Sold to

[email protected]
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
Section 1 ………………………………………………………………………………………………………………..4
Section 2 ………………………..……………………………………………………………………………….…..54

3
Section 1

1. Which of the following EKG leads should be placed in the 5th

intercostal space at the midaxillary line?
A. V3
B. V4
C. V5
D. V6

2. A 69-year-old female patient arrived to the emergency

roomed confused with dehydration. Which of the following
would you expect to find?
A. Bradycardia
B. Jugular venous distention
C. Pedal edema
D. Poor skin turgor

3. You are called to perform bedside spirometry tests on a 58-

year-old female patient. The physician requests the patient’s
tidal volume, peak flow, and FVC. Which of the following
devices would you select in order to obtain these values?
A. Body Plethysmograph
B. Stead-Wells water seal spirometer
C. Maximum inspiratory pressure manometer
D. Differential-pressure pneumotachometer

4. A 49-year-old post-operative patient was just initiated with

volume-control A/C ventilation. It was noted that the patient
has clear, scant secretions. Which of the following
humidification devices would you recommend?

4
 A. Bubble humidifier
B. Pneumatic nebulizer
C. Heated wick humidifier
D. Heat and moister exchanger

5. A sputum sample was ordered on 54-year-old female patient

with a suspected lung infection. Which of the following would
you recommend in order to collect the sample?
A. Lukens trap
B. Coude catheter
C. Yankauer
D. Bulb suction

6. An adult patient has a left ventricular stroke volume of 75 mL

and a heart rate of 88. What is the cardiac output?
A. 11.2 L/min
B. 8.4 L/min
C. 6.6 L/min
D. 3.7 L/min

7. As a Respiratory Therapist, you should recommend an annual

influenza vaccination to which of the following?
A. A 21-year-old female with asthma
B. A 5-month-old infant
C. A 65-year-old male with Guillain-Barr syndrome
D. A 25-year old pregnant female patient

5
8. You are called to measure the strength of a patient’s
respiratory muscles at the bedside. Which of the following
devices would you select?
A. Pressure manometer
B. Peak flowmeter
C. Ergometer
D. Respirometer

9. A patient with acute respiratory acidosis would be expected to

have a base excess in the range of which of the following?
A. + 6 mEq/L
B. - 6 mEq/L
C. +/- 2 mEq/L
D. +/- 8 mEq/L

10. Which of the following is the preferred procedure for

establishing a patent tracheal airway in an emergency
situation?
A. Orotracheal intubation
B. Nasotracheal intubation
C. Tracheostomy procedure
D. Cricothyrotomy

11. A patient performs an FVC maneuver and displays the

following results:

6
 How would you interpret this flow-volume loop tracing?
A. Normal lungs
B. Small airway obstruction
C. Large airway obstruction
D. Restrictive disease

12. The physician ordered an ABG on a 41-year-old patient with

COPD. Before drawing the sample from the radial artery,
which of the following should be performed?
A. Check the patient’s oxygen saturation
B. Modified Allen test
C. Nail bed blanching
D. Blood pressure measurement

13. What is the purpose of using a cuffed artificial airway when

providing long-term positive pressure ventilation?
A. To facilitate the removal of secretions
B. To decrease the airway resistance
C. To prevent gas leaks and aspiration
D. To decrease the work of breathing

7
14. You collected an ABG on a 30-week gestational age infant
that is receiving oxygen via oxyhood at 60%. The results are
as follows:
pH 7.36
PaO2 47 torr
PaCO2 44 torr
After reviewing the results, which of the following would you
recommend?
A. Nasal CPAP at 4 cm H2O
B. Intubate and provide mechanical ventilation
C. Switch the infant to a nonrebreather mask
D. Increase the oxygen to 70%

15. Which of the following is a disadvantage of using a pulse

oximeter for monitoring the oxygenation status of a patient?
A. Pressure sores at the measuring site
B. False results leading to incorrect decisions
C. Electrical shock at the measuring site
D. Skin burns due to using incompatible probes

16. While assessing 50-year-old male patient, you notice that his
trachea is not positioned in the midline. Which of the
following conditions would be the mostly likely cause of this
finding?
A. Lobar collapse
B. Pulmonary edema
C. Pulmonary fibrosis
D. Chronic bronchitis

8
17. You are instructing a patient on how to perform an FVC
maneuver. After looking at the results of an attempt, you
determine that the back extrapolated volume is excessive.
Before another attempt, 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.”

18. A 63-year-old male patient is receiving volume controlled

ventilation with a PEEP of 5 cm H2O. Over a 3-hour period,
his peak pressure has been steadily increasing while his
plateau pressure has remained the same. No ventilator
setting changes have been made. What is the most likely
cause?
A. The patient is developing pneumonia
B. The patient is developing bronchospasm
C. The patient is developing atelectasis
D. The patient’s lung compliance is decreasing

19. A carbon monoxide reading was taken on a 64-year-old

female patient with COPD. Her results were 5 ppm. This
finding indicates which of the following:
A. The patient has abstained for more than 12 hours
B. The patient can be classified as a non-smoker
C. The patient has smoked within the past 24 hours
D. The patient has been exposed to secondhand smoke

9
20. You have a patient that is receiving scheduled aerosol
treatments with albuterol every four hours. The patient does
not take breathing treatments at home and has no history of
smoking. Upon assessment, you note clear breath sounds
that are equal bilaterally. Which of the following would you
recommend for this patient?
A. Continue the treatments as ordered
B. Discontinue the aerosol treatments
C. Perform postural drainage and percussion
D. Switch to an MDI with albuterol

21. You just obtained a peak flow measurement of 3.7 L/sec on a

39-year-old male who is 5 feet 9 inches tall. What is the
interpretation of this test result?
A. The patient has poor gas distribution
B. The patient has decreased lung compliance
C. The patient’s peak flow is normal
D. The patient has an airflow obstruction

22. While reviewing the results of a forced vital capacity

maneuver of an adult male patient, you note that an ‘S’
shaped curve appears on the flow-volume graph. This most
likely indicates which of the following?
A. The patient stopped exhalation too soon
B. The patient was coughing during the attempt
C. The patients was breathing too fast during the attempt
D. The patient gave poor effort at the start of the breath

10
23. A 70-year-old female patient with a progressive
neuromuscular condition needs mechanical ventilation. All of
the following measurements would be useful EXCEPT:
A. Airway resistance
B. Maximum inspiratory pressure
C. Maximum expiratory pressure
D. Vital capacity

24. An ABG was collected on a 59-year-old female patient with

the following results:
pH = 7.52
PaCO2 = 44 torr
HCO3 = 36 mEq/L
PaO2 = 85 torr
The acid-base interpretation can be classified as which of the
following?
A. Acute (uncompensated) respiratory alkalosis
B. Acute (uncompensated) metabolic alkalosis
C. Combined respiratory and metabolic alkalosis
D. Fully compensated respiratory alkalosis

25. Which of the following patients should you avoid the

insertion of an oropharyngeal airway?
A. A patient that has a foreign body obstruction
B. A patient that requires manual ventilation
C. A patient that is unconscious
D. A patient that is less than 12-years-old

