are consistent with which of
the following?
A. Acute respiratory distress syndrome
B. Bronchiectasis
C. Chronic bronchitis
D. Cystic fibrosis

20. During the assessment of a 56-year-old female patient, you

noticed distinct distention of the jugular veins in the neck.
Which of the following is the most likely cause of this
finding?
A. Systolic hypertension
B. Hypovolemia
C. Obstruction of the pulmonary vein
D. Right ventricular failure

11
21. An adult patient has performed an FVC maneuver with the
following results:

How would you interpret this flow-volume loop tracing?

A. Normal lungs
B. Small airway obstruction
C. Large airway obstruction
D. Restrictive disease

22. A 68-year-old male patient with COPD is receiving volume

control SIMV with the following settings:
Tidal volume 480 mL
Rate 12/min
Pressure support 10 cm H2O
PEEP 5 cm H2O
During a spontaneous breathing trial via T-tube, the patient’s
breathing rate increased drastically which required that he
be placed back on the ventilator. Which of the following
would you recommend during the next breathing trial?
A. Increase the sedation dosage
B. CPAP with pressure support via ET tube
C. CPAP without pressure support via ET tube
D. Extubate and provide BiPAP via full face mask

12
23. An order was placed to collect a blood sample from a
neonatal patient in the NICU. It is determined that you
should obtain the sample from a capillary instead of an
artery. Which of the following is true regarding a capillary
blood gas sample?
A. To obtain the sample, you need to milk the puncture site
B. The sample must be drawn from the first drop of surface
blood
C. The pH and PCO2 correlate well with arterial blood
D. The puncture normally is performed on the ball of the
foot

24. A newly admitted adult patient with pneumonia has an

oxygen saturation of 87% on a nasal cannula at 2 L/min.
Which of the following is a potential cause of the patient’s
hypoxemia?
A. Fever and chills
B. Diffusion defect
C. Alveolar consolidation
D. Hypoventilation

25. A 59-year-old female postoperative patient is recovering

from surgery that occurred less than 24 hours ago. Which of
the following would you recommend for this patient in order
to prevent atelectasis?
A. Albuterol via SVN four times daily
B. Pursed-lip breathing as needed
C. Inspiratory resistance exercises three times daily
D. Incentive spirometry 10 times per hour

13
26. A 63-year-old male patient with a tracheostomy is being
mechanically ventilated in the ICU. Upon assessment, you
noticed that as the patient coughs, blood and secretions
were blown back into the circuit. What action should you
take at this time?
A. Flush the blood out of the circuit with normal saline
B. Sedate the patient to prevent more coughing
C. Nebulize a local anesthetic to reduce surgical pain
D. Replace the circuit with a new one

27. A 56-year-old male patient has been admitted and

diagnosed with Guillain-Barré syndrome. In order to
determine the patient's need for ventilatory support, which
of the following values is the most critical to monitor?
A. Residual volume
B. Inspiratory capacity
C. Peak inspiratory flow
D. Expiratory reserve volume

28. A 64-year-old female patient with a history of CHF has been

admitted to the emergency department on a nasal cannula
at 4 L/min. She is coughing up large amounts of pink, frothy
secretions and presents the following ABG results:
pH 7.42
PaCO2 32 mm Hg
HCO3 19 mEq/L
BE -3 mEq/L
PaO2 46 mm Hg
SaO2 81%
Which of the following would you recommend?
A. Nonrebreathing mask at 15 L/min
B. Intrapulmonary percussive ventilation (IPV)
C. Continuous positive airway pressure (CPAP)

14
D. Intermittent positive pressure breathing (IPPB)

29. While attempting to wean an adult patient from mechanical

ventilation, you switched them from the volume control A/C
mode over to CPAP with pressure support. 30 minutes later,
the high respiratory rate alarm begins to sound and the
patient breathing at a rate of 29 breath/min. Which of the
following changes would you make to the ventilator
settings?
A. Increase the pressure support level
B. Increase the high pressure alarm to 50 cm H2O
C. Increase the high rate alarm to 30–35
D. Switch the patient back to volume control A/C

30. A 57-year-old female patient who was admitted and

diagnosed with emphysema displays the following ABG
results:
pH 7.34
PaCO2 65 torr
PaO2 47 torr
HCO3 31 mEq/L
The patient appears to be dyspneic and inspiratory crackles
can be heard during auscultation. Which of the following
would you recommend?
A. Nonrebreathing mask at 10 L/min
B. Air-entrainment mask at 28%
C. Albuterol via a small-volume nebulizer
D. Nasal cannula at 4 L/min

31. A 43-year-old female patient in the emergency department

was just orally intubated with an endotracheal tube. Which

15
of the following would you INITIALLY recommend in order to
confirm that the tube is in the proper position?
A. Auscultate the patient’s chest and abdomen
B. Perform a STAT chest x-ray
C. Use capnography to verify exhaled CO2
D. Observe chest wall movement

32. While assisting with the delivery of a newborn infant, the

physician asks for you to obtain an Apgar score on the
patient. Which of the following ranges is considered to be a
normal score?
A. 1-4
B. 4-7
C. 7-10
D. 10-13

33. After orally intubating an adult patient in the ICU, you are
asked to confirm that the tube is in the correct place. Upon
auscultation, you note that the breath sounds are absent on
the patient's left side. Which of the following is the most
appropriate action to take at this time?
A. Obtain a stat chest radiograph
B. Withdraw the endotracheal tube by 1–2 cm
C. Reintubate the patient
D. Insert a large bore needle in the left upper chest

34. A 58-year-old female patient has arrived in the emergency

department with an extremely deep and fast breathing rate.
Which of the following best classifies this type of breathing?
A. Apneustic breathing
B. Kussmaul breathing

16
C. Biot’s breathing
D. Cheyne-Stokes breathing

35. A 71-year-old male patient is receiving ventilatory support

and it was noted that his secretions are yellow and have
gotten thicker over the past 24 hours. The patient has a
white blood cell count of 17,000/mm3 and a temperature of
102 °F. Which of the following would you suggest?
A. Decrease the humidifier temperature
B. Administer an aerosolized bronchodilator
C. Schedule suctioning twice per hour
D. Obtain a sputum sample for culture and sensitivity

36. While reviewing the medical record of a 55-year-old female

patient, you note that her FEV1/FVC ratio was reported as
being severely decreased. Which of the following conditions
would you expect to be present with this finding?
A. Pulmonary hypertension
B. Morbid obesity
C. Chronic asthma
D. Pneumonia

37. A 60-year-old female patient who in orally intubated is going

through a spontaneous breathing trial. Which of the
following would indicate the need to stop the trial and return
the patient back to full ventilatory support?
A. An increase in heart rate from 96 to 114/min
B. An increase in respiratory rate from 17 to 27/min
C. An increase in arterial PCO2 from 44 to 52 torr
D. A decrease in SpO2 from 92% to 83%

17
38. The physician has requested the dynamic compliance
measurement for an adult patient who is receiving
mechanical ventilation. This value can be obtained by
dividing the patient’s tidal volume by which of the following:
A. (Pplat – PEEP)
B. (PIP – PEEP)
C. (PIP – Paw)
D. (Paw – Pplat)

39. A 63-year-old male patient was admitted to the ICU. Upon

auscultation, you note that bronchial breath sounds are
present over the right lower lobe. This finding indicates
which of the following?
A. The patient has normal lungs
B. A pneumothorax is present in the right lung
C. A pleural effusion is present in the right lower lobe
D. Consolidation is present in the right lower lobe

40. An alert 59-year-old male patient is orally intubated with an

endotracheal tube. During a weaning trial, the patient was
switched to CPAP mode with an FiO2 of 40%. Within the first
5 minutes, the patient’s respiratory rate has increased from
22 to 31 breaths/min with increased usage of accessory
muscles while breathing. Which of the following would you
recommend?
A. Return the patient to full ventilatory support
B. Increase the FiO2 to 50%
C. Apply 5-10 cm H2O of pressure support
D. Extubate the patient and reassess

18
41. After the administration of aerosolized albuterol to a 38-year-
old female patient, which of the following side effects would
you expect?
A. Hypotension
B. Bradycardia
C. Bronchospasm
D. Shaking and tremors

42. A 23-year-old male patient with a severe head cold is

receiving oxygen via nasal cannula at 4 L/min. The pulse
oximeter reveals an SpO2 of 85%. Which of the following
would you recommend?
A. Increase the oxygen flow until the SpO2 equals or
exceeds 90%
B. Decrease the oxygen flow until the patient is more
comfortable
C. Switch to a simple mask
D. Recommend an ABG before considering any changes

43. A stable adult patient who is receiving mechanical

ventilation displays the following results:
pH 7.49
PaCO2 29 mm Hg
HCO3 24 mEq/L
BE +1
PaO2 87 mm Hg
SaO2 96%
Which of the following would you recommend?
A. Add 10 cm H2O PEEP
B. Increase the minute ventilation
C. Decrease the tidal volume
D. Maintain the current settings

19
44. A 68-year-old female patient in the ICU is receiving
mechanical ventilation but appears to be breathing
asynchronously with the ventilator. Which of the following
medications would you recommend?
A. Fluoxetine (Prozac)
B. Lorazepam (Ativan)
C. Dextroamphetamine (Dexedrine)
D. Cisatracurium (Nimbex)

45. A 70-year-old male patient with COPD is receiving

ventilatory support in a volume-controlled mode. Upon
assessment, the high pressure alarm suddenly begins to
sound. Which of the following would recommend?
A. Increase the flow setting
B. Increase the pressure limit setting
C. Suction the airway
D. Remove air from the endotracheal tube cuff

46. A 55-year-old female patient with pneumonia is receiving

oxygen via nasal cannula at 4 L/min. The physician asks for
your suggestion on the best way to evaluate the patient’s
overall ability to breathe. Which of the following would you
recommend?
A. Performing pulse oximetry
B. Drawing an arterial blood sample for analysis
C. Performing a forced vital capacity measurement
D. Performing a full set of pulmonary function tests

20
47. While reviewing the chest x-ray of a 57-year-old male patient,
you note that there is blunting of the left costophrenic angle.
It’s also noted that the patient has a history of CHF. Which of
the following best describes this patient’s condition?
A. There is a pneumothorax on the left side
B. There is a pleural effusion on the left side
C. There is pulmonary edema in the left lung
D. There is pneumonia in the left lower lobe

48. A 69-year-old male patient is undergoing a spontaneous

breathing trial for weaning from mechanical ventilation.
Which of the following changes in the patient’s status would
be acceptable?
A. A decrease in SpO2 from 91% to 81%
B. An increased usage of the scalene muscles during
breathing
C. An increase in heart rate from 97 to 115/min
D. A decrease in the systolic blood pressure from 115 to 76
mmHg

49. An adult patient with fluid overload was given a dose of

furosemide intravenously. After the drug was given, the
patient displayed an arrhythmia on the EKG that was not
present before. Which of the following would you
recommend in this situation?
A. Defibrillate the patient
B. Administer another dose of furosemide
C. Administer a dose of epinephrine
D. Check the patient’s potassium level

21
50. After the extubation of a 54-year-old male patient, he begins
to complain of a sore throat. Which of the following drugs
would you recommend for this patient?
A. Levalbuterol
B. Isoetharine
C. Racemic Epinephrine
D. Acetylcysteine

51. An oropharyngeal airway is being used on a 39-year-old male

patient. Within two minutes after insertion, the patient
begins to gag. Which of the following would you
recommend?
A. Perform the head-tilt, chin-lift maneuver
B. Insert a bite block
C. Remove the airway
D. Replace the current tube with a smaller airway

52. A 66-year-old female was admitted to the emergency

department showing signs of dyspnea, shortness of breath,
and chest tightness. Lab tests were ordered to check her
troponin and BNP levels but the results were negative.
Additionally, her ABG results indicated partially compensated
respiratory acidosis. Which of the following is the most likely
problem for this patient?
A. Pneumonia
B. CHF
C. Exacerbation of COPD
D. Myocardial infarction

53. A 51-year-old male patient is receiving volume-controlled A/C

mechanical ventilation while being monitored with a

22
continuous pulse oximeter. He was briefly removed from the
ventilator so that suctioning could be performed and his
SpO2 dropped from 95% to 88%. Which of the following
would you recommend?
A. Initiate PEEP at 5 cm H2O
B. Increase the FiO2 to 80%
C. Perform bedside hemodynamic monitoring
D. Change to an in-line suctioning catheter

54. During the assessment of an adult patient with chronic

asthma, their results displayed the following:
SVC of 3,500 mL
FVC of 2,500 mL
What is the most likely reason for the difference in these
values?
A. Increased compliance during a forced expiration
B. Poor instruction by the previous respiratory therapist
C. Muscle fatigue during a forced expiration
D. Air trapping during a forced exhalation

55. The physician has ordered acetylcysteine for a 66-year-old

female patient with COPD who has a large amount of thick
secretions. Upon assessment, you note that the patient has a
weak, inadequate cough. Which of the following would you
recommend?
A. Perform a bronchoalveolar lavage
B. Nasotracheal suctioning after the treatment
C. Postpone the therapy until the patient can cough
effectively
D. Administer dornase alpha instead of acetylcysteine

23
56. On discharge, a 52-year-old male patient was prescribed an
inhaled corticosteroid via MDI for two puffs twice a day. In
order to decrease the likelihood of an oral infection, which of
the following would you recommend?
B. An antibiotic prescription
C. Decrease the frequency to once per day
A. A Bronchodilator before the corticosteroid
D. Rinse the mouth after inhalation

57. A 60-year-old female patient is receiving assist-control

mechanical ventilation. Which of the following is the most
common problem associated with this ventilatory mode?
A. Hypoventilation
B. Hyperventilation
C. The need for neuromuscular paralysis
D. Increased work of breathing

58. During the ventilator check of an adult patient who weighs

77 kg, you note the following settings:
Exhaled tidal volume 550 mL
PIP 35 cm H2O
High pressure limit 64 cm H2O
Low pressure alarm 25 cm H2O
Low tidal volume alarm 500 mL
Which of the following changes should be made at this
time?
A. Increase the set tidal volume to 700 mL
B. Increase the low tidal volume alarm to 600 mL
C. Decrease the high pressure limit to 45-50 cmH2O
D. Decrease the low pressure alarm to 10 cmH2O

24
59. An adult patient undergoing a mild asthma attack was
admitted to the ER. Which of the following ABG results
would you expect to see?
A. pH = 7.30 PaCO2 = 49 torr PaO2 = 61 torr
B. pH = 7.32 PaCO2 = 51 torr PaO2 = 51 torr
C. pH = 7.46 PaCO2 = 47 torr PaO2 = 52 torr
D. pH = 7.49 PaCO2 = 30 torr PaO2 = 62 torr

60. A 61-year-old female patient has an FEV1/FVC ratio that is

lower than the predicted value. Her FVC value is also lower
than normal as well. What is the most likely cause of these
findings?
A. The findings are normal
B. A restrictive lung disease
C. An obstructive lung disease
D. Combined obstructive and restrictive lung disease

61. Which of the following tidal volume settings for mechanical

ventilation would be most appropriate for a 5'2" female
patient with normal lungs?
A. 200 mL
B. 400 mL
C. 600 mL
D. 700 mL

62. A 15-year-old male patient who has been diagnosed with

asthma is in need of medications to help prevent future
asthma attacks. All of the following drugs would be helpful
EXCEPT:
A. Cromolyn sodium
B. Zafirlukast

25
C. Epinephrine
D. Zileuton

63. The physician has chosen to use the SIMV mode of

ventilation over the Assist/Control mode. Which of the
following is an advantage of the SIMV mode?
A. SIMV maintains respiratory muscle strength
B. SIMV prevents hyperventilation
C. SIMV increases pleural pressures
D. SIMV increases the need for sedation

64. A newly admitted adult patient in the emergency

department who is intubated has copious amounts of pink
frothy secretions. This is most likely indicates which of the
following:
A. ARDS
B. Cor pulmonale
C. Left ventricular failure
D. An electrolyte imbalance

65. An adult patient has arrived to the emergency department

in respiratory distress with diminished breath sounds. The
patient has a history of asthma. After continuous
bronchodilator therapy, wheezing is now heard during
auscultation. This change suggests which of the following?
A. The onset of pneumonia
B. The development of a pneumothorax
C. The improvement of air flow
D. The development of pulmonary edema

26
66. A 71-year-old female patient is intubated and receiving
positive-pressure ventilation. In order to prevent barotrauma,
you should strive to keep the plateau pressure below which
of the following thresholds?
A. 20 cm H2O
B. 30 cm H2O
C. 40 cm H2O
D. 50 cm H2O

67. While monitoring a 67-year-old male patient who is

receiving volume controlled SIMV, you note bilateral wheezes
during auscultation with an increased peak airway pressure.
Which of the following would you recommend for this
patient?
A. Suction the patient’s airway
B. Order a stat chest X-ray
C. Check the cuff pressure
D. Administer a bronchodilator

68. A 61-year-old female was orally intubated and is now

receiving positive pressure ventilatory support. A chest
radiograph was ordered to confirm the proper placement of
the endotracheal tube. Where should the tip of the tube be
positioned?
A. No more than 2 cm above the carina
B. At the same level as the carina
C. Level with the fifth cervical vertebra
D. Between the 2nd and 4th thoracic vertebra

69. An adult patient was admitted to the emergency

department with an opiate narcotic overdose. The doctor

27
asks for your recommendation to help reverse the effects of
the drugs and enable the patient’s breathing to return to
normal. Which of the following medications would you
recommend?
A. Naloxone (Narcan)
B. Fentanyl (Sublimaze)
C. Indomethacin (Indocin)
D. Vecuronium (Norcuron)

70. Immediately after intubation, a 64-year-old female patient is

showing signs of asymmetrical chest movement while being
ventilated with a bag-valve resuscitator. After auscultation,
you note that no breath sounds are heard on the left side.
These findings are consistent with which of the following?
A. Pneumothorax
B. Atelectasis
C. Right mainstem intubation
D. Pleural effusion

71. An adult patient with a tracheostomy in place is receiving

ventilatory support in the volume-control SIMV mode with a
set rate of 10/min. Upon assessment, the patient has started
to use their accessory muscles during spontaneous breaths.
Which of the following would you recommend?
A. Increase the level of pressure support
B. Decrease the SIMV rate to 8/min
C. Switch to the patient to pressure-control SIMV
D. Switch the patient to a pressure-limited mode

72. While selecting the initial ventilatory settings for a newly

intubated patient, which of the following is most important?

28
A. The type of device that is being used
B. The quality and amount of nursing supervision
C. The patient’s size and clinical condition
D. The amount of spontaneous ventilatory effort

73. A 60-year-old male patient is receiving ventilatory support in

the SIMV mode. A blood gas sample was collected and
analysis shows a PaCO2 of 60 mmHg. Which of the following
would you recommend?
A. Increase the frequency
B. Increase the FiO2
C. Increase the mechanical deadspace in the ventilator
circuit
D. Decrease the tidal volume

74. An ABG was collected on a 71-year-old female patient with a

history of chronic COPD. After reviewing the results, which of
the following values would be most reflective of the severity
of the patient's chronic condition?
A. pH
B. PaCO2
C. HCO3-
D. PaO2

75. An adult patient in the emergency room is unconscious with

an SpO2 of 95%. After re-checking with a CO-oximeter, it
reveals that the patient’s SaO2 is 67%. Which of the following
is the most likely cause of this discrepancy?
A. Opiate drug overdose
B. Diabetic ketoacidosis
C. Acute pulmonary edema

29
D. Carbon monoxide poisoning

76. A 64-year-old female patient has arrived to the emergency

department with chest tightness with radiating left shoulder
pain. Which of the following would you recommend?
A. Obtain a stat chest X-ray
B. Provide 100% oxygen
C. Administer an albuterol treatment
D. Obtain an ABG sample

77. A comatose adult patient in the ICU is receiving mechanical

ventilation. Which of the following pulmonary function tests
can be performed at this time?
A. Peak Expiratory Flow
B. Maximum Voluntary Ventilation
C. Maximum Inspiratory Pressure
D. Forced Expiratory Volume in 1 Second

78. A 61-year-old male patient who is recovering from post-

abdominal surgery has been on a high-flow nasal cannula at
20 L/min for three days. The patient’s ABG results are as
follows:
pH 7.39
PaCO2 43 torr
PaO2 157 torr
SaO2 99%
HCO3 24 mEq/L
BE +2
Which of the following is the best action to take at this time?
A. Decrease the flow
B. Decrease the FiO2

30
C. Decrease the flow and FiO2 together
D. Switch to standard nasal cannula

79. A COPD patient is being discharged and the doctor wants to

prescribe a controller-type bronchodilator for home use.
Which of the following medications would you recommend?
A. Albuterol
B. Levalbuterol
C. Metaproterenol
D. Brovana

80. Upon assessment of a high-risk infant, you note bradycardia

and spells of apnea. Which of the following would you
recommend?
A. Surfactant therapy
B. Nasal CPAP
C. Aerosolized bronchodilator
D. Mechanical ventilation

81. During the assessment of a 1-week-old infant, which of the

following signs would indicate the infant has an increased
work of breathing?
A. Pallor
B. Nasal flaring
C. Digital clubbing
D. Acrocyanosis

82. The physician has ordered mechanical ventilation in the

pressure control A/C mode for a 55 kg postoperative male

31
patient. Which of the following initial settings would you
choose?
A. PIP = 25 cm H2O; Rate = 30/min; Inspiratory time = 1
second
B. PIP = 32 cm H2O; Rate = 12/min; Inspiratory time = 2
seconds
C. PIP = 40 cm H2O; Rate = 20/min; Inspiratory time = 1
second
D. PIP = 25 cm H2O; Rate = 12/min; Inspiratory time = 1
second

83. A sweat chloride test can be used to diagnose which of the

following conditions?
A. Muscular dystrophy
B. Amyotrophic lateral sclerosis
C. Poliomyelitis
D. Cystic fibrosis

84. Which of the following respiratory signs would be

considered abnormal in an adult patient who is at rest under
normal conditions?
A. Respiratory rate of 18 breaths per minute
B. Ribs higher posteriorly than anteriorly at end-expiration
C. Scalene muscle usage at rest
D. Costal angle of 90 degrees increases with inspiration

85. A 22-year-old female patient has been admitted to the

emergency department with acute bronchospasm. Which of
the following medications would you recommend?
A. Albuterol (Proventil)
B. Racemic epinephrine

32
C. Cromolyn sodium (lntal)
D. Acetylcysteine (Mucomyst)

86. A 54-year-old female patient is receiving ventilatory support

in the volume control mode. After performing endotracheal
suctioning, which of the following would indicate effective
clearance of retained secretions?
A. A decreased inspiratory time
B. A smaller tidal volume
C. A lower plateau pressure
D. A lower peak pressure

87. A 59-year old female patient with COPD is receiving

supplemental oxygen via nasal cannula at 2 L/min. Her ABG
results are as follows:
pH 7.37
PaCO2 58 torr
HCO3- 32 mEq/L
PaO2 58 torr
SaO2 85%
Based on this data, which of the following would you
recommend?
A. Increase the oxygen flow to 3 L/min
B. Switch to BiPAP with an FiO2 of 100%
C. Switch to a nonrebreathing mask at 10 L/min
D. Switch to an air entrainment mask at 24%

88. A post-operative adult patient is being treated with incentive

spirometry. The patient's inspiratory capacity has decreased
over the past few days and their level of dyspnea has been
increasing. A chest x-ray reveals consolidation in the lung

33
bases with no shift of the trachea. Which of the following has
most likely developed?
A. Pneumonia
B. Pleural effusion
C. Atelectasis
D. Pneumothorax

89. While assessing a mechanically ventilated patient after a

neurosurgical procedure, the patient has an intracranial
pressure of 20 mmHg but is otherwise stable. The latest ABG
results are as follows:
pH 7.31
PaCO2 48 mm Hg
HCO3 24 mEq/L
PaO2 88 mm Hg
SpO2 95%
Based on this information, which of the following would you
recommend?
A. Increase the minute ventilation
B. Add 10 cm H2O PEEP
C. Decrease the tidal volume
D. Maintain the current settings

90. A newborn 28-week gestational age neonate is being treated

34
A. Start nasal CPAP at 5-8 cm H2O
B. Increase the oxygen hood concentration to 100%
C. Intubate and begin mechanical ventilation with PEEP
D. Obtain a chest X-ray to look for a pneumothorax

91. A 56-year-old female patient’s bedside spirometry results are

as follows:
FVC is decreased
FEV1 is normal
FEV1% is increased
What is the most likely problem?
A. Normal results
B. An obstructive disease
C. Poor patient effort
D. A restrictive disease

92. An 11-year-old boy has just arrived in the ER with cystic

fibrosis and a pulmonary infection. Upon assessment, you
note very thick secretions. Which of the following drugs
would you recommend for this patient?
A. Nebulized acetylcysteine
B. Nebulized dornase alpha
C. Nebulized 0.9% saline
D. Direct instillation of acetylcysteine into the lungs

93. A 64-year-old male patient is intubated and receiving

35
B. Switch from an ET tube to a tracheostomy
C. Maintain the endotracheal tube in place
D. Switch to a pressure-controlled mode

94. An adult patient in ICU who is receiving mechanical

ventilation has been diagnosed with ARDS. Which of the
following would you expect to find in this patient?
A. Refractory hypoxemia
B. Metabolic alkalosis
C. Increased lung volumes
D. Increased compliance

95. You were called to obtain a forced vital capacity maneuver

on an adult patient with normal lungs. What percentage
should the patient be able to exhale within the first second of
the maneuver?
A. 35-50% of the FVC
B. 50-70% of the FVC
C. 70-83% of the FVC
D. 84-93% of the FVC

96. The physician has ordered 2.5 mL ipratropium bromide TID

for a 70-year-old female patient with COPD and
bronchospasm. Which of the following methods would you
recommend in order to deliver the medication?
A. Dry powder inhaler
B. Ultrasonic nebulizer with a mask
C. Small volume nebulizer with a mask
D. Small volume nebulizer with a mouthpiece

36
97. A 52 kg female patient is receiving volume control A/C
mechanical ventilation with a tidal volume of 400 mL, a set
rate of 10/min, and an FiO2 of 35%. Her blood gas results are
as follows:
pH 7.31
PaCO2 49 torr
HCO3 24 mEq/L
BE -2 mEq/L
PaO2 74 torr
SpO2 95%
Based on the given information, which of the following
changes is appropriate at this time?
A. Increase the FiO2
B. Increase the tidal volume
C. Increase the set rate
D. Maintain the current settings

98. An arterial blood gas sample needs to be obtained from a

newborn infant. The physician ordered the sample from
arterialized capillary blood because the artery would be too
difficult to stick. Which of the following sites would you
recommend?
A. The fingertip
B. The toe tip
C. The lateral area of the heel
D. The earlobe

99. Which of the following is true regarding the insertion of a

laryngeal mask airway as compared to endotracheal
intubation?
A. It must be removed in order to insert an endotracheal
tube

37
B. It poses a greater risk of trauma than endotracheal
intubation
C. It can be inserted blindly without any special equipment
D. It can completely prevent the aspiration of gastric
contents

100. A neonate with meconium aspiration syndrome is

receiving mechanical ventilation. If you were to increase the
pressure limit, this would increase the risk of which of the
following?
A. Pneumothorax
B. Oxygen toxicity
C. Tracheoesophageal fistula
D. Retinopathy of prematurity

101. An adult patient is receiving mechanical ventilation with a

PEEP setting of 10 cmH2O. The physician has requested
that you increase the setting to 14 cmH2O. After making the
adjustment, there is a rapid drop in the patient’s blood
pressure and a significant increase in heart rate. Which of
the following actions should you take?
A. Increase the FiO2 by 10%
B. Lower the PEEP back to 10 cmH2O
C. Administer sodium bicarb
D. Obtain a stat EKG

102. After reviewing the results of a patient’s pulmonary

function tests, you note that the FEV1, FVC, and total lung
capacity are all reduced. The FEV1/FVC ratio is normal. What
is the interpretation based on these findings?
A. Restrictive lung disease

38
B. Obstructive lung disease
C. Combined obstructive-restrictive lung disease
D. The test is invalid

103. While reviewing the chest x-ray of a 47-year-old male

patient, you note that the heart is shifted to the patient’s
right. Which of the following is the most likely cause of this
finding?
A. Atelectasis of the left side
B. Tension pneumothorax on the left side
C. Tension pneumothorax on the right side
D. Pleural effusion on the right side

104. An ABG was ordered for a 68-year-old female patient with a

history of COPD. Before entering the patient’s room, you
must first gather all the necessary supplies. Which of the
following is required in order to perform an arterial
puncture?
A. Sterile gloves
B. Lancet
C. Local anesthetic
D. Anticoagulant

105. While assessing a 51-year-old male patient, you note

definitive use of the neck muscles during normal breathing.
This finding is consistent with which of the following?
A. Pulmonary embolism
B. Myasthenia gravis
C. COPD
D. Orthopnea

39
106. A 58-year-old female is receiving volume control A/C
ventilation at a rate of 12/min with a tidal volume of 450 mL.
The FiO2 is set at 40% and her ABG results are as follows:
pH 7.35
PaCO2 44 torr
HCO3 22 mEq/L
BE 0
PaO2 91 torr
SaO2 97%
Based on this information, you should recommend which of
the following?
A. Decrease the minute ventilation
B. Discontinue mechanical ventilation
C. Administer IV bicarbonate
D. Maintain the current settings

107. You were called to perform a set of FVC tests on a 55-year-

old male patient. While looking at the results of the first
attempt, you determined that it took too long for the
patient to reach the peak expiratory flow. Before another
attempt is performed, which of the following instructions
should you give the patient?
A. “Take a deeper breath.”
B. “Don’t hesitate.”
C. “Blast the air out faster.”
D. “Blow out longer.”

108. A 2-year-old girl is showing signs of a severe asthma attack.

The physician has ordered a short-acting bronchodilator
medication that is available in both MDI and SVN doses.

40
Which of the following delivery methods would you
recommend for this patient?
A. An SVN using the “blow by” technique
B. An MDI with a holding chamber and mask
C. A small volume nebulizer with a mouthpiece
D. A breath-actuated MDI with mask

109. During the assessment of a 60-year-old male patient, you

noticed reduced tactile fremitus. This finding is typical in all
of the following conditions EXCEPT:
A. COPD
B. Pneumothorax
C. Pulmonary edema
D. Pleural effusion

110. A 43-year-old male patient admitted to the emergency

department with a suspected drug overdose. The patient is
receiving oxygen via nonrebreather but is unconscious and
isn’t making any respiratory efforts to breathe. The patient’s
body weight is 57 kg and his ABG results are as follows:
pH 7.28
PCO2 74 torr
HCO3 20 mEq/L
PaO2 315 torr
Which of the following would you recommend?
A. Apply BiPAP with: IPAP 20 cm H2O, EPAP 5 cm H2O,
FIO2 30%
B. Intubate and apply: SIMV, tidal volume 600 mL, rate
6/min, FIO2 40 %
C. Intubate and apply: A/C ventilation, tidal volume 450
mL, rate 12/min, FIO2 50%
D. Apply CPAP at 10 cm H2O and an FiO2 of 100%

41
111. A 63-year-old female patient is orally intubated with a size 7
endotracheal tube and is receiving ventilatory support.
While attempting to suction the patient with a size 12 Fr
catheter, you note that the catheter cannot pass beyond
the tip of the tube. Which of the following is the most likely
cause of this problem?
A. There is a kink in the tube
B. The tube is in the right main bronchus
C. The suction catheter too short
D. The suction catheter size is too large

112. A patient in the ICU is receiving positive pressure

ventilatory support but appears to be breathing
asynchronously with the machine-delivered breaths. Which
of the following medications would you recommend?
A. Fluoxetine (Prozac)
B. Midazolam (Versed)
C. Dextroamphetamine (Dexedrine)
D. Cisatracurium (Nimbex)

113. A 59-year-old female patient has a vital capacity of 3.4,

functional residual capacity of 5.8, and an expiratory reserve
volume of 1.2. What is the patient's total lung capacity?
A. 5.9
B. 6.8
C. 8.0
D. 8.8

42
114. A 69-year-old male patient with tachypnea, dyspnea, and
expiratory wheezes did not improve after receiving a
bronchodilator treatment. Which of the following most
likely describes the patient’s condition?
A. Asthma
B. Chronic bronchitis
C. Congestive heart failure
D. Emphysema

115. An adult patient was admitted to the emergency

department with chest trauma after a motor vehicle
accident. Upon assessment, you note crepitus in the upper
chest area. This finding indicates which of the following?
A. A mucus plug is present
B. Subcutaneous emphysema
C. Pleural effusion
D. Tactile fremitus

116. During the assessment of a 64-year-old patient who is

receiving volume-controlled ventilation, you note that the
peak airway pressure has decreased from 36 to 19 cmH2O.
There have been no changes to the ventilator settings.
Which of the following would you recommend?
A. Increase the volume setting until the pressure equals 36
cmH2O
B. Increase the flow setting until the pressure equals 36
cmH2O
C. Check for increased secretions and suction if needed
D. Check the circuit for system leaks

43
117. What is the maximum volume of air that can be inhaled
after a normal quiet inspiration?
A. FVC
B. FRC
C. IRV
D. ERV

118. A 59-year-old male patient who weighs 75 kg is intubated

and receiving mechanical ventilation. During a CPAP
spontaneous breathing trial, the patient has a respiratory
rate of 14 and exhaled tidal volume of 320 mL. The patient is
awake but is unable to follow commands. Which of the
following would you recommend at this time?
A. Extubate the patient
B. Pressure control ventilation
C. Pressure support ventilation
D. Volume control ventilation

119. The physician has requested a mode of ventilation in which

you can maintain a precise I:E ratio. Which of the following
modes would you select?
A. Synchronous Intermittent Mandatory Ventilation
B. Control Mode Ventilation
C. Assist-Control Ventilation
D. Pressure Support Ventilation

120. While administering an adrenergic aerosol bronchodilator

treatment to an adult female patient, you notice an
increase in her pulse rate from 81 to 125 beats/min. Which of
the following actions should you take?
A. Use half of the standard dosage next time

44
B. Add more diluent to the nebulizer chamber
C. Temporarily stop the treatment until the patient’s heart
rate decreases
D. Stop the treatment and notify the physician

121. You are called to review the electrolyte results of a 60-year-

old female patient. Which of the following values is typical
for serum potassium?
A. 2.7 mEq/L
B. 3.2 mEq/L
C. 4.1 mEq/L
D. 5.8 mEq/L

122. It is suspected that a 41-year-old female patient with

wheezing has asthma but that diagnosis has not yet been
confirmed. Which of the following tests would you
recommend in order to obtain confirmation?
A. Airway resistance
B. Flow-volume loop
C. Bronchoprovocation study
D. Pre-and-post bronchodilator study

123. A 4-year-old child has been admitted to the emergency

department with wheezing and stridor. An AP x-ray shows
an area of prominent subglottic edema but the lateral neck
x-ray appears normal. Which of the following is most likely
the problem?
A. Cystic fibrosis
B. Foreign body
C. Epiglottitis
D. Croup

45
124. A 63-year-old female patient is receiving volume control
A/C ventilation and has become agitated. Over the past 3
hours, her PaCO2 has decreased from 38 to 27 torr. Which
of the following is the most likely cause of this problem?
A. High body temperature
B. Increased ventilation
C. Increased cardiac output
D. Mainstem intubation

125. A 64-year-old male patient is receiving an aerosol

treatment with acetylcysteine and hypertonic saline via a
small volume nebulizer. After only a few minutes, the
patient suddenly becomes dyspneic. Which of the following
is the most likely cause of this problem?
A. Hypercapnia
B. Pneumothorax
C. Fluid overload
D. Bronchospasm

126. An adult patient who is receiving mechanical ventilation

has a peak airway pressure of 60 cmH2O and a plateau
pressure of 45 cmH2O. The ventilator flow rate is set at 60
L/min. What is the patient’s airway resistance?
A. 5 cm H2O/L/sec
B. 15 cm H2O/L/sec
C. 30 cm H2O/L/sec
D. 60 cm H2O/L/sec

46
127. A 69-year-old male patient with a severe obstructive airway
disease is intubated and receiving ventilatory support.
Which of the following capabilities would be the most
important to consider when selecting a ventilator for this
patient?
A. Approved for use during MRI procedures
B. The ability to compensate with tube flexibility
C. The ability to run on 12 volt DC (battery) power
D. A variable flow control and adjustable I:E ratio

128. A 49-year-old male is intubated and receiving mechanical

ventilation with a size 7.5 endotracheal tube. Over the past
hour, the patient has been compressing the tube between
his teeth. Which of the following would you recommend?
A. The application of a Brigg’s adapter
B. The use of a bite block
C. The administration of a neuromuscular blocking agent
D. The administration of a strong narcotic analgesic

129. Hemodynamic data was collected on a 39-year-old male

patient. Which of the following indicates that there is a
problem with this patient?
A. Shunt of 3%
B. SVR of 500 dyn/s/cm-5
C. Cardiac Index of 3.7 L/min/m2
D. CVP of 5 cmH2O

130. A 65-year-old female patient with pulmonary edema was

inadvertently given 1000 mL of IV fluids instead of the
ordered amount of 100 mL. Which of the following would
you expect to see in this case?

47
A. Increased PaO2
B. Decreased PAP
C. Increased PCWP
D. Decreased lung markings on the chest x-ray

131. A post-operative patient using a mouthpiece positive

pressure ventilator has an inspiratory time that is prolonged
and the machine does not cycle off without an active
patient effort. Which of the following would you
recommend in order to correct this problem?
A. Increase the control pressure
B. Decrease the sensitivity setting
C. Check for a leak in the circuit or mouthpiece
D. Switch the unit to 100% source gas

132. You are called to administer nebulized albuterol to a 47-

year-old female patient that is receiving oxygen via nasal
cannula at 2 L/min. Her pretreatment heart rate was
recorded at 84 beats/min. You would stop the treatment
once the patient’s heart rate reaches which of the following
levels?
A. 89 beats/min
B. 99 beats/min
C. 109 beats/min
D. 119 beats/min

133. A 69-year-old female patient with advanced COPD is

receiving supplemental oxygen. Which of the following is a
problem that could arise under such circumstances?
A. Hypoventilation
B. Hyperventilation

48
C. Retinopathy of prematurity
D. The development of pulmonary edema

134. Simple spirometry can be used to measure any of the

following EXCEPT:
A. Tidal volume
B. Vital capacity
C. Inspiratory reserve volume
D. Residual volume

135. A 74 kg male patient is intubated and receiving volume

control A/C ventilation with the following settings: FiO2 of
50%, set rate of 15, and tidal volume of 550 mL. The patient’s
total respiratory rate is 29 breaths/min. His ABG results are
as follows:
pH 7.53
PaCO2 27 torr
HCO3 23 mEq/L
BE -2
PaO2 82 torr
SaO2 97%
Which of the following would you recommend?
A. Increase the FiO2
B. Increase the ventilator rate
C. Increase the tidal volume
D. Add mechanical deadspace

136. A high-flow nasal cannula has been ordered for a 44-year-

old female patient. In order to set up this device, you would
need all of the following EXCEPT?
A. Blender

49
B. Humidifier
C. Sterile saline
D. Air and oxygen source

137. A 53-year-old female patient was ordered to perform a 6-

minute walk test during pulmonary rehabilitation. Which of
the following instructions would you give?
A. Walk as slow as possible for 6 minutes and note the
distance covered
B. Walk as fast as possible for 6 minutes and note the
distance covered
C. Walk as far as possible for 6 minutes and note the
distance covered
D. Walk for 1 mile and record the time it took to cover that
distance

138. You are called to increase the expiratory time of a patient

receiving volume control ventilation without altering the
minute ventilation. Which of the following settings would
you adjust in order to fulfill this request?
A. Rate of breathing
B. Inspiratory flow
C. Tidal volume
D. Trigger sensitivity

139. Spirometry tests were performed on a 52-year-old female

with the following results:
Predicted Actual % Predicted
TLC 5.8 8.2 136
RV 1.2 1.7 165

50
FVC 5.1 2.7 53
FEF25-75% 4.3 1.6 37
FEV1/FVC 75% 21% 28
What is the interpretation of this data?
A. Mild restrictive lung disease
B. Mild obstructive lung disease
C. Severe restrictive lung disease
D. Severe obstructive lung disease

140. In order for a home-care patient to disinfect their

respiratory care equipment, which of the following would
you recommend?
A. Warm, soapy water
B. Cool, soapy water
C. Ethylene oxide
D. Acetic acid

141. A 66-year-old female patient is receiving ventilatory

support in the SIMV mode with an FiO2 of 40% and a PEEP
of 10 cmH2O. Over the past hour, her SpO2 has decreased
from 94% to 81%. Which of the following would you
recommend FIRST?
A. Change to VC, A/C
B. Increase the PEEP
C. Increase the FiO2
D. Increase the flow

142. A 26-year-old female patient was admitted to the

emergency department with signs of status asthmaticus.