26. A 3-year-old boy has arrived to the emergency department

having an asthma attack. Which of the following drugs

11
 would you NOT recommend for the initial management of
an acute asthma attack for a child?
A. Epinephrine
B. Albuterol (Proventil)
C. Terbutaline (Brethaire)
D. Cromolyn sodium (Intal)

27. A new patient just finished a cardiothoracic surgery

procedure. Upon assessment, you noticed that the patient
has a paradoxical pulse. Which of the following conditions is
most likely?
A. Pericarditis
B. COPD exacerbation
C. Myocardial infarction
D. Cardiac tamponade

28. While assessing a 71-year-old male patient, you note that

their chest has a barrel-shaped appearance. This indicates
that the patient most likely has which of the following?
A. Pectus excavatum
B. Pectus carinatum
C. Signs of air trapping
D. Normal chest anatomy

29. While assessing a 63-year-old male patient via chest

palpitation, you note that there is less movement on the
patient’s right side compared to the left side. This is an
indication for which of the following conditions?
A. Left-sided chronic bronchitis
B. Right-sided chronic bronchitis

12
 C. Left-sided pneumothorax
D. Right-sided pneumothorax

30. An EKG was taken on a dyspneic 54-year-old male patient in

the emergency department. In which of the following results
should cardioversion be performed?
A. Ventricular fibrillation
B. Atrial flutter
C. Second-degree heart block
D. Ventricular tachycardia with a pulse

31. The doctors requested for an oropharyngeal airway to be

inserted on 46-year-old male patient. This airway type is
useful in supporting which of the following?
A. Aerosol drug therapy
B. Frequent suctioning
C. Bag-mask ventilation
D. Incentive spirometry

32. A 49-year-old male patient has a vital capacity of 3400 mL, a

functional residual capacity of 4600 mL and expiratory
reserve volume of 1400 mL. What is his residual volume?
A. 8700 mL
B. 2100 mL
C. 3200 mL
D. 5800 mL

13
33. You were called by the nurse to assist with the assessment of
a newborn infant in the NICU. Which of the following signs is
an indication that the infant is in respiratory distress?
A. Pallor
B. Cyanosis
C. Grunting
D. Digital clubbing

34. Which of the following would you expect to see during

inspiration to indicate normal diaphragm activity?
A. An inward motion of the abdomen
B. An outward motion of the abdomen
C. Supraclavicular retractions
D. Intercostal retractions

35. While assessing a female patient’s breathing pattern, you

see that her tidal volumes go from small to large to small and
then stop for 10 seconds before starting again. Which of the
following would best describe this breathing pattern?
A. Cheyne-stokes breathing
B. Kussmaul breathing
C. Obstructed expiration
D. Eupnea

36. A 57-year-old male patient with a hemothorax recently had a

chest tube and pleural drainage system inserted. Upon
assessment, you note that the drainage level has stayed the
same over a 2-hour period. Which of the following would you
recommend?
A. Withdraw the chest tube about 3-4 cm

14
 B. Check the connecting tubing for kinks
C. Add water to the water seal chamber
D. Add water to the suction control chamber

37. You are called to the emergency department to help

extubate an adult female patient who is orally intubated. All
of the following equipment should be available for
extubation EXCEPT:
A. New endotracheal tube
B. Suction equipment
C. Bag-valve mask
D. Arterial blood gas kit

38. The physician asks for your opinion on whether or not to

initiate IPPB on a new post-operative adult patient. Which of
the following is an absolute contraindication for this
treatment modality?
A. Acute atelectasis
B. Hemoptysis
C. Congestive heart failure
D. Bacterial pneumonia

39. You are called to assist with the delivery of a high-risk infant.
After being evaluated, the infant is given a five-minute Apgar
score of 8. What should you recommend at this time?
A. Give the infant supplemental oxygen
B. Begin bag/mask rescue breathing on the infant
C. Give the infant to the mother for bonding
D. Give the mother supplemental oxygen

15
40. You are about to perform pulmonary function tests on a 52-
year-old male patient. Before you begin, the patient
mentioned that he smoked 3 cigarettes in the past two
hours. Which of the following tests would be affected by this
finding?
A. FVC
B. FRC
C. Raw
D. Lung Diffusion

41. A male patient arrives to the emergency department in

excruciating pain after a motor vehicle accident. The patient
is screaming and appears to have multiple broken bones in
his legs. Which of the following medications would you
recommend for sedation?
A. Ibuprofen
B. Ipratropium bromide
C. Morphine sulfate
D. Succinylcholine

42. You are called to access a 72-year-old female patient in the

acute phase of ARDS. Which of the following would you
expect to find?
A. Metabolic alkalosis
B. Increased compliance
C. Increased lung volumes
D. Refractory hypoxemia

16
43. What is the primary cause of the S1 heart sound?
A. The opening of the semilunar valves
B. The opening of the atrioventricular valves
C. The closing of the semilunar valves
D. The closing of the atrioventricular valves

44. While interpreting a patient’s ABG results, you note a PaCO2

of 24 torr, a Base Excess of -11 mEq/L, and a pH of 7.36. How
would you interpret these results?
A. Acute respiratory alkalosis
B. Acute metabolic acidosis
C. Compensated respiratory alkalosis
D. Compensated metabolic acidosis

45. A patient arrives in the emergency department intubated

with a King LT airway. After being admitted, you are asked to
exchange the patient’s current airway with an endotracheal
tube. In order to make the switch, you would recommend
which of the following?
A. Insert the ET tube under the King LT
B. Remove the King LT and temporarily apply NIPPV
C. Use an airway exchange catheter
D. Insert the ET tube on top of the King LT

46. The most likely cause of stridor in an adult patient would be

which of the following?
A. Croup
B. Asthma
C. Epiglottitis
D. Post-extubation edema

17
47. The nurse calls and requests for you to suction a pediatric
patient with excess secretions. What is the normal range of
negative pressure that should be used when suctioning the
child?
A. -60 to -80 mm Hg
B. -80 to -100 mm Hg
C. -100 to -120 mm Hg
D. -150 to -200 mm Hg

48. You were called by the physician to perform a Tensilon test

on a new patient. This test is commonly used to confirm the
diagnosis for which of the following conditions?
A. Myasthenia gravis
B. Guillain-Barré syndrome
C. Multiple sclerosis
D. Poliomyelitis

49. While assessing a 72-year-old postoperative patient, you

noted distinct wheezing in both lung fields. Which of the
following would recommend for this condition?
A. Give the patient a bronchodilator
B. Administer incentive spirometry
C. Giver the patient a mucolytic agent
D. Administer chest physiotherapy

50. A 62-year-old male patient is receiving volume control

ventilation and you note that the endotracheal tube has

18
 become obstructed. Which of the following findings would
you expect?
A. Increased peak pressure
B. Decreased peak pressure
C. High volume alarm
D. Decreased lung compliance

51. An adult patient is receiving volume-controlled ventilation in

the ICU. Upon assessment, you note a sudden drop in the
peak inspiratory pressure. Which of the following is most
likely the cause of this problem?
A. Mucous plug
B. Tension pneumothorax
C. Copious airway secretions
D. Exhalation valve leak