51
Which of the following drugs would you recommend for
administration via nebulization?
A. Levalbuterol
B. Montelukast
C. Beclomethasone
D. Magnesium sulfate

143. While reviewing the chest x-ray of an adult patient, it shows

that there is a shift of the trachea and mediastinum to the
patient’s left side. There is also a complete opacification of
the left side as well. These findings indicate which of the
following?
A. Diffuse pulmonary emphysema
B. Right-sided pleural effusion
C. A pneumothorax of the right lung
D. Atelectasis of the left lung

144. A premature newborn infant with an Apgar score of 3 is

showing signs of hypoxemia, grunting, and intercostal
retractions. Which of the following would you recommend?
A. Suction the neonate
B. Nebulize albuterol
C. Provide supplemental oxygen
D. Instill surfactant into the airway

145. The physician has requested to change the airway of a

patient from an endotracheal to a tracheostomy tube.
Which of the following is the primary indication for the
insertion of a tracheostomy?
A. When a patient loses pharyngeal or laryngeal reflexes

52
B. When a patient has a long-term need for mechanical
ventilation
C. When a patient is prone to hemorrhaging
D. When a patient has upper airway obstruction due to
trauma

146. The physician has requested to decrease the PaCO2 of a

patient who is receiving high-frequency oscillation
ventilation. Which of the following settings should you
adjust?
A. Increase the frequency
B. Decrease the bias flow
C. Increase the power/amplitude
D. Increase the mechanical deadspace

147. While reviewing your patient work list, you notice that you
have a patient who was diagnosed with chronic bronchitis
and another patient with emphysema. Which of the
following PFT findings would you expect for these patients?
A. Increased lung compliance
B. Decreased forced expiratory flows
C. Decreased total lung capacity
D. Decreased diffusing capacity

148. While assisting with a bronchoscopy procedure, the

physician requests a medication for direct instillation into
the endotracheal tube. Which of the following would you
recommend?
A. Lidocaine
B. Liquid Heparin
C. Ipratropium bromide

53
D. Saline

149. An 8-year-old girl has been diagnosed with asthma and

was prescribed Proventil via metered dose inhaler for home
use. Which of the following would you recommend in order
to increase the deposition of the bronchodilator?
A. Add a spacer or holding chamber to the MDI
B. Remove the mouthpiece from the MDI
C. Have the child inhale as quickly as possible
D. Switch from an MDI to a DPI

150. A 53-year-old female patient with COPD is receiving

volume controlled A/C ventilation. Rhonchal fremitus was
felt over the central airways and wheezing was heard in all
lung fields. The patient has thick secretions and has a peak
pressure of 45 cm H2O and plateau pressure of 20 cm H2O.
Which of the following would you recommend?
A. Cromolyn sodium (Intal)
B. Triamcinolone (Azmacort)
C. Levalbuterol (Xopenex)
D. Pancuronium bromide (Pavulon)

151. A 33-year-old male patient was admitted to the emergency

department with carbon monoxide poisoning. In order to
provide an adequate FiO2, which of the following would you
recommend?
A. Nonrebreathing mask
B. CPAP mask at 8 cmH2O and 50% O2
C. Simple mask at 6 L/min
D. 60% air entrainment mask

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152. The physician has ordered a dry powder inhaler for an adult
patient who is being discharged. The patient has never
used an inhaler before. Which of the following instructions
would you provide?
A. Blow slowly into the device
B. Hold the device vertically after loading
C. Inhale rapidly for 1-2 seconds
D. Breathe normally in and out of the device

153. Which of the following instructions would you give an adult

patient who is about to perform a maximum expiratory
pressure test for the first time?
A. “Take a normal breath in, then blow out hard.”
B. “Inhale as much as you can, then blow out hard.”
C. “Exhale normally, then inhale as hard as possible.”
D. “Blow out all of your air before you begin.”

154. An EKG was performed on a newly admitted 66-year-old

female patient. While reviewing the results, there are no
identifiable P waves and the patient has an irregular
ventricular rhythm. Which of the following is most likely the
problem?
A. Atrial fibrillation
B. Ventricular tachycardia
C. 1st degree heart block
D. 2nd degree heart block

155. A 61-year-old female patient is receiving mechanical

ventilatory support. Over the past three days, her fluid

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intake has stayed the same but her output fluid level
measurements have been decreasing. Her peak airway
pressure has been steadily increasing over this same time
period. Which of the following is the most likely cause of
this problem?
A. Ventilator-associated pneumonia
B. Acute respiratory distress syndrome
C. Pulmonary arterial hypertension
D. Cardiogenic pulmonary edema

156. A 58-year-old postoperative male who weighs 172 lbs is

receiving volume control A/C ventilation at a rate of 16/min,
tidal volume of 550 mL, and FiO2 of 40%. His ABG results are
as follows:
pH 7.51
PaCO2 30 torr
HCO3 23 mEq/L
BE -1
PaO2 117 torr
SaO2 99%
Based on this information, which of the following would you
recommend?
A. Discontinue mechanical ventilation
B. Administer IV bicarbonate
C. Increase the peak flow setting
D. Decrease the minute ventilation

157. A chest x-ray was ordered to confirm that the endotracheal

tube is positioned in the correct place. Where should the tip
of the tube be located?
A. Even with the carina
B. Level with the 5th cervical vertebra
C. At the sixth intercostal space

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D. 1–2 inches above the carina

158. An adult patient is receiving ventilatory support in the

pressure control A/C mode at a rate of 10/min and peak
pressure of 35 cm H2O. The following ABG results were
obtained:
pH 7.31
PaCO2 49 torr
SaO2 96%
HCO3 23 mEq/L
BE -2 mEq/L
Which of the following would you recommend?
A. Increase the FiO2
B. Increase the rate
C. Change the patient to CPAP
D. Make no changes at this time

159. The physician has ordered ribavirin (Virazole) to be

administered via aerosol to an infant with severe RSV.
Which of the following devices would you recommend?
A. Small particle aerosol generator
B. Small volume jet nebulizer
C. Vibrating mesh nebulizer
D. Dry powder inhaler

160. The status of a 56-year-old male patient has gotten worse

over the past 2 hours. He was switched from an air
entrainment mask to a nonrebreather, and is now receiving
ventilatory support with the following settings:
Assist/Control rate 12

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Tidal volume 650 mL
FiO2 100%
PIP 40 cmH2O
Plateau pressure 35 cmH2O
The patient's arterial blood gas results are as follows:
pH 7.42
PaCO2 35 torr
PaO2 54 torr
SpO2 84%
HCO3- 23 mEq/L
Which of the following best represents the status of this
patient?
A. Cystic fibrosis
B. Acute metabolic alkalosis
C. Hypoventilation from fatigue
D. Intrapulmonary shunting

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Section 2

1. During the assessment of 60-year-old female patient, you note

To get this one correct, you needed to be able to interpret the

signs that were given about the patient in the question. This is a
common type of question for the TMC Exam.

The question tell us that the patient has reduced chest expansion,
a hyperresonant percussion note, absent breath sounds, and
tactile fremitus all on the left side. That to go along with a tracheal
shift to the right. This indicates that the patient has a
pneumothorax on the left side.

Remember that, when a pneumothorax is present, the trachea

will shift away from the affected side. That means you can rule out
left-sided atelectasis because the trachea would shift to that side.

A pleural effusion and consolidation would cause a dull

percussion note, not a hyperresonant note, so we can rule out
those two as well.

The correct answer is: B. A pneumothorax on the left side

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2. A 39-year-old male patient was admitted to the emergency
department with a fever and an SpO2 of 87% on room air.
Upon auscultation, rhonchi is heard and the patient has a
productive cough. Which of the following would you
recommend?
A. Intubate and provide mechanical ventilation with 40%
oxygen
B. Provide noninvasive positive pressure ventilation using a
full face mask
C. Implement postural drainage and percussion with
directed coughing
D. Provide oxygen therapy and obtain a sputum sample for
culture and sensitivity

To get this one correct, you needed to be able to recognize that

the patient has some type of infection, like pneumonia.

You know this because the question states that the patient is
hypoxemic, has a fever, and rhonchi breath sounds. So in this
case, you would want to obtain a sputum sample for culture and
sensitivity in order to identify the type of organism. Oxygen
therapy is indicated for the hypoxemia.

Intubation and NPPV would not be indicated in this case. Postural

drainage and percussion are not recommended either. So by
breaking down the question, the best answer clearly is D.

The correct answer is: D. Provide oxygen therapy and obtain a

sputum sample for culture and sensitivity

3. A 50-year-old male patient is intubated with a size 8

endotracheal tube and is receiving volume-controlled A/C
ventilation. Upon assessment, you note that the patient’s cuff

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pressure is measured at 38 cm H2O. Which of the following
would you recommend?
A. Withdraw the tube 1-2 cm and reassess the patient’s
breath sounds
B. Recommend reintubation with a smaller endotracheal
tube
C. Lower the cuff pressure to < 30 cm H2O
D. Recommend ventilation via a tracheostomy instead

In order to get this one right, you needed to know the normal
values for cuff pressure. And in this case, you needed to recognize
that 38 cm H2O is way too high and could potentially be
dangerous for the patient’s trachea.

So your first action should be to lower the cuff pressure to < 30 cm

H2O and then check to make sure that there are not any leaks.
For the TMC Exam, you need to remember that the cuff pressure
normal range is between 20-30 cm H2O.

There is no indication to withdraw the tube and using a smaller

tube would only cause the patient’s peak pressure to increase
which is something that we do not want. Also, nothing in the
question indicates that a tracheostomy is needed, so we know
that the correct answer has to be C.

The correct answer is: C. Lower the cuff pressure to < 30 cm H2O

4. During the assessment of a 52-year-old female patient that is

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D. The flowmeter pressure is set too high

If you’ve ever accidentally stepped on the tubing when a bubble

humidifier is being used, then you will automatically know that
the correct answer is A.

The relief valve of a bubble humidifier sounds when the pressure

in the reservoir container exceeds the valve’s threshold pressure.
And of course, the most common reason for this to occur is when
there is a downstream obstruction to outflow.

None of the other answer choices really make sense in this

situation, so you know that the correct answer has to be A.

The correct answer is: A. There is an obstruction in the delivery

tube

5. A pre and post bronchodilator test was ordered on a 48-year-

The information that was given in the question suggest that the
patient’s airway obstruction was somewhat relieved because the
FEV1 increased from 60% to 80% of the predicted value. But was it
enough to classify it as a reversible obstruction?

Remember that if pre-to-post values increase by at least 12-15%,

you know that the treatment was effective. So in this case, there

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was a 20% increase, which means that —yes — the increase was
enough and this indicates that there is a reversible airway
obstruction.

We can rule out all of the other answer choices because we know
that the correct answer has to be B.

The correct answer is: B. A reversible airway obstruction

6. A 58-year-old female patient is intubated and appears to be

breathing asynchronously with the ventilator. Her breath
sounds are absent on the left side and the trachea appears to
be shifted to the left. The patient has a dull percussion note on
the left side as well. Which of the following is the most likely
explanation of these findings?
A. A tracheoesophageal fistula has developed
B. A tension pneumothorax has developed on the left side
C. The endotracheal tube is in the right mainstem bronchus
D. The patient is experiencing diffuse bronchospasm

To get this one correct, you need to be able to interpret the

information that was provided about the patient in the question.

It states that she has a dull percussion note on the left side,
tracheal shift toward the left side, and absent breath sounds on
the left side. You needed to recognize that these are all signs of
atelectasis.

So now you have to think, “What would cause atelectasis?” In this

instance, it’s most likely that the endotracheal tube has slipped
into the right mainstem bronchus which has caused left-sided
atelectasis.

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Diffuse bronchospasm would cause bilateral wheezing and a left-
sided pneumothorax would cause a hyperresonant percussion
note, not a dull percussion note. So by breaking down the
question, you can easily determine that the correct answer has to
be C.

The correct answer is: C. The endotracheal tube is in the right

mainstem bronchus

7. A 63-year-old female patient is intubated and receiving

To get this one correct, you must have a basic understanding of

lung compliance. You also have to take into account that the
ventilator is in the pressure control mode, which means that the
pressure is pre-set.

If there is a decrease in lung compliance when the ventilator is

operating in the pressure control mode, the machine will
continue delivering a constant pressure. But, since the lungs
don’t expand as much when there is decreased compliance, it
reaches the set pressure limit much faster. That means that there
will be a decrease in the delivered tidal volume.

In this case, the inspiratory time will decrease and the PEEP levels
should not be affected.

The correct answer is: A. Her delivered volume will decrease

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8. A 70-year-old male patient is intubated and receiving
mechanical ventilation in the volume controlled A/C mode.
After performing endotracheal suctioning, which of the
following would indicate the effective clearance of retained
secretions?
A. An increased tidal volume
B. A decreased inspiratory time
C. A decreased plateau pressure
D. A decreased peak pressure

Generally, you should remember that retained secretions will

increase the patient’s airway resistance and peak airway pressure
during volume control ventilation.

So taking that into consideration, if you were to clear the

secretions via suctioning, that should decrease the patient’s peak
airway pressure.

On the other hand, if the patient had been receiving pressure

controlled ventilation, you would expect an increase in delivered
volume once secretions are cleared. That’s the key to getting this
one correct — you needed to understand the difference between
volume and pressure controlled ventilation.

None of the other answer choices make sense in this situation, so

you know that the correct answer has to be D.

The correct answer is: D. A decreased peak pressure

9. An adult patient who is receiving mechanical ventilation

suddenly started showing signs of tachypnea. Upon
assessment, you note tracheal deviation to the right and

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decreased breath sounds and hyperresonance on the left.
Which of the following would you recommend?
A. The patient needs suctioning
B. The patient needs a bronchoscopy
C. The insertion of a chest tube
D. The patient needs a thoracentesis

For this one, you needed to be able to interpret the signs and
symptoms that were given in the question. And by doing so, you
could easily determine that all of the signs are consistent with a
pneumothorax.

Remember, patients with a pneumothorax will typically show

tracheal deviation away from the affected side. They will also
show decreased breath sounds and hyperresonance on the
affected side as well.

So in order to treat a pneumothorax, the patient requires

immediate insertion of a chest tube on the affected side. None of
the other answer choices really make sense in this situation, so
you know that the correct answer has to be C.

The correct answer is: C. The insertion of a chest tube

10. A 57-year-old female patient with acute pulmonary edema is

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Once you begin working as a Respiratory Therapist, this is
something you will run into far too often. A nurse or new
physician will hear wheezing and automatically request for the RT
to provide a breathing treatment for the patient.

It’s frustrating because wheezing in patients with CHF and

pulmonary edema is usually due to fluid overload, not due to
bronchospasm.

So in general, acute pulmonary edema is best managed with a

diuretic, such as Lasix. Oxygen therapy may be indicated as well if
hypoxemia is present. Also, NPPV is often indicated for these
patients as well.

So by breaking down the question, we can determine that the

best answer in this case is D.

The correct answer is: D. Recommend a diuretic and oxygen

therapy

11. A 39-year-old female patient who is intubate was admitted

To get this one correct, first and foremost, you needed to know
that Naloxone is another name for the drug Narcan. Narcan is

67
given to patients who are having a narcotic overdose — for
example — for drugs like morphine.

You also had to know that some medications can be instilled

directly down endotracheal tube. To make it easy to remember,
you can learn the NAVEL mnemonic.

Here are the drugs that can be delivered down the ET tube:

• N – Naloxone (Narcan)
• A – Atropine
• V – Vasopressin
• E – Epinephrine
• L – Lidocaine

Remember that when directly instilling medications down the ET

tube, you have to administer 2–2.5 times more of the medication
than the normal dose in order for it to be effective.

You will most likely see a question about Narcan (Naloxone) on

the TMC Exam, so prepare accordingly. None of the other answer
choices make sense in this situation, so you know that the correct
answer has to be D.

The correct answer is: D. Through the endotracheal tube

12. A 176 lb male patient is intubated and receiving volume

control A/C ventilation with the following settings: FiO2 of
40%, Rate of 12/min, and Tidal Volume of 550 mL. An ABG was
analyzed and the following results were obtained:

ABG Results Ventilator Settings

pH 7.39 Spontaneous Tidal Volume 180 mL
PaCO2 37 mmHg Spontaneous Rate 37/min
HCO3- 23 mEq/L Vital Capacity 550 mL

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PaO2 107 mmHg MIP/NIF -12 cm H2O

Which of the following would you recommend?

To get this one right, you must be able to interpret the patient’s
ABG results and make the appropriate changes to the ventilator
settings. You will likely see several questions in this format on the
TMC Exam.

The first thing you should note is that the values of the ABG
results are all within the normal ranges. Then you can look at the
bedside measurements.

The patient has a fast spontaneous breathing rate, a low

spontaneous tidal volume, a low vital capacity, and a low MIP/NIF.
All of these findings indicate that this patient is not ready for a
spontaneous breathing trial and should not yet be weaned. So it’s
best to maintain the current setting and re-evaluate the patient
at a later time.

All of the other answer choices demonstrate some type of

weaning, so we can rule them out right away.

The correct answer is: D. Maintain the current ventilator settings

and re-evaluate later

13. An adult patient was admitted to the emergency

department after involvement in a motor vehicle accident.
The patient is hyperventilating and appears to have a flail

69
chest. Which of the following ABG results would you expect
for this patient?
A. Increased pH and decreased SaO2
B. Increased pH and increased SaO2
C. Decreased pH and decreased SaO2
D. Decreased pH and increased SaO2

First and foremost, the question tells us that the patient is

hyperventilating which means that they are blowing off too much
CO2. With that said, you should automatically know that the pH
will be increased.

And for a patient with a flail chest, you would expect them to
have hypoxemia as well.

So by breaking down the question, you should easily be able to

determine that the correct answer is A.

The correct answer is: A. Increased pH and decreased SaO2

14. A 51-year-old female patient with a history of asthma is

To get this one correct, you obviously need to have a basic

understanding of ventilator settings.

If a patient is struggling to initiate inspiration while being

mechanically ventilated in the assist-control mode, you should

70
automatically know that the sensitivity setting is probably set
incorrectly.

Sensitivity uses negative pressure in order to help trigger a breath

and you should strive to use the least amount of sensitivity
possible to trigger the ventilator into the inspiratory phase.
However, sometimes the patient will need a little more help, so
you may need to increase the sensitivity setting.

None of the other answer choices will help the patient initiate a
breath, so you know that the correct answer has to be C.

The correct answer is: C. Sensitivity

15. The physician has requested the insertion of a

For the TMC Exam, need to know the difference between a

nasopharyngeal and oropharyngeal airway.

In general, an oropharyngeal airway must be used in patients that

are unconscious or sedated. They are often used during bag-
mask ventilation to facilitate effective ventilation.

A nasopharyngeal airway can be used in patients with an intact

gag reflex and they help facilitate ventilation and frequent nasal
suctioning. They also help to minimize mucosal trauma.

They are not used in invasive mechanical ventilation and have no

role in either incentive spirometry or aerosol drug therapy.

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The correct answer is: B. Frequent suctioning

16. You would expect there to be difficultly establishing a patent

In general, you should know that it’s often difficult to establish an

airway in a patient with morbid obesity.

Aside from obesity, the other conditions that are generally

associated with a difficult airway include:

• Patients with a thick neck

• Patients with a large tongue
• Patients with a limit ability to move their head or neck

These anatomical differences simply just make it harder to insert

the endotracheal tube properly into the trachea. None of the
other answer choices really make sense in this situation, so you
know that the correct answer has to be B.

The correct answer is: B. A patient that is morbidly obese

17. A premature infant who is receiving positive pressure

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D. Chest transillumination

To get this one correct, you needed to be able to interpret the

signs that were given to you in the question and determine how
to treat the infant.

In this case, you should know that these signs indicate that a
pneumothorax may be present.

Transillumination is a procedure where you shine a light through

the infant’s chest in order to inspect for a pneumothorax. It is
performed in high-risk infants that are showing signs of
respiratory distress.

You should recommend this test to see if the infant has a

pneumothorax. When there is a “halo” sign through the neonate’s
chest wall, this confirms that a pneumothorax is present. In this
case, immediate chest tube insertion would be indicated.

On the other hand, if the transillumination test does not reveal a

pneumothorax but the infant still exhibits signs of respiratory
distress, you should recommend an immediate chest X-ray.

So while each of the tests that are listed in the answer choices
may be indicated, the best answer for this question is D.

The correct answer is: D. Chest transillumination

18. During the assessment of an adult patient who is receiving

mechanical ventilation, you suddenly notice the
simultaneous sounding of both the high pressure and low
volume alarms. What is the most likely cause of this finding?
A. There is a disconnection in the ventilator circuit
B. There is a leak in the ET tube cuff
C. There is a mucous plug in the ET tube

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D. The patient has developed pneumonia

To get this one correct, you needed to have a basic

understanding of ventilator modes and settings. This is a section
that you should spend a lot of time on when preparing for the
TMC Exam.

Since the patient is receiving volume-control ventilation, a high

pressure and low volume condition tells us that an obstruction is
present. Now you can simply look at the answer choices to
determine which one classifies as an obstruction.

A leak or disconnection would cause the low volume alarm to

sound but would decrease the PIP, which means the high
pressure alarm would not sound. Developing pneumonia would
not cause any sudden alarms, so we can rule that one out as well.

The correct answer is: C. There is a mucous plug in the ET tube

19. A 16-year-old male patient has been admitted to the

If you’ve studied up on your pathology, you should know right

away that this patient is showing signs of cystic fibrosis.

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Cystic fibrosis patients typically show signs of poor body
development, malnourishment, and foul-smelling stools. Also,
they usually have a productive cough with large amounts of
secretions. Digital clubbing is a sign of chronic hypoxemia, which
can be seen in cystic fibrosis as well.

Remember that cystic fibrosis is an obstructive lung disease. We

know that air trapping is a side effect of obstructive diseases, and
that is what causes the hyperresonant percussion note to be
heard.

None of the other answer choices make sense in this situation, so

we know that the correct answer has to be D.

The correct answer is: D. Cystic fibrosis

20. During the assessment of a 56-year-old female patient, you

To get this one right, you simply just needed to know what
jugular venous distention is a sign of.

JVD (jugular venous distention) presents when the jugular vein is

noticeably sticking out of the side of the neck. This is a sign of
right heart failure and it can also be seen during exhalation in
patients with an obstructive lung disease.

JVD would not be seen in any of the other answer choices, so we

know that the correct answer has to be D.

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The correct answer is: D. Right ventricular failure

21. An adult patient has performed an FVC maneuver with the

following results:

How would you interpret this flow-volume loop tracing?

A. Normal lungs
B. Small airway obstruction
C. Large airway obstruction
D. Restrictive disease

You will most likely see one of these flow-volume loop tracings on
the exam, so you will need to know how to interpret them. Not to
worry, we break in down for you inside of our Hacking the TMC
Exam video course, if you’re interested.

But in general, you can remember this rule of thumb. For

restrictive diseases the loop will appear tall and skinny. For
obstructive diseases, the loop will appear short and wide.

This one clearly appears to be tall and skinny, so you know that
the correct answer has to be D.

The correct answer is: D. Restrictive disease

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22. A 68-year-old male patient with COPD is receiving volume
control SIMV with the following settings:
Tidal volume 480 mL
Rate 12/min
Pressure support 10 cm H2O
PEEP 5 cm H2O
During a spontaneous breathing trial via T-tube, the patient’s
breathing rate increased drastically which required that he
be placed back on the ventilator. Which of the following
would you recommend during the next breathing trial?
A. Increase the sedation dosage
B. CPAP with pressure support via ET tube
C. CPAP without pressure support via ET tube
D. Extubate and provide BiPAP via full face mask

To get this one correct, you needed to be familiar with SBTs and
the process of weaning from mechanical ventilation.

There are 3 primary ways to perform an SBT:

• Simple T-piece without ventilatory support

• CPAP mode without pressure support
• CPAP mode with pressure support

Using CPAP with pressure support during an SBT can help the
patient overcome the extra work of breathing that is imposed by
the ET tube. It also helps to increase tidal volumes and prevent
tachypnea.

None of the other answer choices are indicated in this case, so

you know that the correct answer has to be B.

The correct answer is: B. CPAP with pressure support via ET tube

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23. An order was placed to collect a blood sample from a
neonatal patient in the NICU. It is determined that you
should obtain the sample from a capillary instead of an
artery. Which of the following is true regarding a capillary
blood gas sample?
A. To obtain the sample, you need to milk the puncture site
B. The sample must be drawn from the first drop of surface
blood
C. The pH and PCO2 correlate well with arterial blood
D. The puncture normally is performed on the ball of the
foot

To get this one correct, you needed to be familiar with the heel-
stick procedure in infants.

The lateral part of the heel is the most common site for collecting
a capillary blood sample in infants. After you puncture the infant’s
heel, you should wipe away first drop of blood and observe for
free flow before collecting a sample. You do not need to squeeze
the heel.

Because the infant’s arteries are so tiny, it’s very difficult to stick
them with a needle. So that is why we use capillary blood from
the heel instead. But there are some differences in the ABG
values of capillary blood when compared to arterial blood. And
you must know these difference for the TMC Exam.

• Capillary blood correlates well with the pH and PaCO2 values

of arterial blood. Therefore, it is useful ONLY for assessing the
acid-base status.
• Capillary blood does not correlate well with the PaO2 values,
so you should never use a capillary sample to assess the
infant’s oxygenation status.

So after going through all the answer choices, you can determine
that the correct answer has to be C.

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The correct answer is: C. The pH and PCO2 correlate well with
arterial blood

24. A newly admitted adult patient with pneumonia has an

To get this one right, you needed to have a basic understanding

of pneumonia as well as the information that is provided in the
answer choices.

A diffusion defect is found in patients with pulmonary fibrosis—

not pneumonia. Patients with pneumonia usually show signs of
hyperventilation, not hypoventilation, so we can rule those two
out right away. Fever and chills are both signs of pneumonia but
they are not related to the cause of the patient’s hypoxemia.

For the TMC Exam, I want you to always remember that

consolidation is associated with pneumonia. So once you read the
question and saw that the patient has alveolar consolidation, you
should automatically know that it is the correct answer.

The correct answer is: C. Alveolar consolidation

25. A 59-year-old female postoperative patient is recovering

from surgery that occurred less than 24 hours ago. Which of
the following would you recommend for this patient in order
to prevent atelectasis?

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A. Albuterol via SVN four times daily
B. Pursed-lip breathing as needed
C. Inspiratory resistance exercises three times daily
D. Incentive spirometry 10 times per hour

In order to treat or prevent atelectasis in postoperative patient,

incentive spirometry or some form of hyperinflation therapy is
recommended. Incentive spirometry should be your first choice
as long as the patient is able to perform the maneuver with
proper technique. If they can’t, then you would recommend IPPB
instead.

For the newest version of the TMC Exam, the term IPPB may not
be used any longer. Instead, it may be referred to as a
mouthpiece positive pressure ventilator. Just keep that in mind.

Airway clearance therapy and early ambulation are also helpful in

preventing atelectasis in postop patients as well. And, in order to
be most effective, an incentive spirometry maneuver should be
performed at least 10 times per hour.

None of the other answer choices really make sense in this

situation, so we know that the correct answer has to be D.

The correct answer is: D. Incentive spirometry 10 times per hour

26. A 63-year-old male patient with a tracheostomy is being

mechanically ventilated in the ICU. Upon assessment, you
noticed that as the patient coughs, blood and secretions
were blown back into the circuit. What action should you
take at this time?
A. Flush the blood out of the circuit with normal saline
B. Sedate the patient to prevent more coughing
C. Nebulize a local anesthetic to reduce surgical pain
D. Replace the circuit with a new one

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Please remember that, according to the AARC, you should only
break a ventilator circuit when it is visibly soiled.

So in this case, the patient has coughed blood and secretions into
the circuit which means that it is visibly soiled and needs to be
changed with a new circuit.

There is no indication to sedate the patient or provide a nebulized

local anesthetic so you know that the correct answer has to be D.

The correct answer is: D. Replace the circuit with a new one

27. A 56-year-old male patient has been admitted and

In order to get this one correct, you needed to know that it’s
important to monitor the inspiratory muscle strength of patients
with neuromuscular conditions, including Guillain-Barré
syndrome. You need to closely monitor the following:

• Tidal volume
• Vital capacity
• Maximum inspiratory pressure

If said patient’s inspiratory capacity were to drop too low,

intubation and mechanical ventilation would be indicated.

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None of the other answer choices are critically important in
regards to monitoring a patient with Guillain-Barré syndrome, so
we know that the correct answer has to be B.

The correct answer is: B. Inspiratory capacity

28. A 64-year-old female patient with a history of CHF has been

The first thing about the question that you should notice is the
patient has pink, frothy secretions. We can always interpret this a
pulmonary edema which makes sense because the questions
states their history of CHF.

Now you can interpret the ABG results which show fully
compensated respiratory alkalosis with severe hypoxemia. It’s to
be expected for patients with pulmonary edema to have
oxygenation issues.

So to help the patient, you need to provide a high FiO2 to improve

oxygenation. But because of the excess fluid in the lungs and
alveoli, the patient needs continuous positive pressure in order to

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help open them up for oxygenation. This is why CPAP would be
needed instead of a nonrebreathing mask.

The correct answer is: C. Continuous positive airway pressure

(CPAP)

29. While attempting to wean an adult patient from mechanical

This one is tricky because at first glance, you probably read the
question and thought that the patient is breathing way too fast.
But keep in mind that, during weaning, it's normal for there to be
a modest increase in respiratory rate. This is common and
generally should be tolerated up to a maximum of 30–35 breaths
per minute.

In this case, the option is to increase high respiratory rate alarm

up to 30–35 breaths per minute and continue to monitor the
patient.

It's not uncommon to increase the pressure support level in a

situation like this, but since this question doesn't give you the
pressure support level, you can't be sure. So that rules out A.

None of the other answer choices really make sense in this

situation, so you know that the correct answer has to be C.

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The correct answer is: C. Increase the high rate alarm to 30–35

30. A 57-year-old female patient who was admitted and

First you need to interpret the ABG results. The acid-base status
shows that the patient has partially compensated respiratory
acidosis. The other thing that should stand out is that the PaO2 is
severely low, so you know that the patient needs supplemental
oxygen.

For a patient with COPD (emphysema), you must be careful not

to give too much oxygen in order to avoid oxygen-induced
hypercapnia. Remember, it’s acceptable for COPD patients to
have a PaO2 in the 55-70 torr range and an SpO2 in the 88 to 93%
range.

There is no indication for a bronchodilator and a nonrebreather

would provide too much oxygen for this patient. In this case, you
need to be able to provide a precise low FiO2, and an air-
entrainment mask can help you do just that.

The correct answer is: B. Air-entrainment mask at 28%

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31. A 43-year-old female patient in the emergency department
was just orally intubated with an endotracheal tube. Which
of the following would you INITIALLY recommend in order to
confirm that the tube is in the proper position?
A. Auscultate the patient’s chest and abdomen
B. Perform a STAT chest x-ray
C. Use capnography to verify exhaled CO2
D. Observe chest wall movement

For the TMC Exam, you must know how to confirm that the tube
is in the proper position. This question is tricky because the
answer choices are all correct methods of confirming tube
placement. The question requires that you know which one to
perform FIRST.

So immediately after intubation, the first thing you should do is

auscultate the lungs to listen for bilateral breath sounds. You
should auscultate the abdomen as well and there should be no
air movement, otherwise, you can suspect that the tube is in the
esophagus instead of the trachea.

All of the answer choices should be performed, just know that

auscultation is what should be performed FIRST. That means that
the correct answer has to be A.

The correct answer is: A. Auscultate the patient’s chest and

abdomen

32. While assisting with the delivery of a newborn infant, the

physician asks for you to obtain an Apgar score on the
patient. Which of the following ranges is considered to be a
normal score?
A. 1-4

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B. 4-7
C. 7-10
D. 10-13

To get this one correct, you simply needed to be familiar with the
Apgar score ranges.

An Apgar score is a quick way to evaluate an infant’s condition

immediately after birth. The evaluation should be performed 1
minute and 5 minutes after birth. Apgar stands for:

• Appearance
• Pulse
• Grimace
• Activity
• Respirations

You can take the infant’s score using these parameters and act
accordingly. An Apgar score of 7-10 is considered to be a normal
score.

Also, you should remember that an infant with an Apgar score of

less than 4 is an emergency and should be resuscitated.

The correct answer is: C. 7-10

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In general, this is something that you should remember for the
TMC Exam when it comes to confirming proper ET tube
placement:

The most likely reason that no breath sounds are heard on the left
side is because the ET tube was pushed too far down into the
trachea and it slid into the right mainstem bronchus.

In this case, you should deflate the cuff and pull back on the tube
1–2 cm and reassess breath sounds. If you hear bilateral breath
sounds at this point, it confirms that the tube was inserted too far
but is now in the correct place.

There is no need to reintubate the patient and you do not need to

insert a large bore needle. A chest x-ray is helpful for confirming
tube placement, but in this case, the FIRST thing you should do is
pull back on the tube and reassess the patient.

The correct answer is: B. Withdraw the endotracheal tube by 1–2

34. A 58-year-old female patient has arrived in the emergency

department with an extremely deep and fast breathing rate.
Which of the following best classifies this type of breathing?
A. Apneustic breathing
B. Kussmaul breathing
C. Biot’s breathing
D. Cheyne-Stokes breathing

You must know the breathing patterns for the TMC Exam. You
will see (at least) one question about them.

When you have a patient that is breathing deep and fast, you
should immediately know that this is classified as Kussmaul
breathing.

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For Kussmaul breathing, they will have an increased respiratory
rate and depth with an irregular rhythm. It is a labored form of
breathing that is usually associated with diabetic ketoacidosis.

Here are the other breathing patterns to be familiar with:

• Eupnea – Normal breathing.

• Hypopnea – Shallow breathing.
• Hyperpnea – Deep breathing.
• Bradypnea – Slow breathing.
• Tachypnea – Fast breathing.
• Cheyne-Stokes – Deep and/or shallow breaths with periods
of apnea. Seen in stroke and head trauma patients.
• Biot – Rapid breaths with periods of apnea. Seen in
neurological diseases.
• Agonal – Labored breathing or gasping.
• Apnea – No breathing.

So by looking at the answer choices, we could quickly determine

that this one has to be B.

The correct answer is: B. Kussmaul breathing

35. A 71-year-old male patient is receiving ventilatory support

The question tells us that the patient has a fever and increased
white cell count. That means that you needed to know that a

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normal white blood cell count is between 5,000–10,000/mm3. This
suggests that an infection is present.

The changes in the patient’s sputum also indicates that an

infection is present. So in this case, you need to obtain a sputum
sample for culture and sensitivity in order to identify what
organism is present so that the infection can be treated.

None of the other answer choices really make sense in this

situation, so you know that the correct answer has to be D.

The correct answer is: D. Obtain a sputum sample for culture and
sensitivity

36. While reviewing the medical record of a 55-year-old female

To get this one right, you needed to be familiar with the FEV1/FVC
ratio and what is means. This ratio is a measurement of the
percentage of a patient's vital capacity that can be expired in the
first second of expiration. People with normal lungs can exhale at
least 70% of their vital capacity within the first 1 second (FEV1).

When you see a reduced FEV1/FVC ratio, that should

automatically tell you that an obstructive disease is present. Now
all you have to do is look through the answer choices and select
the one that is an obstructive disease.

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Using the CBABE mnemonic, you can quickly determine that the
correct answer is C. We dive deeper into CBABE and the
obstructive diseases inside of our Hacking the TMC Exam video
course, so definitely check it out if you’re interested.

The correct answer is: C. Chronic asthma

37. A 60-year-old female patient who in orally intubated is going

To get this one correct, you simply needed to be familiar with the
indications of a failed SBT. They are:

• Inadequate gas exchange

• An increase in PaCO2 ≥ 10 torr
• Unstable hemodynamics
• Unstable ventilatory pattern

During an SBT, it’s normal for a patient’s heart rate and

respiratory rate to increase. In this case, however, it’s not a big
concern because the heart rate stayed below 120/min and the
respiratory rate stayed below 30/min.

The PaCO2 increased as well, but again, not enough for there to
be a huge concern.

The oxygen, however, dropped significantly — enough so that you

should immediately stop the trail and return the patient back to
full ventilatory support.

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The correct answer is: D. A decrease in SpO2 from 92% to 83%

38. The physician has requested the dynamic compliance

measurement for an adult patient who is receiving
mechanical ventilation. This value can be obtained by
dividing the patient’s tidal volume by which of the following:
A. (Pplat – PEEP)
B. (PIP – PEEP)
C. (PIP – Paw)
D. (Paw – Pplat)

To get this one right, you simply needed to know the formulas for
static and dynamic compliance. Just an FYI, as you may have
suspected, you will need to know these for the TMC Exam as well.

Here are the formulas:

• Static compliance = Exhaled VT / (Pplat – PEEP)

• Dynamic compliance = Exhaled VT / (PIP – PEEP)

Again, be sure to remember these formulas for the exam. But for
this question, as long as you knew the formulas, you could easily
determine that the correct answer is B.

The correct answer is: B. (PIP – PEEP)

39. A 63-year-old male patient was admitted to the ICU. Upon

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D. Consolidation is present in the right lower lobe

In order to get this one correct, you needed to be familiar with

bronchial breath sounds. You needed to know that they are
normal when heard over the trachea. However, if you hear
bronchial breath sounds over the lobes of the lungs, this is an
abnormal finding.

A pneumothorax or pleural effusion are not identified by

bronchial breath sounds, so we can rule those out immediately.

Bronchial breath sounds are commonly heard over the lungs in

patients with pneumonia. And for the TMC Exam, you must
remember that patient’s with pneumonia will likely have
consolidation. Taking that into consideration, you can determine
that the correct answer has to be D.

The correct answer is: D. Consolidation is present in the right

lower lobe

40. An alert 59-year-old male patient is orally intubated with an

Remember that, when weaning a patient from full ventilatory

support, it’s common to use the CPAP mode with pressure
support. So in this case, before terminating the breathing trial,

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your first action should be to add pressure support in order to
assist with the patient’s breath.

Doing so will lower the work of breathing for the patient which
will typically decrease the respiratory rate. It will also decrease the
need for the patient to use their accessory muscles while
breathing as well.

There is no indication to increase the FiO2 and you wouldn’t want

to extubate yet because the patient has not passed the SBT at
this point. So by breaking down the question, we can determine
that the best answer has to be C.

The correct answer is: C. Apply 5-10 cm H2O of pressure support

41. After the administration of aerosolized albuterol to a 38-year-

old female patient, which of the following side effects would
you expect?
A. Hypotension
B. Bradycardia
C. Bronchospasm
D. Shaking and tremors

To get this one right, you simply just needed to know the side
effects of beta-2 adrenergic bronchodilators, such as albuterol.

Albuterol usually causes tachycardia, not bradycardia, so we can

rule that one out. Albuterol is used to treat bronchospasm, so if
definitely does not cause bronchospasm which means that we
can rule that one out as well. Hypotension is also not a side effect
of albuterol.

Albuterol does, however, sometimes cause tremors, shakiness,

and nervousness in patients.

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So by using what we know about albuterol, as well as the process
of elimination, we know that the correct answer has to be D.

The correct answer is: D. Shaking and tremors

42. A 23-year-old male patient with a severe head cold is

The first thing you should note about the question is that an SpO2
of 85% indicated hypoxemia. You must read these types of
questions carefully because it gives you an important detail about
the patient which is: He has a severe head cold.

The most likely issue here is that the patient has a stuffy nose,
therefore is not able to take in the oxygen through the nasal
cannula.

So with that said, the best action to take at this time is to switch
the patient to a simple mask so that he will be able to breathe in
the oxygen through his mouth. The oxygen flow with a simple
mask for this patient can be set at 5–7 L/min.

This one was tricky, but after breaking it down, we can determine
that the correct answer is C.

The correct answer is: C. Switch to a simple mask

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43. A stable adult patient who is receiving mechanical
ventilation displays the following results:
pH 7.49
PaCO2 29 mm Hg
HCO3 24 mEq/L
BE +1
PaO2 87 mm Hg
SaO2 96%
Which of the following would you recommend?
A. Add 10 cm H2O PEEP
B. Increase the minute ventilation
C. Decrease the tidal volume
D. Maintain the current settings

To get this one correct, you needed to be able to interpret the

ABG results and make the appropriate changes to the ventilator
settings. These are the types of questions you will see on the TMC
Exam. So let’s break this one down.