52. A 60 kg postoperative female patient is intubated and the

physician orders volume control A/C ventilation. Which of the
following settings would you choose for this patient?
A. Tidal Volume 250 mL; Rate 10/min; PEEP 10
B. Tidal Volume 300 mL; Rate 22/min; PEEP 5
C. Tidal Volume 350 mL; Rate 12/min; PEEP 10
D. Tidal Volume 450 mL; Rate 12/min; PEEP 5

53. It is noted that a 61-year-old female patient with pneumonia

has consolidation in the left lung. Which of the following
positions would you recommend for postural drainage?
A. Right lateral decubitus position
B. Left lateral decubitus position
C. Prone position with a pillow under the hips

19
 D. Trendelenburg position with a pillow under the hips

54. In which of the scenarios would it be appropriate to select

and HME during mechanical ventilation instead of a heated
wick humidifier?
A. A patient with a high fever
B. A patient intubated via the nasal route
C. A patient without thick secretions
D. A patient needing lung protective strategies

55. A 62-year-old male patient is receiving pressure control A/C

mechanical ventilation. Which of the following would you
recommend in order to help prevent ventilator-associated
pneumonia?
A. Use heated humidification
B. Provide daily oral care
C. Use disposable circuit components
D. Change the ventilator circuit every 24 hours

56. A 57-year-old male patient is receiving oxygen via a

nonrebreathing mask. Upon assessment, you note that the
reservoir bag collapses all the way during inspiration. Which
of the following is the most likely cause of this problem?
A. The patient is a nose-breather
B. The patient is a mouth-breather
C. The oxygen flowmeter setting is too low
D. The mask is not tight enough on the face

20
57. While inspecting a 64-year-old female patient, you note that
her sternum appear to have a caved-in appearance. This best
describes which of the following?
A. Kyphosis
B. Scoliosis
C. Kyphoscoliosis
D. Pectus excavatum

58. You are called to give an aerosolized breathing treatment

with albuterol to a 41-year-old male patient. If the patient’s
heart rate were to increase during the treatment, that would
be a result of which of the following?
A. Alpha only
B. Beta 1 only
C. Beta 2 only
D. Beta 1 and Beta 2

59. While assessing a 54-year-old male patient, you note that he

has diminished breath sounds in the right lower lobe with a
trachea that has shifted to the right. What is most likely the
cause of these findings?
A. Pneumothorax on the left side
B. Pneumonia on the left side
C. Pneumothorax on the right side
D. Atelectasis on the right side

60. An unresponsive 21-year-old male patient has arrived to the

emergency department. His family states that he was
dealing with depression and an overdose is suspected.
Which of the following medications would you recommend?

21
 A. Naloxone
B. Fentanyl
C. Indomethacin
D. Vecuronium

61. A 52-year-old male patient has arrived in the ER with severe

upper airway trauma. After multiple failed endotracheal
intubation attempts, you are beginning to find it difficult to
ventilate the patient using a bag mask resuscitator. Which of
the following would you recommend?
A. Nasotracheal intubation
B. Cricothyrotomy
C. Laryngeal mask airway
D. Esophageal-tracheal tube

62. A 24-year-old female patient who was admitted to the

emergency department is showing signs of respiratory
distress. You would expect to find all of the following except:
A. Diaphoresis
B. A normal respiratory rate
C. Accessory muscle usage
D. Intercostal retractions

63. The administration of theophylline would pose the greatest

risk for a patient with which of the following conditions?
A. Emphysema
B. Chronic asthma
C. Chronic bronchitis
D. Sinus tachycardia

22
64. A 72-year-old female patient who was diagnosed with severe
COPD is in for a visit with the pulmonologist. It is noted that
the patient has pulmonary hypertension and cor pulmonale.
Which of the following would you recommend for this
patient?
A. Corticosteroid therapy
B. Systemic vasodilators
C. Long-term oxygen therapy
D. Long-acting beta agonist therapy

65. A 6-month-old infant with cystic fibrosis was admitted to the

emergency department with retained secretions. Which of
the following airway clearance techniques would you
recommend for this patient?
A. Autogenic drainage
B. Postural drainage with percussion
C. Intrapulmonary percussive ventilation
D. Positive expiratory pressure

66. Which of the following is true regarding the synchronous

intermittent mandatory ventilation mode of mechanical
ventilation?
A. Machine breaths cannot be pressure controlled
B. The patient contributes to minute ventilation
C. Asynchrony is prevented during machine breaths
D. Only partial ventilatory support can be provided

67. Noninvasive positive pressure ventilation would be indicated

for acute respiratory failure in which of the following
conditions?

23
 A. Narcotic drug overdose
B. Smoke inhalation injuries
C. Cardiogenic pulmonary edema
D. Acute respiratory distress syndrome

68. A patient who has developed a sudden upper airway

obstruction would display all of the following signs EXCEPT:
A. Intercostal retractions
B. Inspiratory crackles
C. Increased levels of anxiety
D. Usage of accessory muscles

69. A 2-year-old boy was admitted to the emergency

department showing signs of respiratory distress. Upon
assessment, you note wheezes in the right lung and with
normal lung sounds heard on the left side. Which of the
following would you recommend?
A. Intubation and mechanical ventilation
B. Albuterol via small volume nebulizer
C. Epinephrine via small volume nebulizer
D. Rigid bronchoscopy

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

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

24
71. 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 with a pleural effusion
C. A patient with a thick neck
D. A patient with ventilator-associated pneumonia

72. A newly admitted 70-year-old female patient with

pneumonia has an oxygen saturation of 86% on a nasal
cannula at 2 L/min. Which of the following is a potential
cause the patient’s hypoxemia?
A. Fever and chills
B. Diffusion defect
C. Capillary shunting
D. Hypoventilation

73. A 57-year-old female patient has been admitted and

diagnosed with Myasthenia Gravis. 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. Peak inspiratory flow
C. Expiratory reserve volume
D. Inspiratory capacity

74. While reviewing the medical record of a 59-year-old male

patient, you note that his FEV1/FVC ratio was reported as

25
 being severely decreased. Which of the following conditions
would you expect with this finding?
A. Pneumonia
B. Chronic asthma
C. Morbid obesity
D. Pulmonary hypertension

75. A 58-year-old male patient who in orally intubated is

undergoing a spontaneous breathing trial. Which of the
following would indicate that you need to stop the trial and
return the patient back to full ventilatory support?
A. A decrease in SpO2 from 95% to 91%
B. An increase in heart rate from 91 to 116/min
C. An increase in respiratory rate from 16 to 27/min
D. An increase in arterial PCO2 from 44 to 56 torr

76. A 58-year-old female patient was intubated and auscultation

reveals that she has no breath sounds over the left lung. Her
SpO2 has decreased from 96% to 81% and her PIP has
increased from 33 to 53 cm H2O. It was noted that the tube
length marking is 26 cm at the lip. What action should you
take at this time?
A. Recommend a stat chest X-ray
B. Increase the FiO2 and the flow rate
C. Withdraw the ET tube 2-3 cm and reassess
D. Administrator a bronchodilator

77. A 62-year-old male was admitted to the emergency

department showing signs of dyspnea and shortness of
breath. Lab tests were ordered to check his troponin and

26
 BNP levels but the results were negative. Additionally, his
ABG results displayed acute respiratory acidosis with
moderate hypoxemia. Which of the following is the most
likely problem for this patient?
A. Pneumonia
B. CHF
C. COPD
D. Myocardial infarction

78. Which of the following tidal volume settings for mechanical

ventilation would be most appropriate for a 6'2" male patient
with normal lungs?
A. 300 mL
B. 500 mL
C. 700 mL
D. 900 mL

79. You are called to administer acetylcysteine to a 66-year-old

female patient. This drug can be helpful in treating which of
the following conditions?
A. Bronchospasm
B. Mucous plugs
C. Pleural effusion
D. Pulmonary hypertension

80. The physician has ordered mechanical ventilation in the

volume control A/C mode for a 60 kg postoperative female
patient. Which of the following initial settings would you
choose?