The pH is increased which means alkalosis. The PaCO2 is

decreased. The HCO3, BE, PaO2, and SaO2 are all within their
normal ranges. This means that the patient has acute respiratory
alkalosis. In other words, the patient is hyperventilating.

When a patient is hyperventilating, or breathing too fast, you

need to decrease the minute ventilation. You can do that by
either decreasing the rate or by decreasing the tidal volume.

By looking at the answer choices, only one of those two options

are listed which means that the correct answer has to be C.

The correct answer is: C. Decrease the tidal volume

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44. A 68-year-old female patient in the ICU is receiving
mechanical ventilation but appears to be breathing
asynchronously with the ventilator. Which of the following
medications would you recommend?
A. Fluoxetine (Prozac)
B. Lorazepam (Ativan)
C. Dextroamphetamine (Dexedrine)
D. Cisatracurium (Nimbex)

To get this one correct, you needed to have a basic

understanding of the medications that 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 those out right away.

Lorazepam (Ativan) 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:

• Alprazolam (Xanax)
• Diazepam (Valium)
• Midazolam Versed)
• Propofol (Diprivan)

So by using what we know about mechanical ventilation

pharmacology, as well as the process of elimination, you know
that the correct answer has to be B.

The correct answer is: B. Lorazepam (Ativan)

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45. A 70-year-old male patient with COPD is receiving
ventilatory support in a volume-controlled mode. Upon
assessment, the high pressure alarm suddenly begins to
sound. Which of the following would recommend?
A. Increase the flow setting
B. Increase the pressure limit setting
C. Suction the airway
D. Remove air from the endotracheal tube cuff

For the TMC Exam, you must know the common reasons that
would cause the high pressure alarm to sound. Some examples
include:

• An obstruction or mucous plug

• Any factor that increases airway resistance or decreases
compliance
• Secretions
• A kink in the ET tube

We actually cover this topic in more details inside of our Hacking

the TMC Exam video course, so check that out if you’re interested.

So if you know the causes of a high pressure alarm, you can

determine the solution. By looking through the answer choices,
you can see that suctioning the airway is an option. Clearing
secretions will decrease the patient’s peak pressure back down
within the normal range, which should stop the high pressure
alarm from sounding.

None of the other answer choices really make sense in this

situation, so you know that the correct answer is C.

The correct answer is: C. Suction the airway

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46. A 55-year-old female patient with pneumonia is receiving
oxygen via nasal cannula at 4 L/min. The physician asks for
your suggestion on the best way to evaluate the patient’s
overall ability to breathe. Which of the following would you
recommend?
A. Performing pulse oximetry
B. Drawing an arterial blood sample for analysis
C. Performing a forced vital capacity measurement
D. Performing a full set of pulmonary function tests

To get this one right, you simply needed to have a basic

understanding of the purpose drawing an ABG. The results of an
ABG can help us assess the patient’s ability to oxygenate and
ventilate — meaning that it’s used to assess their ability to
breathe.

Pulse oximetry only looks at the patient’s oxygenation status—

not the ventilation status. PFTs do not give any information on
the PaO2 or PaCO2 levels, so we can rule out C and D as well.

So by using what we know about ABGs, as well as the process of

elimination, you can determine that the correct answer is B.

The correct answer is: B. Drawing an arterial blood sample for

analysis

47. While reviewing the chest x-ray of a 57-year-old male patient,

you note that there is blunting of the left costophrenic angle.
It’s also noted that the patient has a history of CHF. Which of
the following best describes this patient’s condition?
A. There is a pneumothorax on the left side
B. There is a pleural effusion on the left side
C. There is pulmonary edema in the left lung
D. There is pneumonia in the left lower lobe

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Please remember this for the TMC Exam: When there is blunting
of the costophrenic angle on a chest x-ray, you should
automatically know that a pleural effusion is present.

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.

The correct answer is: B. There is a pleural effusion on the left side

48. A 69-year-old male patient is undergoing a spontaneous

To answer this one correctly, you have to know the indications of

a successful weaning trial. Some of those indications include:

• SpO2 ≥ 85-90% or PaO2 ≥ 50-60 torr

• pH ≥ 7.30
• An increase in PaCO2 ≤ 10 torr
• An increase in heart rate < 20/min from original or <120-
135/min
• Systolic BP < 180-200 mmHg and > 90 mmHg

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• Respiratory rate ≤ 30/min
• No accessory muscle usage

So after reviewing the answer choices, we can see that only one
would be deemed acceptable while weaning.

An SpO2 of 81% is dangerously low. Scalene muscle activity means

that the patient is using their accessory breathing muscles which
is a sign of respiratory distress. And a systolic blood pressure of 76
is dangerously low as well.

However, an increase in heart rate from 97 to 115 isn’t anything

out of the ordinary. It’s is typical for the heart rate to increase
some during an SBT.

So we know that the correct answer has to be C.

The correct answer is: C. An increase in heart rate from 97 to

115/min

49. An adult patient with fluid overload was given a dose of

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.

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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.

So by using what we know about the administration of Lasix, as

well as the process of elimination, you know that the correct
answer has to be D.

The correct answer is: D. Check the patient’s potassium level

50. After the extubation of a 54-year-old male patient, he begins

to complain of a sore throat. Which of the following drugs
would you recommend for this patient?
A. Levalbuterol
B. Isoetharine
C. Racemic Epinephrine
D. Acetylcysteine

For the exam, you should remember that inspiratory stridor is a

sign of post-extubation laryngeal edema. This explains why the
patient has a sore throat.

The best option to treat inspiratory stridor and post-extubation

edema is to provide cool mist aerosol and racemic epinephrine.

None of the other medications that are listed would be helpful in

this situation, so you know that the correct answer has to be C.

The correct answer is: C. Racemic Epinephrine

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51. An oropharyngeal airway is being used on a 39-year-old male
patient. Within two minutes after insertion, the patient
begins to gag. Which of the following would you
recommend?
A. Perform the head-tilt, chin-lift maneuver
B. Insert a bite block
C. Remove the airway
D. Replace the current tube with a smaller airway

To get this one right, you needed to have a basic understanding

of oropharyngeal airways. Remember that oropharyngeal airways
are always contraindicated in patients that are awake, conscious,
and have an intact gag reflex.

If a patient gags when an oropharyngeal airway is inserted, you

should remove the airway immediately and consider using a
nasopharyngeal airway instead.

For the TMC Exam, you must remember that for oropharyngeal
airways, the patient must be unconscious. However, for
nasopharyngeal airways, the patient can be conscious with an
intact gag reflex.

None of the other answer choices make sense in this situation, so

you know that the correct answer has to be C.

The correct answer is: C. Remove the airway

52. A 66-year-old female was admitted to the emergency

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respiratory acidosis. Which of the following is the most likely
problem for this patient?
A. Pneumonia
B. CHF
C. Exacerbation of COPD
D. Myocardial infarction

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.

So by using what we know about COPD, as well as the process of

elimination, we know that the correct answer has to be C.

The correct answer is: C. Exacerbation of COPD

53. A 51-year-old male patient is receiving volume-controlled A/C

mechanical ventilation while being monitored with a
continuous pulse oximeter. He was briefly removed from the
ventilator so that suctioning could be performed and his
SpO2 dropped from 95% to 88%. Which of the following
would you recommend?
A. Initiate PEEP at 5 cm H2O
B. Increase the FiO2 to 80%

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C. Perform bedside hemodynamic monitoring
D. Change to an in-line suctioning catheter

When you have a patient on the ventilator, whenever possible,

you should always try to use a closed-system or in-line suctioning
catheter. Not only does this help to prevent VAP, is also prevents
the patients SpO2 from dropping when briefly removed from the
ventilator.

PEEP is not necessary in this case, nor is increasing the FiO2.

Hemodynamic monitoring isn’t necessary either which means
that the correct answer has to be D.

The correct answer is: D. Change to an in-line suctioning catheter

54. During the assessment of an adult patient with chronic

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.

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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.

None of the other answer choices really make sense in this

situation, so we know that the correct answer has to be D.

The correct answer is: D. Air trapping during a forced exhalation

55. The physician has ordered acetylcysteine for a 66-year-old

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.

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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. So by breaking it down, we can
determine that the correct answer has to be B.

The correct answer is: B. Nasotracheal suctioning after the

treatment

56. On discharge, a 52-year-old male patient was prescribed an

inhaled corticosteroid via MDI for two puffs twice a day. In
order to decrease the likelihood of an oral infection, which of
the following would you recommend?
B. An antibiotic prescription
C. Decrease the frequency to once per day
A. A Bronchodilator before the corticosteroid
D. Rinse the mouth after inhalation

To get this one right, you simply needed to be aware that oral
candidiasis (thrush) is a potential adverse effect of aerosolized
steroids.

With that said, this problem can easily be avoided simply by

having the patient rinse out their mouth with water or
mouthwash after using the MDI.

None of the other answer choices really make sense in this

situation, so we could quickly determine that the correct answer
has to be D.

The correct answer is: D. Rinse the mouth after inhalation

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57. A 60-year-old female patient is receiving assist-control
mechanical ventilation. Which of the following is the most
common problem associated with this ventilatory mode?
A. Hypoventilation
B. Hyperventilation
C. The need for neuromuscular paralysis
D. Increased work of breathing

To get this one right, you have to have a basic understanding of

the assist-control mode of ventilation. While in assist-control,
patients are able to trigger machine breaths at a higher rate than
the rate that is set on the ventilator.

So in some cases, this can cause the patient to develop

tachypnea, which means that they are breathing too fast — aka —
hyperventilation.

This most commonly occurs in patients suffering from pain,

anxiety, and other causes of acute distress. Also note that
tachypnea in this mode can cause breath stacking or auto-PEEP,
which is definitely something that we want to avoid.

None of the other answer choices really make sense in this

situation, so we know that the correct answer has to be B.

The correct answer is: B. Hyperventilation

58. During the ventilator check of an adult patient who weighs

77 kg, you note the following settings:
Exhaled tidal volume 550 mL
PIP 35 cm H2O
High pressure limit 64 cm H2O
Low pressure alarm 25 cm H2O
Low tidal volume alarm 500 mL

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Which of the following changes should be made at this
time?
A. Increase the set tidal volume to 700 mL
B. Increase the low tidal volume alarm to 600 mL
C. Decrease the high pressure limit to 45-50 cmH2O
D. Decrease the low pressure alarm to 10 cmH2O

To answer this one correctly, you needed to have a basic

understanding of ventilator alarms. You should definitely spend
some time learning about them before taking the TMC Exam.

For this patient, all of the settings are acceptable except for the
high pressure limit. In general, it should be set 10-15 cmH2O
above the PIP.

So in this case, it is set too high which increases the chances of

barotrauma or lung injury. None of the other answers choices
really make sense in this situation, so we know that the correct
answer has to be C.

The correct answer is: C. Decrease the high pressure limit to 45-
50 cmH2O

59. An adult patient undergoing a mild asthma attack was

admitted to the ER. Which of the following ABG results
would you expect to see?
A. pH = 7.30 PaCO2 = 49 torr PaO2 = 61 torr
B. pH = 7.32 PaCO2 = 51 torr PaO2 = 51 torr
C. pH = 7.46 PaCO2 = 47 torr PaO2 = 52 torr
D. pH = 7.49 PaCO2 = 30 torr PaO2 = 62 torr

To get this one right, you needed to be familiar with the typical
ABG results for patients with asthma.

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For a mild asthma attack, you would expect the results to show
respiratory alkalosis with hypoxemia. That is because, for a mild
attack, it’s normal for the patient to be hyperventilating due to
the shortness of breath. Now we just have to go through the
answer choices to find the set of results for this interpretation.

We can automatically rule out A and B because the pH is

decreased, which means acidosis is present. C shows alkalosis,
however, the PaCO2 is elevated which means that it’s a metabolic
issue—not respiratory alkalosis.

For option D, the pH is increased and the PaCO2 is decreased,

which shows respiratory alkalosis. So by breaking down the
question and using the process of elimination, we can determine
that the correct answer has to be D.

The correct answer is: D. pH = 7.49 PCO2 = 30 torr PaO2 = 62 torr

60. A 61-year-old female patient has an FEV1/FVC ratio that is

Let’s break this one down. The patient has a reduced FEV1/FVC
ratio which automatically tells us that an obstructive disease is
present.

BUT, they also have a reduced FVC as well. This tells us that a
restrictive disease is also present.

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So combined, this patient has both an obstructive and restrictive
disease.

The correct answer is: D. Combined obstructive and restrictive

lung disease

61. Which of the following tidal volume settings for mechanical

ventilation would be most appropriate for a 5'2" female
patient with normal lungs?
A. 200 mL
B. 400 mL
C. 600 mL
D. 700 mL

The first thing we need to do is calculate the patient’s ideal body

weight:

IBW = 50 kg + (2 x Number of Inches over 5 feet)

IBW = 54 kg

Then we can use the range of 5 to 10 mL/kg in order to determine

the appropriate tidal volume range for this patient. In this case, it
would be 270 to 540 mL.

By looking at the answer choices, we can rule out A, C, and D

automatically because the value falls outside of the range that we
calculated.

The correct answer is: B. 400 mL

62. A 15-year-old male patient who has been diagnosed with

asthma is in need of medications to help prevent future

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asthma attacks. All of the following drugs would be helpful
EXCEPT:
A. Cromolyn sodium
B. Zafirlukast
C. Epinephrine
D. Zileuton

To get this one right, you needed to have a basic understanding

of the drugs that are listed in the answer choices, as well as which
medications are used to treat asthma.

Cromolyn sodium, Zafirlukast, and Zileuton are all prophylactic

agents that are used to help prevent asthma attacks.

Epinephrine is a drug that is given during CPR to increase the

patient’s heart rate and blood pressure. Although it technically is
an ultra-short acting bronchodilator, it’s not used as a
preventative medication for asthma attacks.

So by using what we know about asthma medications, as well as

the process of elimination, you know that the correct answer has
to be C.

The correct answer is: C. Epinephrine

63. The physician has chosen to use the SIMV mode of

This one is simple as long as you know the difference between

SIMV and Assist/Control ventilation.

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Each mode of ventilation has advantages and disadvantages over
one another. One major advantage of SIMV is that it requires the
patient to do a lot of the work, so it maintains the patient’s
respiratory muscle strength and avoids muscular atrophy.

Assist/Control provides full ventilatory support but also allows the

patient to control the frequency by taking additional breaths,
meaning that hyperventilation can sometimes be an issue.

SIMV does not prevent hyperventilation, nor does it increase the

pleural pressure or increase the need for sedation.

The correct answer is: A. SIMV maintains respiratory muscle

strength

64. A newly admitted adult patient in the emergency

Please remember this for the TMC Exam! Whenever you see a
patient with pink frothy secretions, you should automatically
know that they have pulmonary edema. And more specifically,
cardiogenic pulmonary edema, which means that they have left
heart (ventricular) failure or CHF.

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

The correct answer is: C. Left ventricular failure

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65. An adult patient has arrived to the emergency department
in respiratory distress with diminished breath sounds. The
patient has a history of asthma. After continuous
bronchodilator therapy, wheezing is now heard during
auscultation. This change suggests which of the following?
A. The onset of pneumonia
B. The development of a pneumothorax
C. The improvement of air flow
D. The development of pulmonary edema

In general, whenever a patient is having an asthma attack with

diminished breath sounds — this is a sign of severe
bronchoconstriction.

Although we typically think of wheezing as a bad sign, in this

case, it actually means that there has been some bronchodilation
and improvement of air flow.

When the patient arrived, their breath sounds were diminished

which means that little or no air was moving during breathing.
Again, this is a sign of severe bronchoconstriction which occurs
during an asthma attack.

But now that you hear wheezing, it suggests that the patient’s air
flow has improved and their airways have opened up some
thanks to the bronchodilator therapy.

The correct answer is: C. The improvement of air flow

66. A 71-year-old female patient is intubated and receiving

positive-pressure ventilation. In order to prevent barotrauma,
you should strive to keep the plateau pressure below which
of the following thresholds?

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A. 20 cm H2O
B. 30 cm H2O
C. 40 cm H2O
D. 50 cm H2O

Plateau pressure can be obtained by checking the pressure at an

end-inspiratory pause. In order to prevent barotrauma and the
risk of a lung injury, you should try to maintain the plateau
pressure below 30 cm H2O.

If the plateau pressure were to increase greater than 30 cm H2O,

this is an indication that you should switch the patient from a
volume-cycled mode to a pressure-cycled mode.

So to get this one right, you simply just needed to have a basic
understanding of plateau pressure.

The correct answer is: B. 30 cm H2O

67. While monitoring a 67-year-old male patient who is

This is a tricky one. Remember, for the TMC Exam, sometimes the
question may appear to have two correct answers — BUT — you
have to choose the BEST answer of the two. This is one of those
questions.

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The question tells us that the patient is receiving volume
controlled ventilation. In this mode, when there is an increase in
peak pressure without an increase in plateau pressure, it’s usually
because the airway resistance has increased. The question states
that the patient is wheezing, which is what is causing the airway
resistance to increase.

So the FIRST thing you would want to do for this patient is to

administer a fast-acting, bronchodilator such as albuterol to
relieve bronchospasm. By doing so, the wheezing should stop
and the peak pressure should decrease back to the original level.

A lot of times, when there is an increase in peak pressure, the first

thing we think to do is suction the patient’s airway. But in this
case, because of the wheezing, the best action to take is to
provide a bronchodilator.

The correct answer is: D. Administer a bronchodilator

68. A 61-year-old female was orally intubated and is now

You absolutely must know the proper position of the ET tube for
the exam. You will see questions about it. There are a few ways to
confirm proper positioning.

When looking at a chest x-ray, a properly positioned ET tube

should appear about 1.5 inches above the carina. This means that

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the tip will sit between the 2nd and 4th thoracic vertebra in the x-
ray.

In adults, the ET tube should be inserted 3–4 cm through the

vocal cords. Another mark to look for is this: The tube should be
inserted 21–24 cm at the patient’s lip, which you can verify by the
markings on the tube.

So as long as you knew how to determine proper ET tube

placement, you could easily come up with the correct answer.

The correct answer is: D. Between the 2nd and 4th thoracic
vertebra

69. An adult patient was admitted to the emergency

department with an opiate narcotic overdose. The doctor
asks for your recommendation to help reverse the effects of
the drugs and enable the patient’s breathing to return to
normal. Which of the following medications would you
recommend?
A. Naloxone (Narcan)
B. Fentanyl (Sublimaze)
C. Indomethacin (Indocin)
D. Vecuronium (Norcuron)

In order to get this one correct, you needed to know what

medication is given to reverse a narcotic drug overdose.

Narcan is an opioid antagonist that can reverse narcotic

depression that is induced by the overdose of natural and
synthetic opioid narcotics such as heroin and morphine.

So when a patient arrives to the ER with an apparent drug

overdose, you always want to recommend Narcan in cases such

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as this. You will definitely see a question similar to this one on the
TMC Exam.

None of the other answer choices really make sense in this

situation, so we know that the correct answer has to be A.

The correct answer is: A. Naloxone (Narcan)

70. Immediately after intubation, a 64-year-old female patient is

You absolutely have to know this for the exam because, I promise,
you will see a question on this topic. Asymmetrical chest
movement along with no breath sounds on the left side indicates
that the ET tube was pushed too far down into the trachea and it
slid into the right mainstem bronchus.

Without even looking at any of the other answer choices, you

should be able to determine that the correct answer is C.

The correct answer is: C. Right mainstem intubation

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71. An adult patient with a tracheostomy in place is receiving
ventilatory support in the volume-control SIMV mode with a
set rate of 10/min. Upon assessment, the patient has started
to use their accessory muscles during spontaneous breaths.
Which of the following would you recommend?
A. Increase the level of pressure support
B. Decrease the SIMV rate to 8/min
C. Switch to the patient to pressure-control SIMV
D. Switch the patient to a pressure-limited mode

There’s a lot going on in this question, so let’s break it down.

An increase in the of usage accessory muscles indicates dyspnea

or an increased work of breathing. This can likely be attributed to
the resistance caused by the tracheal airway. You can help the
patient overcome this resistance by increasing the pressure
support level.

If you were to decrease the rate, this would force the patient to
take more spontaneous breaths, which would make matters
worse. Switching to a pressure controlled or limited mode isn’t
going to do any good either.

The correct answer is: A. Increase the level of pressure support

72. While selecting the initial ventilatory settings for a newly

intubated patient, which of the following is most important?
A. The type of device that is being used
B. The quality and amount of nursing supervision
C. The patient’s size and clinical condition
D. The amount of spontaneous ventilatory effort

When setting up a new patient on the ventilator, the first step is

to establish the initial settings.

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For the TMC Exam, you must remember that the initial settings
are dependent on the patient’s size and clinical condition. For
example, you can use the patient’s ideal body weight in order to
determine the initial tidal volume setting.

The type of device does not matter in this case, nor does the
amount of nursing supervision.

So by using what we know about ventilator settings, as well as the

process of elimination, we can determine that the correct answer
has to be C.

The correct answer is: C. The patient’s size and clinical condition

73. A 60-year-old male patient is receiving ventilatory support in

This is a simple question about making the proper ventilator

changes according to the patient’s ABG results. This is something
that you absolutely must know how to do in order to pass the
TMC Exam.

In this case, the patient is clearly hypoventilating because the

PaCO2 is elevated outside of the normal range. So you can adjust
the ventilator settings by increasing the frequency to blow off
some of that excess CO2. There’s no indication to increase the
FiO2 or mechanical deadspace, and decreasing the tidal volume
would only make matters worse.

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The correct answer is: A. Increase the frequency

74. An ABG was collected on a 71-year-old female patient with a

history of chronic COPD. After reviewing the results, which of
the following values would be most reflective of the severity
of the patient's chronic condition?
A. pH
B. PaCO2
C. HCO3-
D. PaO2

This one is a little tricky. Since the question tells us that the
patient has chronic COPD, we can assume that they are a CO2
retainer. So with that said, we should expect their PaCO2 levels to
be increased.

In this case, the arterial Bicarb level is actually most reflective of

chronic CO2 retention. With an increased PaCO2, the body will
compensate by increasing the amount of Bicarb in order to get
the pH back into the normal range.

The pH, PaCO2, and PaO2 values tell us more about the patient's
acute condition — whereas the question is asking about the
patient’s chronic condition. That is why looking at the Bicarb level
to check for compensation is the most important value in this
case.

The correct answer is: C. HCO3-

75. An adult patient in the emergency room is unconscious with

an SpO2 of 95%. After re-checking with a CO-oximeter, it
reveals that the patient’s SaO2 is 67%. Which of the following
is the most likely cause of this discrepancy?

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A. Opiate drug overdose
B. Diabetic ketoacidosis
C. Acute pulmonary edema
D. Carbon monoxide poisoning

A co-oximeter is a device that is capable of measuring the

carboxyhemoglobin and methemoglobin saturation of the blood.

In other words, once you saw it mentioned in the question, you

should have automatically known that carbon monoxide was the
most likely issue. Especially since the patient is unconscious.

When a patient was in a fire or near a burning building, the first

thing you should do is provide 100% oxygen as quickly as possible.
Never check their SpO2 with a regular pulse oximeter because
the results will be falsely high, as is the case for the patient in this
question. Instead, always use a co-oximeter.

None of the other answer choices really make sense in this

situation, so we know that the correct answer has to be D.

The correct answer is: D. Carbon monoxide poisoning

76. A 64-year-old female patient has arrived to the emergency

By reading the signs that were given in the question, you should
immediately be able to determine that the patient is likely having
a heart attack.

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And when you have a patient with a suspected heart attack, the
first thing you should do as a Respiratory Therapist is provide
100% oxygen. This will decrease the myocardial workload of the
heart, which is critical if the patient is, in fact, having a heart
attack.

The quickest and easiest method to provide high concentrations

of oxygen is a nonrebreathing mask.

So by using what we know about treating patients with a

suspected myocardial infarction, we could determine that the
correct answer has to be B.

The correct answer is: B. Provide 100% oxygen

77. A comatose adult patient in the ICU is receiving mechanical

There is only one test in the answer choices that does not require
any cooperation from the patient. So, obviously, in order to get
this one right, you needed to have an understanding of each of
these pulmonary function tests.

A peak expiratory flow, MVV, and FEV1 all require an active patient
effort, so we can eliminate those right away. That means we know
the correct answer has to be C.

An MIP can be performed by occluding the airway for a full 20

seconds and recording the pressure. This is a valuable reading in
regards to knowing when to wean a patient from the ventilator.

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For the TMC Exam, remember that the patient must have an MIP
of at least -20 cm H2O in order to be weaned.

The correct answer is: C. Maximum Inspiratory Pressure

78. A 61-year-old male patient who is recovering from post-

The first thing you need to do is interpret the ABG results. The
acid-base status is normal because the pH, PaCO2, HCO3, and BE
are all within their normal ranges.

However, the PaO2, on the other hand, is too high. So you know
that you need to decrease this value and you can do so by
decreasing the FiO2.

In general for a high-flow nasal cannula, you need a flow of at

least 20-30 L/min in order to deliver the set FiO2 to adult patients.
So if you were to decrease the flow below 20 L/min, it’s not going
to provide the set FiO2 adequately. And in general, you should
avoid adjusting two parameters at the same time.

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So by using our ABG interpretation skills, as well as what we know
about high-flow nasal cannulas, we could determine that the
correct answer has to be B.

The correct answer is: B. Decrease the FiO2

79. A COPD patient is being discharged and the doctor wants to

prescribe a controller-type bronchodilator for home use.
Which of the following medications would you recommend?
A. Albuterol
B. Levalbuterol
C. Metaproterenol
D. Brovana

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.

The correct answer is: D. Brovana

80. Upon assessment of a high-risk infant, you note bradycardia

and spells of apnea. Which of the following would you
recommend?
A. Surfactant therapy
B. Nasal CPAP
C. Aerosolized bronchodilator

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D. Mechanical ventilation

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.

So by using our knowledge of treating neonates with apnea, as

well as the process of elimination, you know that the correct
answer has to be D.

The correct answer is: D. Mechanical ventilation

81. During the assessment of a 1-week-old infant, which of the

following signs would indicate the infant has an increased
work of breathing?
A. Pallor
B. Nasal flaring
C. Digital clubbing
D. Acrocyanosis

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

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

None of the other answer choices really make sense in this

situation, so you know that the correct answer has to be B.

The correct answer is: B. Nasal flaring

82. The physician has ordered mechanical ventilation in the

pressure control A/C mode for a 55 kg postoperative male
patient. Which of the following initial settings would you
choose?
A. PIP = 25 cm H2O; Rate = 30/min; Inspiratory time = 1
second
B. PIP = 32 cm H2O; Rate = 12/min; Inspiratory time = 2
seconds
C. PIP = 40 cm H2O; Rate = 20/min; Inspiratory time = 1
second
D. PIP = 25 cm H2O; Rate = 12/min; Inspiratory time = 1
second

In order to get this one correct, you needed to know the normal
ranged for the initial ventilator settings of an adult patient. And
might I add, this is definitely something that you MUST know for
the TMC Exam.

In general, the initial settings for the assist/control pressure

control mode are as follows:

• PIP: 20-30 cm H2O

• Rate: 8-20/min
• I:E ratio of less than or equal to 1:2

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Now, by going through the answer choices, you can easily see
that there is only one choice where all the numbers are in the
correct ranges.

The correct answer is: D. PIP = 25 cm H2O; Rate = 12/min;

Inspiratory time = 1 second

83. A sweat chloride test can be used to diagnose which of the

following conditions?
A. Muscular dystrophy
B. Amyotrophic lateral sclerosis
C. Poliomyelitis
D. Cystic fibrosis

This one is very simple as long as you know what condition can be
diagnosed by performing a sweat chloride test.

For the TMC Exam, remember that a sweat chloride test is used to
diagnose cystic fibrosis. The test works because it shows that the
chloride in the patient’s sweat is much higher in those with cystic
fibrosis than that of those without.

None of the other answer choices make sense in this situation, so

we know that the correct answer has to be D.

The correct answer is: D. Cystic fibrosis

84. Which of the following respiratory signs would be

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D. Costal angle of 90 degrees increases with inspiration

When a patient uses accessory muscles during breathing, this is a

sign of respiratory distress. The accessory muscles of breathing
include:

• Scalenes
• Sternocleidomastoids
• Pectoralis major

A respiratory rate of 18 is normal, so you can rule that one out. The
ribs should be higher posteriorly than anteriorly at end-expiration,
so you can rule that one out as well. A costal angle of 90 degrees
that increases with inspiration is also a normal finding.

So by breaking down the question and using process of

elimination, we could determine that the correct answer has to
be C.

The correct answer is: C. Scalene muscle usage at rest

85. A 22-year-old female patient has been admitted to the

emergency department with acute bronchospasm. Which of
the following medications would you recommend?
A. Albuterol (Proventil)
B. Racemic epinephrine
C. Cromolyn sodium (lntal)
D. Acetylcysteine (Mucomyst)

Just from reading the question, you should know the correct
answer to this one immediately.

In order to treat a patient with acute bronchospasm, you need to

provide an aerosolized bronchodilator, like albuterol.

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Mucomyst is a mucolytic that would only worsen bronchospasm
in sensitive patients, so you know it can’t be that one. Cromolyn
sodium is a prophylactic anti-inflammatory drug that is useful in
preventing bronchospasm in patients with asthma — it is not
given for acute bronchospasm.

Racemic epinephrine is typically used to reverse the vasodilation

and mucosal edema that can cause upper airway obstruction
episodes in diseases such as croup.

So by using what we know about treating acute bronchospasm,

as well as the process of elimination, you know that the correct
answer has to be A.

The correct answer is: A. Albuterol (Proventil)

86. A 54-year-old female patient is receiving ventilatory support

To get this one right, you needed to know that retained

secretions increases the airway resistance and peak airway
pressures during volume control ventilation.

So in order to fix the issue, you need to remove the secretions via
suctioning which will decrease the peak airway pressure.

On the other hand, if the patient was in the pressure control

mode, you would expect an increase in the delivered volume
once secretions are cleared.

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None of the other answer choices really make sense in this
situation which means that the best answer has to be D.

The correct answer is: D. A lower peak pressure

87. A 59-year old female patient with COPD is receiving

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.

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Switching to a 24% air entrainment mask likely isn’t going to
change her inspired level of oxygen, 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.

The correct answer is: A. Increase the oxygen flow to 3 L/min

88. A post-operative adult patient is being treated with incentive

spirometry. The patient's inspiratory capacity has decreased
over the past few days and their level of dyspnea has been
increasing. A chest x-ray reveals consolidation in the lung
bases with no shift of the trachea. Which of the following has
most likely developed?
A. Pneumonia
B. Pleural effusion
C. Atelectasis
D. Pneumothorax

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

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that pneumonia is present. This is what is causing the shortness
of breath for the patient in this question.

The correct answer is: A. Pneumonia

89. While assessing a mechanically ventilated patient after a

The first thing you have to interpret is that the patient has a
higher than normal ICP. Remember, the normal range for ICP is
10-12 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.

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The correct answer is: A. Increase the minute ventilation

90. A newborn 28-week gestational age neonate is being treated

in an oxygen hood with an FiO2 of 50%. The physician
believes that the patient has infant respiratory distress
syndrome. The following blood gas results were obtained:
pH 7.36
PaCO2 38 mm Hg
HCO3 25 mEq/L
BE 0 mEq/L
PaO2 46 mm Hg
Based on the results, what should you recommend?
A. Start nasal CPAP at 5-8 cm H2O
B. Increase the oxygen hood concentration to 100%
C. Intubate and begin mechanical ventilation with PEEP
D. Obtain a chest X-ray to look for a pneumothorax

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. None of the other
answer choices really make sense in this case, so you know that
the correct answer has to be A.

The correct answer is: A. Start nasal CPAP at 5-8 cm H2O

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91. A 56-year-old female patient’s bedside spirometry results are
as follows:
FVC is decreased
FEV1 is normal
FEV1% is increased
What is the most likely problem?
A. Normal results
B. An obstructive disease
C. Poor patient effort
D. A restrictive disease

This is one of the classic PFT interpretation questions that you

definitely must know how to do for the TMC Exam.

The results of this patient demonstrate a classic restrictive disease

because the flows appear to be normal or increased while the
volumes are decreased.

The FEV1% is increased so you know it can’t be an obstructive

disease, and clearly it’s not normal results or else it would say
normal next to each of the results.

The correct answer is: D. A restrictive disease

92. An 11-year-old boy has just arrived in the ER with cystic

To get this one correct, you simply just needed to know the most
common drug that is given for cystic fibrosis.

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Dornase alpha, aka Pulmozyme, is the drug that you always want
to recommend for patients with cystic fibrosis that have thick
secretions. None of the other medications are indicated at this
time which means that the correct answer has to be B.

The correct answer is: B. Nebulized dornase alpha

93. A 64-year-old male patient is intubated and receiving

ventilatory support in the volume-controlled SIMV mode. The
physician anticipates that the patient will be on the
ventilator for another 3–5 days. Which of the following would
you recommend?
A. Switch to the patient to NPPV
B. Switch from an ET tube to a tracheostomy
C. Maintain the endotracheal tube in place
D. Switch to a pressure-controlled mode

If a patient is expected to be on the ventilator for less than one

week, it is best to just continue using an endotracheal tube as the
airway for ventilation. This is considered short-term ventilation.

For long-term ventilation, which generally means 21 days or

longer, you would want to recommend the use of a tracheostomy
instead.

There is no indication for NPPV, nor should you switch the patient
to pressure control ventilation. The best action to take, in this
case, is to maintain the ET tube in place.

The correct answer is: C. Maintain the endotracheal tube in place

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94. An adult patient in ICU who is receiving mechanical
ventilation has been diagnosed with ARDS. Which of the
following would you expect to find in this patient?
A. Refractory hypoxemia
B. Metabolic alkalosis
C. Increased lung volumes
D. Increased compliance

For this one, you should be able to determine the correct answer
right away. Refractory hypoxemia is the key finding of patients
with ARDS.

Patients with ARDS will have decreased lung volumes and

compliance — not increased — so we can rule out those two
answer choices immediately.

ARDS patients typically have physiologic shunting that causes

severe hypoxemia that does not respond well to increases in the
FiO2. This, of course, is referred to as refractory hypoxemia. In this
case, the patient needs high levels of PEEP because increasing
their FiO2 isn’t going to do any good.

The ABG results of a patient with ARDS would likely show

metabolic acidosis, not alkalosis, so we can rule that one out as
well.

The correct answer is: A. Refractory hypoxemia

95. You were called to obtain a forced vital capacity maneuver

on an adult patient with normal lungs. What percentage
should the patient be able to exhale within the first second of
the maneuver?
A. 35-50% of the FVC
B. 50-70% of the FVC
C. 70-83% of the FVC

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D. 84-93% of the FVC

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.

The correct answer is: C. 70-83% of the FVC

96. The physician has ordered 2.5 mL ipratropium bromide TID

To get this one correct, you basically just needed to know when
it’s appropriate to use a mask or mouthpiece when giving a
breathing treatment.

In general, you always want to use the mouthpiece as longer as

the patient is able. If they are unable to hold the mouthpiece,
then you would use the mask instead.

By using the mouthpiece, the patient is able to intake more of the

aerosol medication because less leaks out compared to using a
mask. Also, using the mask increases the likelihood that the
medication will get in the patient’s eyes.

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

The correct answer is: D. Small volume nebulizer with a

mouthpiece

97. A 52 kg female patient is receiving volume control A/C

mechanical ventilation with a tidal volume of 400 mL, a set
rate of 10/min, and an FiO2 of 35%. Her blood gas results are
as follows:
pH 7.31
PaCO2 49 torr
HCO3 24 mEq/L
BE -2 mEq/L
PaO2 74 torr
SpO2 95%
Based on the given information, which of the following
changes is appropriate at this time?
A. Increase the FiO2
B. Increase the tidal volume
C. Increase the set rate
D. Maintain the current settings

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.

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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.

The correct answer is: C. Increase the set rate

98. An arterial blood gas sample needs to be obtained from a

To get this one correct, you simply just needed to know that the
lateral area of the heel is the preferred puncture site when
collecting a capillary sample from a neonate.

You could potentially use the infant’s fingertip, toe, or earlobe if

the lateral heel puncture is unsuccessful, but these are not the
preferred sites. The heel is the preferred site.

After you puncture the heel, you should wipe away first drop of
blood and observe for free flow before collection. You should not
squeeze or milk the puncture site.

Here’s another important thing to remember:

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Capillary samples are useful only for assessing the infant’s acid-
base status — not the oxygenation status. The pH and PCO2
correlate well with arterial blood, however, the PaO2 does not.

The correct answer is: C. The lateral area of the heel

99. Which of the following is true regarding the insertion of a

laryngeal mask airway as compared to endotracheal
intubation?
A. It must be removed in order to insert an endotracheal
tube
B. It poses a greater risk of trauma than endotracheal
intubation
C. It can be inserted blindly without any special equipment
D. It can completely prevent the aspiration of gastric
contents

A Laryngeal Mask Airway (LMA) is an airway that is indicated for

short-term ventilation when normal ET tube intubation attempts
were unsuccessful.

The major advantage of an LMA is that it’s easy to insert. It can be

inserted blindly without any special equipment. It also avoids
laryngeal and tracheal trauma. One thing to note is that you can
actually insert an ET tube through a properly sized LMA without
removing it.

An LMA cannot prevent the aspiration of gastric contents, so it is

contraindicated when that risk is present.

So by using what we know about Laryngeal Mask Airways, as well

as the process of elimination, you know that the correct answer
has to be C.

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The correct answer is: C. It can be inserted blindly without any
special equipment

100. A neonate with meconium aspiration syndrome is

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.

The correct answer is: A. Pneumothorax

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101. An adult patient is receiving mechanical ventilation with a
PEEP setting of 10 cmH2O. The physician has requested
that you increase the setting to 14 cmH2O. After making the
adjustment, there is a rapid drop in the patient’s blood
pressure and a significant increase in heart rate. Which of
the following actions should you take?
A. Increase the FiO2 by 10%
B. Lower the PEEP back to 10 cmH2O
C. Administer sodium bicarb
D. Obtain a stat EKG

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.

The correct answer is: B. Lower the PEEP back to 10 cmH2O

102. After reviewing the results of a patient’s pulmonary

function tests, you note that the FEV1, FVC, and total lung
capacity are all reduced. The FEV1/FVC ratio is normal. What
is the interpretation based on these findings?
A. Restrictive lung disease
B. Obstructive lung disease
C. Combined obstructive-restrictive lung disease
D. The test is invalid

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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.

The correct answer is: A. Restrictive lung disease

103. While reviewing the chest x-ray of a 47-year-old male

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.

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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 correct answer is: B. Tension pneumothorax on the left side

104. An ABG was ordered for a 68-year-old female patient with a

To get this one correct, you needed to know what supplies are
REQUIRED in order to collect an ABG sample. The key word here
is — required.

You are required to use the following equipment:

• Syringe
• Anticoagulant
• Transport container with label (i.e. biohazard bag)
• Container with ice if you are unable to analyze the sample
immediately
• Antiseptic swabs and tape or a bandage
• Clean exam gloves
• Sterile gauze.

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A local anesthetic is not required— it is optional. A lancet is used
for capillary sampling—not for an arterial puncture. And yes, you
must wear gloves when sticking an ABG, but they do not have to
be sterile gloves.

The correct answer is: D. Anticoagulant

105. While assessing a 51-year-old male patient, you note

definitive use of the neck muscles during normal breathing.
This finding is consistent with which of the following?
A. Pulmonary embolism
B. Myasthenia gravis
C. COPD
D. Orthopnea

The use of neck muscles during normal breathing is not a normal

finding. Neck muscles are considered “accessory muscles of
breathing” and when they are used, it indicates an increased
work of breathing.

Increased accessory muscle usage is a common observation in

patients with COPD, especially those with emphysema.

None of the other answer choices really make sense in this

situation, so we know that the correct answer has to be C.

The correct answer is: C. COPD

106. A 58-year-old female is receiving volume control A/C

ventilation at a rate of 12/min with a tidal volume of 450 mL.
The FiO2 is set at 40% and her ABG results are as follows:
pH 7.35
PaCO2 44 torr

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HCO3 22 mEq/L
BE 0
PaO2 91 torr
SaO2 97%
Based on this information, you should recommend which of
the following?
A. Decrease the minute ventilation
B. Discontinue mechanical ventilation
C. Administer IV bicarbonate
D. Maintain the current settings

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 correct answer is: D. Maintain the current settings

107. You were called to perform a set of FVC tests on a 55-year-

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.