27
 A. Tidal volume = 400 cmH2O; Rate = 30/min; Inspiratory
time = 1 second
B. Tidal volume = 650 cmH2O; Rate = 12/min; Inspiratory
time = 2 seconds
C. Tidal volume = 500 cmH2O; Rate = 22/min; Inspiratory
time = 1 second
D. Tidal volume = 450 cmH2O; Rate = 12/min; Inspiratory
time = 1 second

81. A high-flow nasal cannula has been ordered for a 54-year-old

male patient. In order to set up this device, you would need
all of the following EXCEPT?
A. Blender
B. Bubble humidifier
C. Sterile water
D. Air and oxygen source

82. A 61-year-old male patient is receiving volume-controlled A/C

mechanical ventilation with an FiO2 of 60% and a PEEP of 5
cmH2O. Over the past hour, his SpO2 has decreased from
95% to 82%. Which of the following would you recommend
FIRST?
A. Change to SIMV
B. Increase the PEEP
C. Increase the FiO2
D. Increase the flow

83. 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. Hyperlucency of the patient’s right side

28
 was noted as well. These findings indicate which of the
following?
A. Diffuse pulmonary emphysema
B. Right-sided pleural effusion
C. Pneumothorax in the right lung
D. Atelectasis of the left lung

84. While assisting with the care of an adult patient with no IV

access who is in cardiac and pulmonary arrest, the physician
requests a medication for direct instillation into the
endotracheal tube. Which of the following would you
recommend?
A. Epinephrine
B. Liquid Heparin
C. Ipratropium bromide
D. Saline

85. High-frequency oscillatory ventilation has been ordered for

an adult patient in the ICU. All of the following are required
for this type of therapy EXCEPT:
A. Humidifier
B. Circuit tubing
C. High-pressure oxygen source
D. Spirometer to measure tidal volume

86. A 72-year-old male patient states that he has had a

productive cough for at least four months a year for the past
two years. This describes which of the following conditions?
A. Chronic bronchitis
B. Status asthmaticus

29
 C. Panlobular emphysema
D. Centrilobular emphysema

87. A 70-year-old male patient with ARDS is receiving

mechanical ventilation in a pressure-controlled mode.
During a routine ventilator check, it was noted that the
plateau pressure was increased. In order to prevent
barotrauma, which of the following modes would you
recommend?
A. Volume control ventilation
B. Pressure support ventilation
C. Continuous positive airway pressure
D. Airway pressure release ventilation

88. A 65-year-old female patient was admitted with cardiogenic

pulmonary edema. What is the primary goal of treating this
condition?
A. To increase the venous return to the heart
B. To increase the pulmonary fluid and blood volume
C. To decrease the right heart and systemic venous
pressures
D. To decrease the left heart and pulmonary vascular
pressures

89. Which of the following patients would you not recommend

the use noninvasive positive pressure ventilation?
A. Trauma and burns to the face
B. The need for moderate sedation
C. The need for suctioning of secretions
D. The need for an FiO2 greater than 40%

30
90. A 61-year-old male patient with emphysema is receiving
oxygen via air-entrainment mask at 45%. One hour after
oxygen therapy was initiated, the patient appears lethargic
and obtunded. Which of the following is the most likely
cause in the change of the patient’s status?
A. Hypotension
B. Refractory hypoxemia
C. Respiratory muscle fatigue
D. Oxygen-induced hypoventilation

91. A 33-year-old female patient has arrived to the emergency

department in the early stages of an asthma attack. Which of
the following would you expect for this patient?
A. Respiratory alkalosis
B. Moderate hypoxemia
C. Decreased expiratory flow rates
D. No response to beta adrenergic medications

92. A pulmonary artery catheter was inserted on a 68-year-old

male patient who is receiving mechanical ventilatory
support. Five minutes after insertion, the patient appears to
be rapidly deteriorating and the high pressure alarm is
sounding. The patient is now hypotensive and has decreased
breath sounds on the right side. Which of the following
conditions is most consistent with these findings?
A. Pulmonary edema
B. Pulmonary embolism
C. Tension pneumothorax
D. Acute Respiratory Distress Syndrome

31
93. Intubation is indicated for a 62-year-old female patient in the
emergency department. After three failed endotracheal
attempts, your efforts to ventilate the patient using a bag-
valve-mask are beginning to fail. Which of the following
would you recommend?
A. Perform one more endotracheal intubation attempt
B. Stop intubation efforts and continue bagging
C. Insert a laryngeal mask airway
D. Perform a percutaneous tracheotomy procedure

94. A 61-year-old male patient was administered lidocaine prior

to a fiberoptic bronchoscopy procedure. Which of the
following is the primary reason for administering this drug?
A. To provide moderate sedation
B. To provide topical anesthesia
C. To decrease vagal responses
D. To provide bronchodilation

95. A 70-year-old male patient was admitted to the emergency

department receiving oxygen via nonrebreathing mask with
unstable atrial flutter. After an initial shock via cardioversion,
the patient’s SpO2 drops to 82% and his breathing rate has
become slow and shallow. His heart rate is now 84/min with
normal sinus rhythm. Which of the following would you
recommend?
A. Direct instillation of naloxone (Narcan)
B. Deliver an additional synchronized shock
C. Intubate and initiate mechanical ventilation
D. Ventilate the airway with 100% oxygen via bag valve mask

32
96. An indwelling arterial catheter was just inserted on a 69-
year-old female patient in the ICU. The physician asks for you
to confirm that the catheter was successfully placed into the
artery. Which of the following would you assess?
A. Adequate blood return
B. A positive modified Allen test
C. Proper blood pressure and waveform
D. The ability to flush the line

97. A cardiopulmonary exercise test is being performed on a 58-

year-old female patient. During the test, her heart rate, SpO2,
and EKG are being monitored. What additional value would
you recommend for monitoring?
A. The physiologic deadspace
B. The peak expiratory flow rate
C. The maximum inspiratory pressure
D. The patient’s perceived level of exertion

98. The following bedside spirometry measurements were

obtained on an adult patient:
Respiratory rate = 12
Tidal volume = 450 mL
Dead space = 147 mL
Vital capacity = 1.2 L
Based on this data, what is the alveolar minute ventilation?
A. 2.6 L/min
B. 3.6 L/min
C. 4.6 L/min
D. 5.4 L/min