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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.

The correct answer is: C. “Blast the air out faster.”

108. A 2-year-old girl is showing signs of a severe asthma attack.

The physician has ordered a short-acting bronchodilator
medication that is available in both MDI and SVN doses.
Which of the following delivery methods would you
recommend for this patient?
A. An SVN using the “blow by” technique
B. An MDI with a holding chamber and mask
C. A small volume nebulizer with a mouthpiece
D. A breath-actuated MDI with mask

In general, most infants and small children should receive

aerosolized drugs via an MDI with a valved holding chamber and
a mask.

You should avoid using the “blow by” technique with an SVN
because too much of the medication is wasted during this
technique.

An SVN with a mask could be considered but oftentimes with

small children, they will not tolerate the mask very well. Also,
young children generally will not be able to use an SVN with a
mouthpiece either.

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So by using what we know about aerosol drug delivery in
children, as well as the process of elimination, we can determine
that the correct answer has to be B.

The correct answer is: B. An MDI with a holding chamber and

mask

109. During the assessment of a 60-year-old male patient, you

noticed reduced tactile fremitus. This finding is typical in all
of the following conditions EXCEPT:
A. COPD
B. Pneumothorax
C. Pulmonary edema
D. Pleural effusion

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.

The correct answer is: C. Pulmonary edema

110. A 43-year-old male patient admitted to the emergency

department with a suspected drug overdose. The patient is
receiving oxygen via nonrebreather but is unconscious and

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isn’t making any respiratory efforts to breathe. The patient’s
body weight is 57 kg and his ABG results are as follows:
pH 7.28
PCO2 74 torr
HCO3 20 mEq/L
PaO2 315 torr
Which of the following would you recommend?
A. Apply BiPAP with: IPAP 20 cm H2O, EPAP 5 cm H2O,
FIO2 30%
B. Intubate and apply: SIMV, tidal volume 600 mL, rate
6/min, FIO2 40 %
C. Intubate and apply: A/C ventilation, tidal volume 450
mL, rate 12/min, FIO2 50%
D. Apply CPAP at 10 cm H2O and an FiO2 of 100%

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.

The correct answer is: C. Intubate and apply: A/C ventilation, tidal
volume 450 mL, rate 12/min, FIO2 50%

111. A 63-year-old female patient is orally intubated with a size 7

endotracheal tube and is receiving ventilatory support.
While attempting to suction the patient with a size 12 Fr
catheter, you note that the catheter cannot pass beyond
the tip of the tube. Which of the following is the most likely
cause of this problem?

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A. There is a kink in the tube
B. The tube is in the right main bronchus
C. The suction catheter too short
D. The suction catheter size is too large

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.

So by reading the question carefully and using our knowledge of

endotracheal tubes and suction catheters, we could determine
that the correct answer has to be A.

The correct answer is: A. There is a kink in the tube

112. A patient in the ICU is receiving positive pressure

ventilatory support but appears to be breathing
asynchronously with the machine-delivered breaths. Which
of the following medications would you recommend?
A. Fluoxetine (Prozac)

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B. Midazolam (Versed)
C. Dextroamphetamine (Dexedrine)
D. Cisatracurium (Nimbex)

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.

So by using what we know about the drugs for mechanically

ventilated patients, as well as the process of elimination, you
know that the correct answer has to be B.

The correct answer is: B. Midazolam (Versed)

113. A 59-year-old female patient has a vital capacity of 3.4,

functional residual capacity of 5.8, and an expiratory reserve
volume of 1.2. What is the patient's total lung capacity?
A. 5.9
B. 6.8
C. 8.0
D. 8.8

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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

If you need more help with using the “lung box” for PFTs, we
cover it inside of our Hacking the TMC Exam video course.

The correct answer is: C. 8.0

114. A 69-year-old male patient with tachypnea, dyspnea, and

expiratory wheezes did not improve after receiving a
bronchodilator treatment. Which of the following most
likely describes the patient’s condition?
A. Asthma
B. Chronic bronchitis
C. Congestive heart failure
D. Emphysema

To get this one correct, you must have a basic understanding of

the cardiopulmonary diseases that are listed in the answer
choices.

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Since the patient has expiratory wheezing but did not respond to
a bronchodilator treatment, this tells us that the wheezing is
being caused by something other than an obstructive disease.

So that means we can rule out asthma, chronic bronchitis, and

emphysema because they are obstructive diseases.

CHF or pulmonary edema is a condition in which fluid

accumulates in the lungs and this is the cause of the wheezing.

This explains why the bronchodilator didn’t work, and in this case,
you would want to recommend a diuretic instead.

The correct answer is: C. Congestive heart failure

115. An adult patient was admitted to the emergency

All you needed to know in order to get this one correct is the
meaning of crepitus.

Crepitus is grating, crackling, or popping sound that is heard

when there are air bubbles under the skin. It’s a sign of
subcutaneous emphysema which, in most cases, indicates that a
pneumothorax is present.

None of the other answer choices really make sense in this

situation, so you know that the correct answer has to be B.

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The correct answer is: B. Subcutaneous emphysema

116. During the assessment of a 64-year-old patient who is

When you see a major drop in peak pressure, the first thing you
should check for is a leak or disconnection and correct it as soon
as possible.

You wouldn’t just want to blindly increase the volume or flow

setting without first knowing what caused the drop in peak
pressure.

Increased secretions would increase the peak pressure, not

decrease it, which means that you can rule that one out as well.

The correct answer is: D. Check the circuit for system leaks

117. What is the maximum volume of air that can be inhaled

after a normal quiet inspiration?
A. FVC
B. FRC
C. IRV
D. ERV

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To get this one correct, you simply just needed to know the
definitions of the pulmonary volumes and capacities that are
listed in the answer choices.

It should go without saying that you absolutely need to know

these for the exam.

• VT – the volume of air that is inhaled or exhaled from the

lungs during effortless breathing.
• RV – the volume of gas remaining in the lungs after a
complete exhalation.
• IRV – the maximum volume of air that can be inhaled after a
normal inspiration.
• ERV – the total amount of gas that can be exhaled from the
lungs after a normal exhalation.
• VC – the total amount of air that can be exhaled after a
maximum inspiration. It is also the sum of the inspiratory
reserve volume, tidal volume, and expiratory reserve volume.
• IC – the maximum volume of air that can be inhaled after a
normal inspiration.
• FVC – the maximum volume of gas that can be exhaled as
forcefully and quickly as possible.
• FRC – the total amount of gas left in the lungs after a resting
expiration.
• TLC – the total amount of gas in the lungs after a maximum
inspiration.

The correct answer is: C. IRV

118. A 59-year-old male patient who weighs 75 kg is intubated

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A. Extubate the patient
B. Pressure control ventilation
C. Pressure support ventilation
D. Volume control ventilation

To get this one correct, you needed to have a basic

understanding of spontaneous breathing trials and when (or
when not) to extubate a patient from mechanical ventilation.

At first glance, you may think it’s appropriate to extubate this

patient but they actually do not meet the required criteria. For a
70 kg male, an exhaled tidal volume of 320 mL is a bit too low.
And the fact that he is unable to follow commands is another
indication that he is not yet ready to be extubated.

Adding pressure support can assist the patient’s breathing effort

and increase his tidal volume, so that is what needs to be
recommended in this case.

For the TMC Exam, remember that PSV is commonly used for
weaning during an SBT. None of the other answer choices really
make sense in this situation, so you know that the correct answer
has to be C.

The correct answer is: C. Pressure support ventilation

119. The physician has requested a mode of ventilation in which

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In order to maintain a precise I:E ratio, you need to be able to set a
mandatory rate and tidal volume.

Control Mode Ventilation (CMV) is the only possibility of the four

choices that will allow you to do that, so you should know
immediately that it is the correct answer.

In CMV, the patient cannot trigger any breaths. All ventilatory

support is provided by the machine. And as we stated, it can’t be
any of the other answer choices, so you know that the correct
answer has to be B.

The correct answer is: B. Control Mode Ventilation

120. While administering an adrenergic aerosol bronchodilator

treatment to an adult female patient, you notice an
increase in her pulse rate from 81 to 125 beats/min. Which of
the following actions should you take?
A. Use half of the standard dosage next time
B. Add more diluent to the nebulizer chamber
C. Temporarily stop the treatment until the patient’s heart
rate decreases
D. Stop the treatment and notify the physician

When administering an adrenergic bronchodilator, like albuterol,

it’s important to keep an eye on the patient’s heart rate. That is
because, tachycardia is a common side effect.

When giving a breathing treatment with this type of medication,

if the patient’s heart rate increases by more than 20 beats/min
from the pre-treatment heart rate, you should stop the treatment
immediately, document the results, and notify the physician.

The correct answer is: D. Stop the treatment and notify the
physician

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121. You are called to review the electrolyte results of a 60-year-
old female patient. Which of the following values is typical
for serum potassium?
A. 2.7 mEq/L
B. 3.2 mEq/L
C. 4.1 mEq/L
D. 5.8 mEq/L

You will need to know the normal values for serum electrolytes
for the TMC Exam. Here are the normal ranges:

• Sodium: 135 – 145 mEq/L

• Potassium: 3.5 – 4.5 mEq/L
• Chloride: 80 – 100 mEq/L

We cover a shortcut that makes memorizing these ranges easy

inside of our Hacking the TMC Exam video course, so definitely
check that out if you’re interested.

But for this questions, as long as you knew the normal ranges,
you can easily determine that the correct answer is C.

The correct answer is: C. 4.1 mEq/L

122. It is suspected that a 41-year-old female patient with

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To get this one correct, you needed to have an understanding of
all of the tests that are listed in the answer choices. This one is
tricky because all of the tests that are listed are valuable in
helping to diagnose asthma — but only one is specifically used for
that purpose.

A bronchoprovocation study, aka a Methacholine challenge test,

is performed to evaluate how responsive a patient’s lungs are to
triggers, and it is specifically used to diagnose unconfirmed
asthma.

The correct answer is: C. Bronchoprovocation study

123. A 4-year-old child has been admitted to the emergency

For the TMC Exam, you absolutely must know how to tell the
difference between croup and epiglottitis.

Croup, also known as Laryngotracheobronchitis, is characterized

as subglottic edema, which means that the swelling occurs below
the glottis. It is associated with inspiratory stridor and the onset
occurs more slowly, usually over 24–48 hours. Look for the
“steeple” sign on a lateral neck x-ray.

Epiglottitis is characterized as inflammation of the epiglottis and

supraglottic structures, which means that the swelling occurs
above the glottis. The onset occurs rapidly and this condition can

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be considered a medical emergency. Look for the “thumb” sign
on the lateral neck x-ray.

The question tells us that the child has subglottic edema, which is
a dead giveaway that croup is the correct answer.

The correct answer is: D. Croup

124. A 63-year-old female patient is receiving volume control

A/C ventilation and has become agitated. Over the past 3
hours, her PaCO2 has decreased from 38 to 27 torr. Which
of the following is the most likely cause of this problem?
A. High body temperature
B. Increased ventilation
C. Increased cardiac output
D. Mainstem intubation

Since we know that the patient is agitated, we can determine

that the most likely cause of the decrease in PaCO2 is
hyperventilation.

Treating the cause of the agitation would most likely restore her
ventilation back to normal and thus normalize PaCO2 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.

The correct answer is: B. Increased ventilation

125. A 64-year-old male patient is receiving an aerosol

treatment with acetylcysteine and hypertonic saline via a
small volume nebulizer. After only a few minutes, the

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patient suddenly becomes dyspneic. Which of the following
is the most likely cause of this problem?
A. Hypercapnia
B. Pneumothorax
C. Fluid overload
D. Bronchospasm

To get this one correct, you simply needed to know that common
side effect of acetylcysteine is bronchospasm. Also, of course, you
needed to know that acetylcysteine is another name for the drug
Mucomyst.

Any time that you administer Mucomyst to a patient, you MUST

also give the patient a bronchodilator as well in order to prevent
bronchospasm.

None of the other answer choices really make sense in this

situation, so we know that the correct answer has to be D.

The correct answer is: D. Bronchospasm

126. An adult patient who is receiving mechanical ventilation

To get this one correct, you simply needed to know the formula
for Raw (airway resistance).

Raw = (PIP – PPLAT)/Flow

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As long as you knew the formula, the calculation is simple
because all you have to do is plug the numbers in.

Raw = (60 – 45)/1

(Remember, 60 L/min = 1 L/second)

We share our complete strategy for the calculations inside of our

Hacking the TMC Exam video course. Definitely check that out if
you’re interested in learning more.

The correct answer is: B. 15 cm H2O/L/sec

127. A 69-year-old male patient with a severe obstructive airway

disease is intubated and receiving ventilatory support.
Which of the following capabilities would be the most
important to consider when selecting a ventilator for this
patient?
A. Approved for use during MRI procedures
B. The ability to compensate with tube flexibility
C. The ability to run on 12 volt DC (battery) power
D. A variable flow control and adjustable I:E ratio

Let’s break this one down.

Being approved for MRI procedures has nothing to do with a

patient with severe COPD, so we can rule that one out right away.

The ability to compensate with tube flexibility — that’s not

relevant to this patient either. And the need to run on a 12 volt
battery — again, not really relevant.

So, simply by using common sense, we can already tell that the
correct answer has to be D.

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The ability to control the flow and I:E ratio will allow you to make
sure that the expiratory time is sufficiently long in order to
prevent air-trapping and auto-PEEP.

The correct answer is: D. A variable flow control and adjustable I:E
ratio

128. A 49-year-old male is intubated and receiving mechanical

While orally intubated, it’s common for a patient to bite the

endotracheal tube, which is what’s going on in this question.

To fix the problem, you would want to recommend the use of a

bite block or oropharyngeal airway in order to prevent the patient
from biting the tube.

None of the other answer choices are indicated in this situation,

so we know that the correct answer has to be B.

The correct answer is: B. The use of a bite block

129. Hemodynamic data was collected on a 39-year-old male

patient. Which of the following indicates that there is a
problem with this patient?
A. Shunt of 3%
B. SVR of 500 dyn/s/cm-5

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C. Cardiac Index of 3.7 L/min/m2
D. CVP of 5 cmH2O

To get this one correct, you simply needed to know the normal
values of the hemodynamic data that is listed in the answer
choices. If you can interpret that, you can easily come up with the
correct answer.

• Normal shunt is 5% or less.

• Normal SVR is 900-1400 dyn/s/cm-5
• Normal CI is 2.5-4 L/min/m2
• Normal CVP for an adult is 2-8 cmH2O

By looking at the normal values, you can see that only one falls
outside of the normal range and it’s B.

The correct answer is: B. SVR of 500 dyn/s/cm-5

130. A 65-year-old female patient with pulmonary edema was

inadvertently given 1000 mL of IV fluids instead of the
ordered amount of 100 mL. Which of the following would
you expect to see in this case?
A. Increased PaO2
B. Decreased PAP
C. Increased PCWP
D. Decreased lung markings on the chest x-ray

To get this one correct, you needed to have a basic

understanding of hemodynamics and what to expect when a
patient is fluid overloaded.

Excess fluids will accumulate in the pulmonary vessels which will

cause the pulmonary artery pressure and the pulmonary capillary
wedge pressure to increase.

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With CHF or pulmonary edema, the chest x-ray would show
increased lung markings, not decreased. Also, with excess fluid,
the PaO2 would likely decrease, not increase.

So by using what we know about fluid overload, as well as the

process of elimination, you can determine that the correct answer
has to be C.

The correct answer is: C. Increased PCWP

131. A post-operative patient using a mouthpiece positive

In a situation such as this, when the machine doesn’t cycle off, the
first thing you should check for is a leak in the circuit or near the
mouthpiece.

Decreasing the sensitivity would only make it more difficult to

trigger a breath. Switching to a 100% gas source is irrelevant. And
increasing the pressure would make it even more difficult for the
machine to cycle off.

So again, when the machine does not cycle off, it most likely
means that a leak is present.

The correct answer is: C. Check for a leak in the circuit or

mouthpiece

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132. You are called to administer nebulized albuterol to a 47-
year-old female patient that is receiving oxygen via nasal
cannula at 2 L/min. Her pretreatment heart rate was
recorded at 84 beats/min. You would stop the treatment
once the patient’s heart rate reaches which of the following
levels?
A. 89 beats/min
B. 99 beats/min
C. 109 beats/min
D. 119 beats/min

As a Respiratory Therapist, when administering a breathing

treatment, if the patient’s heart rate increases too much from
their baseline pre-treatment heart rate, you must stop the
treatment and notify the physician.

Here’s the rule of thumb to remember:

You need to stop the treatment is the heart rate increases by 20%
or more from the baseline heart rate.

Or, a more simplified version of the rule that also works: You
should stop the treatment if it increases by 20 beats/min or more
from the pre-treatment heart rate.

So in this case, the patient’s pre-treatment heart rate was 84

which means that you would need to stop the treatment once
her heart rate reaches 101.

The correct answer is: C. 109 beats/min

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133. A 69-year-old female patient with advanced COPD is
receiving supplemental oxygen. Which of the following is a
problem that could arise under such circumstances?
A. Hypoventilation
B. Hyperventilation
C. Retinopathy of prematurity
D. The development of pulmonary edema

Oxygen-induced hypoventilation is something that you have to

be aware of when providing supplemental oxygen to a patient
with COPD.

Giving them too much oxygen can elevate their PaO2 levels too
much which can knock out their hypoxic drive resulting in
hypoventilation and an elevated PaCO2.

None of the other answer choices really make sense in this

situation, so you know that the correct answer has to be A.

The correct answer is: A. Hypoventilation

134. Simple spirometry can be used to measure any of the

following EXCEPT:
A. Tidal volume
B. Vital capacity
C. Inspiratory reserve volume
D. Residual volume

A spirometer is a device that measures exhaled flow rates and

volumes. It can be used to obtain measurements such as tidal
volume, vital capacity, and FEV1.

To get this one right, you needed to have a basic understand of

residual volume. Basically, the residual volume is the amount of
air that is left in the lungs after a full exhalation and it cannot be

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exhaled. This means that it cannot be measured via simple
spirometry.

Tidal volume, vital capacity, and IRV all can be measured with a
spirometer. You would need a plethysmograph (body box) in
order to measure the residual volume.

The correct answer is: D. Residual volume

135. A 74 kg male patient is intubated and receiving volume

The first thing you should do is interpret the ABG results, which
indicates that the patient has acute respiratory alkalosis. This
means that the patient is hyperventilating and blowing off too
much CO2.

The PaO2 and SaO2 values are normal, so you do not need to
adjust the FiO2. The rate is already too fast, so you do not need to
increase the rate. And by looking at the patient’s body weight,

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you can see that the tidal volume is set appropriately at around 8
mL/kg.

This means that the best action to take is to add mechanical

deadspace.

Adding mechanical deadspace to the circuit is a method for

treating hyperventilation. It works because the patient will
essentially rebreathe the gas from their anatomic deadspace,
which will in turn, increase the PaCO2 levels.

The correct answer is: D. Add mechanical deadspace

136. A high-flow nasal cannula has been ordered for a 44-year-

old female patient. In order to set up this device, you would
need all of the following EXCEPT?
A. Blender
B. Humidifier
C. Sterile saline
D. Air and oxygen source

To get this one correct, you simply needed to know the basics of
setting up a high-flow nasal cannula.

You would need the following:

• The HFNC device

• Circuit tubing
• Humidifier
• Blender
• High-pressure oxygen source
• High-pressure air source
• Sterile water

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Sterile water is needed, not sterile saline, which means that for
this question, the correct answer has to be C.

The correct answer is: C. Sterile saline

137. A 53-year-old female patient was ordered to perform a 6-

In order to get this one correct, you simply just needed to have a
basic understanding of the 6-minute walk test.

The objective of the test is to travel as far as possible during a 6-

minute time period. An increased distance covered indicates
improvement and means that the pulmonary rehabilitation
program is working.

None of the other answer choices provide accurate instructions

for the 6-minute walk test, which means that the correct answer
has to be C.

The correct answer is: C. Walk as far as possible for 6 minutes and
note the distance covered

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138. You are called to increase the expiratory time of a patient
receiving volume control ventilation without altering the
minute ventilation. Which of the following settings would
you adjust in order to fulfill this request?
A. Rate of breathing
B. Inspiratory flow
C. Tidal volume
D. Trigger sensitivity

We know that adjusting the rate or tidal volume would alter

minute ventilation, so we can rule those two out right away.