33
99. A 69-year-old female patient was discharged with orders for
IPPB therapy with oxygen twice per day while at home. A
pneumatically powered machine has been provided. Which
of the following gas sources would you recommend power
the device?
A. An oxygen concentrator
B. A liquid oxygen reservoir
C. A high-pressure air cylinder
D. A high-pressure oxygen cylinder

100. You are called to help obtain a cardiac index measurement

using a Swan-Ganz catheter. Before the measurement is
taken, the physician asks, “what is the normal range for
cardiac index?” Which of the following would you select?
A. 2 - 6 mmHg
B. 4 - 12 mmHg
C. 4 - 8 L/min
D. 2 - 4 L/min/m2

101. It is suspected that a patient has excess fluid around the

lungs in the pleural space. Which of the following would
you recommend in order to further inspect this patient?
A. CT scan of the chest
B. Fiberoptic bronchoscopy
C. Ultrasound
D. Lung Biopsy

34
102. A patient arrived to the emergency room after a motor
vehicle accident with chest trauma. The doctor stated that
subcutaneous emphysema was present. Which of the
following would you expect to find?
A. Mucus plug
B. Crepitus
C. Expiratory wheezes
D. Tactile fremitus

103. What is the total amount of gas left in the lungs after a
resting expiration?
A. FVC
B. FRC
C. IRV
D. ERV

104. On physical examination of a patient with pulmonary

emphysema, which of the following would you expect to
find?
A. Increased sputum production
B. Decreased AP chest diameter
C. Signs of cor pulmonale
D. Productive cough

105. A 58-year-old female patient is receiving mechanical

ventilation in the CPAP mode. In this mode, a breath will be
triggered in response to which of the following?
A. The patient’s inspiratory efforts only

35
 B. Either the patient’s inspiratory efforts or a timing
mechanism
C. The timing mechanism of the ventilator only
D. The timing mechanism and the pressure settings on
the ventilator

106. The physician is considering initiating pressure-controlled

ventilation on a 62-year-old female patient. How would you
describe this mode of ventilation?
A. “Inspiration begins after a specific pressure is inhaled.”
B. “Expiration ends after a pre-set pressure is delivered.”
C. “Inspiration ends after a pre-set pressure limit is
reached.”
D. “Inspiration ends after the patient exhales a pre-set
pressure.”

107. A patient is receiving 2 L/min of oxygen from an H-cylinder

at 1500 psi. What is the approximate duration of flow?
A. 22 hours, 43 minutes
B. 27 hours, 20 minutes
C. 39 hours, 15 minutes
D. 45 hours, 35 minutes

108. It has been determined that a 64-year-old male patient has

bronchiectasis. This disorder can be classified as which of
the following?
A. A restrictive disorder
B. An obstructive disorder
C. Both a restrictive and obstructive disorder

36
 D. Neither a restrictive or obstructive disorder

109. A 62-year-old female patient is receiving therapy with a

pressure-cycled ventilator via mouthpiece. In order to
increase the inspiratory time, you can do which of the
following?
A. Increase the flow
B. Decrease the flow
C. Increase the sensitivity
D. Decrease the sensitivity

110. What size suction catheter is most appropriate for an infant

that is intubated with a size 3.0 mm endotracheal tube?
A. 5 Fr
B. 6 Fr
C. 8 Fr
D. 10 Fr

111. A 48-year-old male patient is receiving volume-control

SIMV with 40% oxygen and has following ABG results:
pH 7.51
PaCO2 27 torr
PaO2 85 torr
HCO3 24 mEq/L
BE -1
The patient’s blood gas results indicate which of the
following?
A. Acute respiratory alkalosis
B. Acute respiratory acidosis
C. Acute metabolic alkalosis

37
 D. Acute hypoxemic failure

112. What is the maximum time in seconds that can be devoted

to an intubation attempt before you need to return the
patient back to manual ventilation?
A. 30 seconds
B. 45 seconds
C. 60 seconds
D. 90 seconds

113. An 8-year-old child is in need of immediate intubation and

mechanical ventilation. Which of the following
endotracheal tube sizes would you select for this patient?
A. 4.0 mm
B. 5.0 mm
C. 6.0 mm
D. 7.0 mm

114. 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 1100 dyn/s/cm-5
C. Cardiac Index of 3.3 L/min/m2
D. CVP of 11 cmH2O

115. A 62-year-old male patient with CHF was inadvertently

given 1500 mL of IV fluids instead of the ordered amount of

38
 150 mL. Which of the following would you expect to see in
this case?
A. Increased PaO2
B. Increased PAP
C. Decreased PCWP
D. Decreased lung markings on the chest x-ray

116. A 59-year-old male home care patient states that he does

not feel any oxygen coming from the prongs of the nasal
cannula and is unsure if it is functioning properly. You
should recommend all of the following EXCEPT:
A. Tighten up all connections
B. Refill the humidifier with sterile water
C. Place the cannula under water to check for bubbles
D. Switch the patient from his concentrator to his tank

117. A 61-year-old adult patient is receiving bronchodilator

therapy during mechanical ventilation. Which of the
following ventilator graphics would you recommend in
order to assess the patient’s response to the
bronchodilator?
A. Volume vs Time
B. Flow vs Volume
C. Flow vs Time
D. Pressure vs Volume

118. A 60-year-old female patient has been admitted to the

emergency department with the following ABG results:
pH 7.48
PaCO2 41 torr

39
 PaO2 98 torr
HCO3- 52 mEq/L
These results of this ABG can be interpreted as:
A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Metabolic acidosis

119. While performing a 12-lead EKG on a patient, you are

unable obtain an electrical reading. The device is fully
charged and working properly. Which of the following is the
most likely cause of this problem?
A. Motion artifact
B. Improper filtering
C. A missing lead
D. The patient has too much adipose tissue

120. Which of the following would you assess for during

inspiration to indicate normal diaphragm activity?
A. Supraclavicular retractions
B. Intercostal retractions
C. Inward motion of the abdomen
D. Outward motion of the abdomen

121. During the assessment of a 67-year-old female patient, you

note peripheral edema and wheezing. Which of the
following is the most likely cause of this finding?
A. Emphysema
B. Dehydration
C. Hypertension

40
 D. Fluid overload

122. A 57-year-old patient with a history of CHF presents to the

emergency room with dyspnea, shortness of breath, and
wheezing. Which of the following would you recommend?
A. Aerosolized albuterol
B. Aerosolized pulmicort
C. Furosemide (Lasix)
D. Rigid bronchoscopy

123. A 49-year-old post-operative patient is showing signs of

atelectasis. The patient awake and receiving oxygen via
nasal cannula at 2 L/min. Which of the following would you
recommend in order to improve the patient’s ventilation?
A. Incentive spirometry
B. IPPB
C. Flutter
D. Nasotracheal suctioning

124. A 53-year-old female patient that is receiving volume

control ventilation had a sudden increase in peak
inspiratory pressure. All of the following could be a possible
cause EXCEPT:
A. Kinking of the endotracheal tube
B. Patient-ventilator asynchrony
C. A mucous plug
D. Bronchodilation

41
125. A patient in the emergency department is receiving
oxygen via a nonrebreather at 15 L/min. There ABG results
are as follows:
pH 7.21
PaCO2 38 torr
PaO2 569 torr
SpO2 100%
HCO3 23 mEq/L
BE -1
Which of the following is the best interpretation for these
results?
A. Respiratory acidosis
B. Metabolic acidosis
C. Laboratory error
D. Large physiologic shunt

126. What purpose does the pilot balloon of an endotracheal or

tracheostomy tube serve during intubation and airway
management?
A. To minimize mucosal trauma during insertion
B. To protect the airway against aspiration
C. To monitor cuff integrity and pressure
D. To help with proper tube positioning

127. Upon entering the patient’s room, you heard the physician
instruct the patient to “inhale as deeply as possible and
then blow out all of the air as hard as you can.” Which
pulmonary function test is being performed?
A. IC
B. TLC
C. MVV
D. FVC

42
128. Your patient is a healthy male with average body size. What
would be considered the normal vital capacity range for this
patient?
A. 2000 – 3000 mL
B. 3000 – 4000 mL
C. 4000 – 5000 mL
D. 5000 – 6000 mL

129. A one-week-old neonate in the NICU is receiving gas via

nebulizer into an oxyhood. Which of the following could be
a potential problem for this patient?
A. The production of harmful noise levels
B. An increased potential for CO2 accumulation
C. Difficulty in maintaining stable high FIO2s
D. Difficulty in maintaining adequate humidification

130. An adult patient is about to be intubated in the emergency

department. How far should the endotracheal tube should
be advanced into the trachea during the oral intubation
procedure?
A. Until the cuff has passed the vocal cords by 3–4 inches
B. Until the cuff has passed the vocal cords by 3–4
centimeters
C. Until the proximal end of the tube is at the teeth
D. Just far enough so that the tube cuff is no longer visible

131. A 67-year-old female patient is undergoing a spontaneous

breathing trial for weaning from mechanical ventilation.

43
 Which of the following changes in the patient’s status
would be acceptable?
A. An increased usage of the scalene muscles during
breathing
B. An increase in heart rate from 97 to 136/min
C. A decrease in the systolic blood pressure from 115 to 76
mm Hg
D. A decrease in SpO2 from 95% to 90%

132. A 42-year-old female patient with dyspnea and wheezing

for the past 24 hours has not responded to bronchodilator
therapy. This describes which of the following conditions?
A. Chronic bronchitis
B. Status asthmaticus
C. Pulmonary embolism
D. Emphysema

133. A bronchodilator treatment was administered to a 67-year-

old male patient with COPD. Afterwards, the following PFT
data was obtained:
FEV1/FVC = 68%
FEV1 = 83% predicted
The stage of the patient’s COPD can be classified as which
of the following?
A. Mild
B. Moderate
C. Severe
D. Very severe

44
134. A 47-year-old female patient who was admitted for an
acute asthma attack is being treated with bronchodilators
and oxygen therapy. An ABG was obtained and you note an
increased in their PaCO2 to 50 mmHg with a pH of 7.27. The
patient appears to be anxious but otherwise is alert and
cooperative. Which of the following would you
recommend?
A. Administer nebulized corticosteroids
B. Administer a CNS respiratory depressant
C. Intubate and provide mechanical ventilation
D. Maintain their current therapy and continue to monitor
closely

135. A 29-year-old male patient with a history of bronchiectasis

was admitted with signs of purulent sputum and has an
SpO2 of 93% on 3 L/min. Upon assessment, auscultation
reveals course rhonchi and wheezing in the right lower
lobes. A chest X-ray shows infiltrates in the same area.
Which of the following would you recommend?
A. Epinephrine via small volume nebulizer
C. Incentive spirometry with 12 breaths/hour
D. Nonrebreathing mask at 12 L/min
D. Intrapulmonary percussive ventilation (IPV)

136. A 69-year-old male has arrived to emergency department

complaining of chest tightness and radiating left shoulder
pain. He has a 25-pack per year smoking history and shows
physical signs of COPD. Which of the following would you
recommend FIRST?
A. Collect an arterial blood gas sample
B. Recommend a STAT chest radiograph
C. Initiate oxygen therapy via nasal cannula

45
 D. Initiate oxygen therapy via nonrebreathing mask

137. After entering the room of a 66-year-old female patient,

you found that she is unresponsive and without pulse. You
called for help and requested a defibrillator but no one
responds. Which of the following actions would you take?
A. Intubate and initiate mechanical ventilation
B. Check the patient’s advance directive order
C. Immediately begin giving chest compressions
D. Wait for the defibrillator to arrive

138. A 60-year-old male patient is receiving therapy via a

pressure-controlled mouthpiece ventilator. Their tidal
volume goal is 750 mL but they are only exhaling 550 mL
and there is no air leak. Which of the following would you
recommend in order to deliver a larger tidal volume?
A. Increase the flow setting
B. Increase the pressure setting
C. Use a sealed mouthpiece
D. Instruct the patient to inhale more forcefully

139. An adult patient who receiving mechanical ventilation has

a PIP of 30 cmH2O and a plateau pressure of 10 cmH2O
with a set flow rate of 60 L/min. What is the airway
resistance?
A. 20 cm H2O/L/sec
B. 24 cm H2O/L/sec
C. 30 cm H2O/L/sec
D. 24 cm H2O/L/sec

46
140. Cardiopulmonary resuscitation is being performed on a 56-
year-old male patient in the emergency department. The
doctor orders an ABG to be collected. Which of the
following sample sites would you recommend?
A. Radial artery
B. Brachial artery
C. Carotid artery
D. Femoral artery

141. A sputum sample via Lukens trap has been ordered for a
64-year-old male patient. All of the following are true
regarding this device EXCEPT:
A. The use of a vacuum source is required
B. The use of a suction catheter is required
C. It is indicated for a patient with a productive cough
D. All connections must be tight for it to work properly

142. A neonate was born with meconium aspiration syndrome

and is receiving ventilatory support. The attending
physician wants to increase the pressure limit but doing so
would increase the risk of which of the following?
A. Pneumothorax
B. Oxygen toxicity
C. Tracheoesophageal fistula
D. Retinopathy of prematurity

47
143. A 67-year-old female patient with emphysema is receiving
ventilatory support with an HME in place. Immediately after
an aerosolized breathing treatment was administered, the
patient begins to cough secretions into the HME and their
high-pressure alarm begins to sound. Which of the
following would you recommend?
A. Suction the patient
B. Replace the HME
C. Increase the high-pressure alarm
D. Provide an additional breathing treatment

144. A V/Q scan was performed on a 69-year-old male patient

for analysis. Which of the following findings would suggest
that a pulmonary embolism is present?
A. Areas with normal ventilation and normal perfusion
B. Areas with no ventilation and no perfusion
C. Areas with normal ventilation but no perfusion
D. Areas with no ventilation but normal perfusion

145. A 67-year-old male patient with a history of smoking was

admitted for shortness of breath. A chest radiograph shows
depressed hemidiaphragms and an increased
anteroposterior diameter of the chest. Which of the
following conditions is most likely present?
A. Left-ventricular failure
B. Pneumothorax
C. Pulmonary fibrosis
D. Emphysema