On most ventilators operating in the volume control mode,

expiratory time is not set directly but is dependent on other
settings. Essentially, expiratory time depends on the rate, volume,
and flow settings.

But since we already ruled out rate and tidal volume, we know
the correct answer has to be inspiratory flow.

Adjusting the sensitivity would only affect the expiratory time if it

were in a full control mode, but this would also affect the minute
ventilation, therefore, we can rule that one out as well.

The correct answer is: B. Inspiratory flow

139. Spirometry tests were performed on a 52-year-old female

with the following results:
Predicted Actual % Predicted
TLC 5.8 8.2 136
RV 1.2 1.7 165
FVC 5.1 2.7 53
FEF25-75% 4.3 1.6 37
FEV1/FVC 75% 21% 28

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What is the interpretation of this data?
A. Mild restrictive lung disease
B. Mild obstructive lung disease
C. Severe restrictive lung disease
D. Severe obstructive lung disease

To get this one correct, you needed to be able to interpret the

spirometry data that was provided in the question. You will see
one of these on the TMC Exam.

For this one, the patient’s TLC and RV are both greater than 120%
of the predicted value, which indicates that significant air
trapping is present. This should tell you automatically that an
obstructive disease is present.

Also note that all three flow measurements are far lower than the
predicted values which indicates that an obstructive disease is
present.

On the other hand, for a restrictive disease, the TLC and RV would
be lower than the predicted value — not greater than.

The correct answer is: D. Severe obstructive lung disease

140. In order for a home-care patient to disinfect their

respiratory care equipment, which of the following would
you recommend?
A. Warm, soapy water
B. Cool, soapy water
C. Ethylene oxide
D. Acetic acid

To get this one correct, you just needed to know which substance
is recommended to disinfect home care equipment.

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Acetic acid is another name for vinegar, and it is commonly used
as a low-level disinfectant is the home setting. It is often
recommended because it can easily be purchased in local
grocery stores.

Soapy water is not classified as a disinfectant and ethylene oxide

is often too expensive for home use.

The correct answer is: D. Acetic acid

141. A 66-year-old female patient is receiving ventilatory

To get this one correct, you needed to have a basic

understanding of adjusting and making proper changes to
ventilator settings. You will see several questions like this on the
TMC Exam.

Since this patient’s SpO2 has decreased below the normal range,
this tells us that the patient is in need of more oxygen. Now you
simply must decide between increasing the FiO2 or the PEEP
setting.

The rule of thumb is this: You should increase the FiO2 up to 60%
then, if needed, you can increase the PEEP.

Changing modes is irrelevant in this case, and increasing the flow

will not improve the patient’s oxygenation status. Since the

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patient’s FiO2 is only at 40%, this means we can increase it up to
60% and reassess to see if the SpO2 increases back within the
normal range.

The correct answer is: C. Increase the FiO2

142. A 26-year-old female patient was admitted to the

emergency department with signs of status asthmaticus.
Which of the following drugs would you recommend for
administration via nebulization?
A. Levalbuterol
B. Montelukast
C. Beclomethasone
D. Magnesium sulfate

A patient with signs of status asthmaticus basically tells us that

they are having an asthma attack. In such case, you must provide
a beta-adrenergic bronchodilator which, of course, is a rescue
drug.

So to get this one correct, you needed to be able to choose this

type of medication from the answer choices that are listed.

Beclomethasone is an inhaled steroid and should not be used to

treat acute exacerbations of asthma.

Montelukast is a leukotriene receptor antagonist that can be

given for asthma, but it is generally a maintenance medication
that is taken orally — not via nebulization.

Magnesium sulfate helps to relax smooth muscle but is given via

IV, so we can rule it out as well.

Levalbuterol is a short-acting bronchodilator that increases air

flow to the lungs and can be given for status asthmaticus.

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The correct answer is: A. Levalbuterol

143. While reviewing the chest x-ray of an adult patient, it shows

To get this one right, you needed to have a basic understanding

of chest radiograph findings and what they tell you about a
patient’s condition.

With a tracheal and mediastinal shift to the left side, this means
that there is either a collapse on that side, or there is a
pneumothorax on the opposite side.

By looking at the answer choices, this tells us that the correct

answer has to be either C or D.

When there is opacification on a chest x-ray, this tells us that

either consolidation or atelectasis present. Since the trachea
shifted towards the area of opacification, this means that there is
an area of collapse on the left side, which of course, is atelectasis.

A pneumothorax would show hyperlucency of the affected side,

not opacification. Emphysema would show hyperlucency of both
lungs. For a pleural effusion, the key finding on a chest x-ray is
blunting of the costophrenic angle, which is not occurring here.

The correct answer is: D. Atelectasis of the left lung

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144. A premature newborn infant with an Apgar score of 3 is
showing signs of hypoxemia, grunting, and intercostal
retractions. Which of the following would you recommend?
A. Suction the neonate
B. Nebulize albuterol
C. Provide supplemental oxygen
D. Instill surfactant into the airway

This infant is showing severe signs of respiratory distress and an

extremely low Apgar score of 3 tells us that the neonate likely has
Respiratory Distress Syndrome.

In order to improve the infant’s condition, you need to administer

exogenous surfactant which can be instilled directly into the
airway.

Suctioning and albuterol are not indicated at this time. Although

supplemental oxygen may help the infant’s hypoxemia, more
extensive measures are needed in this case, so we can rule that
one out as well.

So by using what we know about treating high-risk infants, as

well as the process of elimination, you know that the correct
answer has to be D.

The correct answer is: D. Instill surfactant into the airway

145. The physician has requested to change the airway of a

patient from an endotracheal to a tracheostomy tube.
Which of the following is the primary indication for the
insertion of a tracheostomy?
A. When a patient loses pharyngeal or laryngeal reflexes

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B. When a patient has a long-term need for mechanical
ventilation
C. When a patient is prone to hemorrhaging
D. When a patient has upper airway obstruction due to
trauma

This one is very simple and, hopefully, you knew the answer right
away.

Long-term ventilation is the primary indication for the insertion of

a tracheostomy. They are used to replace the ET tube in patients
that are expected to be on the ventilator for more than 21 days.

None of the other answer choices really make sense in this

situation so we know that the correct answer has to be B.

The correct answer is: B. When a patient has a long-term need for
mechanical ventilation

146. The physician has requested to decrease the PaCO2 of a

To get this one right, you needed to have an understanding of the

settings for HFOV.

In order to decrease a patient’s PaCO2, you need to increase the

tidal volume. And you can do that by increasing the amplitude
setting on the ventilator.

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Increasing the frequency (in HFOV) would actually cause the
PaCO2 to increase because it would decrease the tidal volume.
Remember, HFOV is different than conventional ventilation.

You can also rule out B and D because decreasing the bias flow
and increasing the mechanical deadspace would not help to
decrease the PaCO2.

The correct answer is: C. Increase the power/amplitude

The first thing you need to interpret in this question is that both
diseases that were mentioned are obstructive diseases. Now you
can look through the answer choices and which finding is
common in obstructive diseases.

When an obstructive disease is present, the patient will have

decreased expiratory flow rates. Their FEV1% will be less than 70%.

Air trapping is also common in obstructive diseases which will

cause the TLC to be increased. A decreased diffusing capacity
tends to occur only in emphysema.

So by using what we know about obstructive diseases, as well as

the process of elimination, we could determine that the correct
answer has to be B.

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The correct answer is: B. Decreased forced expiratory flows

148. While assisting with a bronchoscopy procedure, the

physician requests a medication for direct instillation into
the endotracheal tube. Which of the following would you
recommend?
A. Lidocaine
B. Liquid Heparin
C. Ipratropium bromide
D. Saline

There are two ways that you can use to come up with the correct
answer.

First, if you know and understand the bronchoscopy procedure,

you will know which medication is needed. Second, even if you
don’t, you can still get this one correct by knowing the NAVEL
mnemonic.

You can remember NAVEL as an easy way to memorize which

medications can be instilled directly down the ET tube.
Remember the following:

• N – Narcan
• A – Atropine
• V – Valium/Versed
• E – Epinephrine
• L – Lidocaine

Lidocaine is the only answer choice found in the NAVEL

mnemonic, which tells us that the correct answer has to be A. If
you want to learn more hacks and tricks like this one, consider
checking out our Hacking the TMC Exam video course.

The correct answer is: A. Lidocaine

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149. An 8-year-old girl has been diagnosed with asthma and
was prescribed Proventil via metered dose inhaler for home
use. Which of the following would you recommend in order
to increase the deposition of the bronchodilator?
A. Add a spacer or holding chamber to the MDI
B. Remove the mouthpiece from the MDI
C. Have the child inhale as quickly as possible
D. Switch from an MDI to a DPI

To get this one correct, you needed to have a basic

understanding of how to instruct the use of a metered dose
inhaler.

In general, a spacer or holding chamber should be used to help

increase drug deposition because it requires less patient hand-
breath coordination. Also, it helps prevent drug aerosols from
depositing in the pharynx.

None of the other answer choices really make sense in this

situation, so you know that the correct answer has to be A.

The correct answer is: A. Add a spacer or holding chamber to the

MDI

150. A 53-year-old female patient with COPD is receiving

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D. Pancuronium bromide (Pavulon)

The question provides a lot of details about the patient. So, in

order to come up with the correct answer, you have to take it all
in and break it all down.

The first thing that should stand out is that the patient is
wheezing, which indicates that bronchospasm is present. This is
the most immediate problem, which should be treated with a
bronchodilator.

Levalbuterol is the only bronchodilator of the answer choices,

which means that the correct answer has to be C.

Rhonchal fremitus indicates that the patient has thick secretions

which is likely what is causing an increased PIP and plateau
pressure. So with that said, a bronchodilator and possibly a
mucolytic would be indicated for this patient.

Triamcinolone is a corticosteroid, pancuronium is a

neuromuscular blocking agent, and cromolyn is a mast cell
stabilizer. None, of which, are indicated for this patient.

The correct answer is: C. Levalbuterol (Xopenex)

151. A 33-year-old male patient was admitted to the emergency

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By going through the answer choices, you should quickly be able
to determine the correct answer. For a patient with carbon
monoxide poisoning, ALWAYS treat them with 100% oxygen or
provide the highest possible FiO2.

You can immediately apply a nonrebreather but your ultimate

goal should be to place the patient in a hyperbaric oxygen tank if
possible. Please remember this because it’s always on the exam.

None of the other answer choices will provide enough oxygen for
this patient, so you know that the correct answer has to be A.

The correct answer is: A. Nonrebreathing mask

152. The physician has ordered a dry powder inhaler for an adult
patient who is being discharged. The patient has never
used an inhaler before. Which of the following instructions
would you provide?
A. Blow slowly into the device
B. Hold the device vertically after loading
C. Inhale rapidly for 1-2 seconds
D. Breathe normally in and out of the device

To get this one correct, you simply just needed to know how to
properly instruct a patient to use a DPI.

The patient should never blow or breathe into the device. Also,
the patient should hold the inhaler horizontally — never vertically
because this could dump the powder dose out of the device.

When using a DPI, the patient should make a tight seal with the
lips around the mouthpiece and inhale rapidly for 1-2 seconds.
Remember, in order to use a DPI, the patient must be able to
generate an inspiratory flow rate of greater than 60 L/min in order
for the medication to reach the lungs.

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The correct answer is: C. Inhale rapidly for 1-2 seconds

153. Which of the following instructions would you give an adult

To get this one correct, you needed to know what an MEP test is
and how to perform it. A Maximum Expiratory Pressure test
measures the output of the expiratory muscles against a
maximum stimulus. It is a test that can check to see if the patient
is ready to be extubated.

If they can generate an MEP of > 60 cm H2O, this is an indication

that they can clear secretions on their own and extubation can be
recommended if they meet the other criteria.

But back to the question..

In order to get the best results, you should have the patient inhale
to Total Lung Capacity, then blow out as hard as possible.

The correct answer is: B. “Inhale as much as you can, then blow
out hard.”

154. An EKG was performed on a newly admitted 66-year-old

female patient. While reviewing the results, there are no
identifiable P waves and the patient has an irregular
ventricular rhythm. Which of the following is most likely the
problem?

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A. Atrial fibrillation
B. Ventricular tachycardia
C. 1st degree heart block
D. 2nd degree heart block

To get this one correct, you needed to have a basic

understanding of EKG interpretation. The description of the
rhythm that is provided in the question describes atrial fibrillation.

The typical findings of atrial fibrillation are absent P waves and

irregular R–R intervals due to irregular conduction of impulses to
the ventricles.

But even if you didn’t know much about EKGs before reading the
question, you could still use the process of elimination for choose
the best answer.

Here’s a little hint that comes from our Hacking the TMC Exam
video course:

For the TMC Exam, they’re not going to expect you to know any of
the heart block rhythms. So with that said, for this question, we
could automatically rule out C and D right away.

Then, at this point, you pretty much know that the correct answer
has to be A.

The correct answer is: A. Atrial fibrillation

155. A 61-year-old female patient is receiving mechanical

ventilatory support. Over the past three days, her fluid
intake has stayed the same but her output fluid level
measurements have been decreasing. Her peak airway
pressure has been steadily increasing over this same time

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period. Which of the following is the most likely cause of
this problem?
A. Ventilator-associated pneumonia
B. Acute respiratory distress syndrome
C. Pulmonary arterial hypertension
D. Cardiogenic pulmonary edema

The question tells us that the patient is not excreting fluids

properly which means that the fluids are being retained in the
body. Since the her peak pressure has been increasing as well,
this means that the fluid is causing a decrease in lung
compliance.

Now, you can look through the answer choices to see which
condition would cause a decreased lung compliance along with
fluid retention.

Cardiogenic pulmonary edema is a type of congestive heart

failure where fluid accumulates in the lungs due to a failing left
ventricle. This would explain why the patient’s output fluid levels
have been decreasing — because the fluid has been
accumulating in the lungs instead.

In a case such as this, it’s typical to see an increase in peak

pressure as well.

The correct answer is: D. Cardiogenic pulmonary edema

156. A 58-year-old postoperative male who weighs 172 lbs is

receiving volume control A/C ventilation at a rate of 16/min,
tidal volume of 550 mL, and FiO2 of 40%. His ABG results are
as follows:
pH 7.51
PaCO2 30 torr
HCO3 23 mEq/L

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BE -1
PaO2 117 torr
SaO2 99%
Based on this information, which of the following would you
recommend?
A. Discontinue mechanical ventilation
B. Administer IV bicarbonate
C. Increase the peak flow setting
D. Decrease the minute ventilation

The first thing you need to do is interpret the ABG results, which
tells us that there is acute respiratory alkalosis.

As we can see, the PaCO2 is decreased, so to correct this problem,

we need to increase the PaCO2. And to do so, you must decrease
the minute ventilation.

To take it even further, you can use the patient’s ideal body
weight to figure out that the tidal volume is set appropriately, so
the only other way to decrease the minute ventilation is to
decrease the rate.

None of the other answer choices really make sense in this

situation, so we know that the correct answer has to be D.

The correct answer is: D. Decrease the minute ventilation

157. A chest x-ray was ordered to confirm that the endotracheal

tube is positioned in the correct place. Where should the tip
of the tube be located?
A. Even with the carina
B. Level with the 5th cervical vertebra
C. At the sixth intercostal space
D. 1–2 inches above the carina

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You must know and understand the proper placement of an
endotracheal tube for the TMC Exam.

In general, here’s how to determine if the tip of the ET tube is in

the correct place:

• In adults, the ET tube should be inserted 3–4 cm through the

vocal cords.
• Another mark to look for is this: The tube should be inserted
21–24 cm at the patient’s lip, which you can verify by the
markings on the tube.
• And finally, the tube is in the proper place when it’s 1.5
inches (or 3-4 cm) above the carina. This can be verified with
a chest x-ray.

The correct answer is: D. 1–2 inches above the carina

158. An adult patient is receiving ventilatory support in the

First and foremost, we have to interpret the ABG results. The pH is

low. The PaCO2 is high. The SaO2, HCO3, and BE are all within the

187
normal range. This tells us that the patient has acute respiratory
acidosis with normal oxygenation.

This means that the patient is hypoventilating, which is what is

causing the increased PaCO2. So in order to blow over some of
that CO2, you simply need to increase the rate.

The correct answer is: B. Increase the rate

159. The physician has ordered ribavirin (Virazole) to be

This one is very straightforward. You simply just needed to know

that Ribavirin (Virazole) must be administered with a SPAG, or
small particle aerosol generator.

Ribavirin is a drug that is used to treat RSV or severe lung

infections in infants. You must use a SPAG to deliver this drug
because it can provide small and uniformly distributed aerosol
particles that can penetrate into the fine bronchioles of infants.

Also note that Ribavirin may be used in treating RSV infections in

immunocompromised adults as well.

The correct answer is: A. Small particle aerosol generator

160. The status of a 56-year-old male patient has gotten worse

over the past 2 hours. He was switched from an air

188
entrainment mask to a nonrebreather, and is now receiving
ventilatory support with the following settings:
Assist/Control rate 12
Tidal volume 650 mL
FiO2 100%
PIP 40 cmH2O
Plateau pressure 35 cmH2O
The patient's arterial blood gas results are as follows:
pH 7.42
PaCO2 35 torr
PaO2 54 torr
SpO2 84%
HCO3- 23 mEq/L
Which of the following best represents the status of this
patient?
A. Cystic fibrosis
B. Acute metabolic alkalosis
C. Hypoventilation from fatigue
D. Intrapulmonary shunting

The ventilator settings appear to be set properly because the ABG

results tell us that the patient’s ventilatory status is good, being
that the pH and PaCO2 are in the normal ranges. This issue here
is with the patient’s oxygenation.

The PaO2 and SpO2 are extremely low, especially considering that
the patient is receiving an FiO2 of 100%. This is a classic case of
refractory hypoxemia that is most likely caused by
intrapulmonary shunting.

We know that this is the case because the patient is not

responding to high levels of oxygen. The patient needs increased
levels of PEEP instead.

The correct answer is: D. Intrapulmonary shunting

189
One More Thing!
Before you move on to the next Module, I just wanted to remind
you about our Practice Questions Pro membership.

As you can most likely already tell, our practice questions are
loaded with helpful tidbits of information that can help you
prepare for (and) pass the TMC Exam.

Now, you can get these TMC Practice Questions sent to your
inbox on a daily basis.

Yes, it’s same practice questions that are inside of this Test Bank.
And you only get one question per day…

BUT, like I said before, repetitions are super important!

And the more practice questions you see, the better.

For many students, it’s very convenient to wake up each day and
have a new TMC Practice Question waiting in their inbox.

If this is something that sounds interesting to you, definitely

consider signing up.

Click Here to Get Daily Practice Questions via Email

I hope you enjoy and I’ll see you in the next Module. J

190
References

1. AARC Clinical Practice Guidelines, (2002-2020) Respirator Care.

www.aarc.org.

2. Egan’s Fundamentals of Respiratory Care. (2010) 11th Edition.

Kacmarek, RM, Stoller, JK, Heur, AH. Elsevier.

3. Mosby’s Respiratory Care Equipment. Cairo, JM. (2014) 9th

Edition. Elsevier.

4. Pilbeam’s Mechanical Ventilation. (2012) Cairo, JM. Physiological

and Clinical Applications. 5th Edition. Saunders, Elsevier.

5. Ruppel’s Manual of Pulmonary Function Testing. (2013)

Mottram, C. 10th Edition. Elsevier.

6. Rau’s Respiratory Care Pharmacology. (2012) Gardenhire, DS.

8th Edition. Elsevier.

7. Perinatal and Pediatric Respiratory Care. (2010) Walsh, BK,

Czervinske, MP, DiBlasi, RM. 3rd Edition. Saunders.

8. Wilkins’ Clinical Assessment in Respiratory Care (2013) Heuer, Al.

7th Edition. Saunders. Elsevier.

9. Clinical Manifestations and Assessment of Respiratory Disease.

(2010) Des Jardins, T, & Burton, GG. 6th edition. Elsevier.

10. Neonatal and Pediatric Respiratory Care. (2014) Walsh, Brian K.

4th edition. RRT. Elsevier.

11. Clinical Application of Mechanical Ventilation (2013) Chang,

David W. 4th edition. Cengage Learning.

191

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