48
146. A 51-year-old female patient who is intubated has been
transported from the emergency room to the intensive care
unit. The physician is concerned that the endotracheal tube
has moved out of the correct position. Which of the
following is the best way to determine its location?
A. Auscultate the stomach
B. Palpate the larynx
C. Order a chest radiograph
D. Perform percussion to the chest

147. A series of pulmonary function tests were performed on a

60-year-old female patient with the following results:
Vital Capacity = 3,500 mL
Functional Residual Capacity = 4,500 mL
Expiratory Reserve Volume = 1,400 mL
What is the patient’s residual volume?
A. 1,000 mL
B. 3,100 mL
C. 4,900 mL
D. 5,900 mL

148. A 52-year-old male patient has a P/F ratio of 425. This value
indicates which of the following?
A. Mild ARDS
B. Moderate ARDS
C. Severe ARDS
D. Normal oxygenation

49
149. A 61-year-old male postoperative patient who is receiving
ventilatory support has started to awaken. The patient is
receiving an FiO2 of 40% with PEEP of 5. This indicates
which of the following?
A. The patient is at risk of oxygen toxicity
B. The patient has an increased PaO2/FiO2 Ratio
C. The patient has adequate oxygenation for weaning
D. The patient needs continued ventilatory support

150. An upper airway inspection prior to the intubation of an

adult patient revealed that only the hard palate, soft palate,
and base of the uvula are visible. What is the Mallampati
classification?
A. Class 1
B. Class 2
C. Class 3
D. Class 4

151. A newborn infant in the has neonatal intensive care unit

has a Silverman score of 4. How should this be interpreted?
A. No respiratory distress
B. Moderate respiratory distress
C. Severe respiratory distress
D. Invasive suctioning is indicated

152. The pulmonologist wants to run tests on a 68-year-old male

patient with a history of smoking to assess for the possible
diagnosis of lung cancer. Which of the following imaging
techniques would you recommend?

50
 A. Pulmonary Ventilation/Perfusion Scan
B. Barium Swallow
C. Magnetic Resonance Imaging
D. Positron Emission Tomography

153. A spontaneous breathing trial was performed on a 64-year-

old male patient to evaluate if he can be weaned from the
ventilator but the physician deemed the attempt
unsuccessful. Which of the following would you
recommend?
A. Attempt another spontaneous breathing trial in 1 hour
B. Attempt another spontaneous breathing trial in 6 hours
C. Attempt another spontaneous breathing trial in 12 hours
D. Allow the patient to rest for 24 hours before another
attempt is made

154. The physician has requested to switch an adult patient

from a standard tracheostomy tube over to a fenestrated
tracheostomy tube. What is the primary advantage of using
a fenestrated tube?
A. Fenestrated tubes reduce tracheal injuries
B. Fenestrated tubes help minimize secretions
C. Fenestrated tubes allow the patient to speak
D. Fenestrated tubes minimize the risk of infection

155. During your shift in the neonatal ICU, the physician has
recommended hyperventilation as a method of treatment
for a newborn infant. For which of the following conditions
would this treatment modality typically be recommended?

51
 A. Respiratory distress syndrome
B. Meconium aspiration
C. An infant with normal lung compliance
D. Persistent Pulmonary Hypertension of the Newborn

156. Which of the following patients would the application of a

heated humidifier would pose the greatest potential
hazard?
A. A patient with hyperthermia
B. A patient with hypothermia
C. A patient with thick secretions
D. A patient with hypovolemia

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

ventilatory support in the pressure controlled SIMV mode.
Upon assessment, you feel rhonchal fremitus on the chest
wall during inspiration and expiration. Which of the
following would you recommend?
A. Switch to volume controlled SIMV
B. Perform endobronchial suctioning
C. Administer a bronchodilator treatment
D. Decrease the pressure limit setting

158. During the assessment of a patient 70-year-old female

patient, you noticed that her trachea is slightly positioned
to right side of the neck. Which of the following conditions
is most likely present?
A. Atelectasis
B. Pulmonary edema

52
 C. Pulmonary fibrosis
D. Chronic bronchitis

159. The following data was obtained on a 63-year-old female

patient who is receiving ventilatory support:
Rate = 12/min
Tidal Volume = 450 mL
Inspiratory Time = 1.3 seconds
PIP = 25
PEEP = 5
What is the patient’s mean airway pressure?
A. 7.3 cmH2O
B. 9.4 cmH2O
C. 10.2 cmH2O
D. 13.7 cmH2O

160. In addition to counseling, which of the following

prescription medications may be an effective modality to
help with smoking cessation?
A. Midazolam (Versed)
B. Buproprion (Zyban)
C. Beclomethasone (Vanceril)
D. Formoterol (Foradil)

53
Section 2

1. Which of the following EKG leads should be placed in the 5th

intercostal space at the midaxillary line?
A. V3
B. V4
C. V5
D. V6

You absolutely must know the proper placement for the chest
leads of an EKG for the TMC Exam. They are as follows:

• V1 – 4th intercostal space, patient’s right sternum

• V2 – 4th intercostal space, patient’s left sternum
• V3 – Between V2 and V4
• V4 – 5th intercostal space, Midclavicular line
• V5 – 5th intercostal space, between V4 and V6
• V6 – 5th intercostal space, Midaxillary line

So for this one, the correct answer has to be D.

The correct answer is: D. V6

2. A 69-year-old female patient arrived to the emergency

roomed confused with dehydration. Which of the following
would you expect to find?
A. Bradycardia
B. Jugular venous distention
C. Pedal edema
D. Poor skin turgor

To get this one correct, you simply just needed to know that signs
of dehydration.

54
Also, it’s helpful to recognize that JVD and pedal edema are signs
of fluid overload, so you can rule those two out immediately. You
would expect to see tachycardia with dehydration, not
bradycardia.

Skin turgor is refers to the elasticity of the skin. If the skin turgor is
poor, this means that the patient is dehydrated. So now you know
that the correct answer has to be D.

The correct answer is: D. Poor skin turgor

3. You are called to perform bedside spirometry tests on a 58-

year-old female patient. The physician requests the patient’s
tidal volume, peak flow, and FVC. Which of the following
devices would you select in order to obtain these values?
A. Body Plethysmograph
B. Stead-Wells water seal spirometer
C. Maximum inspiratory pressure manometer
D. Differential-pressure pneumotachometer

To get this one correct, you simply just needed to understand

what device can obtain the values that are mentioned in the
question.

A Stead-Wells water seal spirometer is larger and typically isn’t

used at bedside, so we can rule that one out right away. The same
can be said about a body plethysmograph.

An MIP manometer is used for an MIP test and does not measure
flows.

A differential-pressure pneumotachometer is a portable device

that is commonly used at a patient’s bedside. It can measure their
tidal volume, FVC, and peak flow.

55
So by using what we know about PFT measurements, as well as
the process of elimination, you know that the correct answer has
to be D.

The correct answer is: D. Differential-pressure

pneumotachometer

4. A 49-year-old post-operative patient was just initiated with

volume-control A/C ventilation. It was noted that the patient
has clear, scant secretions. Which of the following
humidification devices would you recommend?
A. Bubble humidifier
B. Pneumatic nebulizer
C. Heated wick humidifier
D. Heat and moister exchanger

To get this one correct, you needed to be familiar with the

different types of humidification devices.

HMEs (Heat and Moisture Exchangers) are used to provide

humidification during mechanical ventilation. What I want you to
remember is that the HME may become obstructed if the patient
has really thick secretions and this will cause an increase in peak
pressure.

In this case, you should remove the HME and replace it with a
heated wick humidifier. These are the only humidification devices
that can condition gas to 100% body humidity (44 mg/L).

But for this patient, the question tells us that they do not have
any secretions, so we know that D has to be the correct answer.
So just to recap — for the exam — know to never use an HME on a
patient with thick secretions.

The correct answer is: D. Heat and moister exchanger

56
5. A sputum sample was ordered on 54-year-old female patient
with a suspected lung infection. Which of the following would
you recommend in order to collect the sample?
A. Lukens trap
B. Coude catheter
C. Yankauer
D. Bulb suction

For the TMC Exam, you need to be familiar with the types of
suctioning devices.

• Yankauer – used for oral suctioning

• Coude tip catheter – is bent near the tip specifically to help
suction the left mainstem bronchus
• Bulb suction – used for an infant’s nose or mouth
• Ballard® – the brand name for in-line suctioning that we use
during mechanical ventilation
• Lukens trap – used to obtain a sputum sample

So for this patient, in order to collect a sample, you can easily

determine that the correct answer has to be A.

The correct answer is: A. Lukens trap

6. An adult patient has a left ventricular stroke volume of 75 mL

and a heart rate of 88. What is the cardiac output?
A. 11.2 L/min
B. 8.4 L/min
C. 6.6 L/min
D. 3.7 L/min

57
To get this one correct, you needed to know how to perform the
simple cardiac output calculation. We share our strategy for ALL
the calculation inside of our Hacking the TMC Exam video course.
But this one is simple enough that we’ll cover it now.

The formula for cardiac output is:

CO = HR × SV (L)

Now all you have to do is plug the numbers in.

There is one thing to remember: The stroke volume value was

given in mL but it must be converted to L. You can do this simply
by moving the decimal over 3 spaces to the left.

CO = 88 × 0.075
CO = 6.6 L/min.

The correct answer is: C. 6.3 L/min

7. As a Respiratory Therapist, you should recommend an annual

influenza vaccination to which of the following?
A. A 21-year-old female with asthma
B. A 5-month-old infant
C. A 65-year-old male with Guillain-Barr syndrome
D. A 25-year old pregnant female patient

To get this one correct, you basically just need to know the
indications and contraindication for recommending a flu shot.

Flu shots are not recommend for infants under 6 months of age.
Also, they are contraindicated in patients with Guillain-Barr
syndrome as well. Flu shots are contraindicated in pregnant
females in their first trimester, so we can rule that one out as well.

58
Flu shots are recommend for all healthcare workers due to the
high-risk of contact with infected patients.

Flu shots are also recommend for those with preexisting

cardiopulmonary diseases to help prevent exacerbations of their
condition. Flu shot are generally recommended for everyone over
the age of 50.

So by using what we know about the influenza vaccination, as

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

The correct answer is: A. A 21-year-old female with asthma

8. You are called to measure the strength of a patient’s

respiratory muscles at the bedside. Which of the following
devices would you select?
A. Pressure manometer
B. Peak flowmeter
C. Ergometer
D. Respirometer

In order to measure the patient’s respiratory muscle strength, you

need to obtain an MIP or MEP reading. And to get this
measurement, you can use a pressure manometer with a
disposable mouthpiece.

Remember, MIP is used to assess the possibility of weaning from

mechanical ventilation. MEP is helpful in assessing the patient’s
ability to cough and clear secretions, which is also helpful in
determining if it’s safe to extubate the patient.

None of the other answer choices can provide you with a

measurement of the patient’s respiratory muscle strength, so you
know that the correct answer has to be A.

59
The correct answer is: A. Pressure manometer

9. A patient with acute respiratory acidosis would be expected to

have a base excess in the range of which of the following?
A. + 6 mEq/L
B. - 6 mEq/L
C. +/- 2 mEq/L
D. +/- 8 mEq/L

To get this one right, you simply just had to know the normal
range for Base Excess—which of course, is +/- 2 mEq/L.

Base Excess simply refers to the excess amount of base that’s

present in the blood.

The question tells us that the patient has acute or

uncompensated respiratory acidosis, and in this case, the base
excess should always fall within the normal range.

In another scenario, if there was renal compensation present, like

you would see in a patient with chronic COPD, the Base Excess
would be elevated above the normal range due to the increased
levels of Bicarb. Remember, when the PaCO2 levels are
chronically increased, the Bicarb levels will increase as well in
order to compensate.

But for this patient, there is an acute condition so we know that

the correct answer has to be C.

The correct answer is: C. +/- 2 mEq/L

60
10. Which of the following is the preferred procedure for
establishing a patent tracheal airway in an emergency
situation?
A. Orotracheal intubation
B. Nasotracheal intubation
C. Tracheostomy procedure
D. Cricothyrotomy

The key word in this question is the word emergency.

In an emergency situation, orotracheal intubation is the best

option because it is usually a quicker and easier procedure to
perform compared to the nasotracheal route.

A cricothyrotomy would be performed in an emergency life-

threatening situation, but it is not the preferred method. It should
only be attempted after orotracheal intubation attempts are
unsuccessful.

Tracheostomy tubes are indicated for long-term mechanical

ventilation patients, therefore, it’s not recommended in this case.
So we know that the correct answer is A.

The correct answer is: A. Orotracheal intubation

11. A patient performs an FVC maneuver and displays the

following results:

61
 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 have 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 course, if you’re interested.

You should be able to recognize the tracing pattern for normal

lungs.

Also, 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 definitely appears to be short and wide which tells us

that the patient has a large or fixed airway obstruction.
This most likely means that there is an obstruction in the trachea
or mainstem bronchus.

The key finding to this loop is the reduced inspiratory and

expiratory flow rates, and that is what gives it the flat appearance.

62
None of the other answer choices could possibly be correct, so we
know that the correct answer has to be C.

The correct answer is: C. Large airway obstruction

12. The physician ordered an ABG on a 41-year-old patient with

COPD. Before drawing the sample from the radial artery,
which of the following should be performed?
A. Check the patient’s oxygen saturation
B. Modified Allen test
C. Nail bed blanching
D. Blood pressure measurement

ALWAYS remember— whenever you’re going to stick an ABG in

the radial artery, you first have to perform the modified Allen test
in order to check for collateral circulation.

The test is performed by occluding the radial artery to check for

circulation through the ulnar artery. That way, if something
happens to the radial artery during an ABG stick, the hand will
still be perfused via the ulnar artery.

None of the other answer choices are required before an ABG

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

The correct answer is: B. Modified Allen test

13. What is the purpose of using a cuffed artificial airway when

providing long-term positive pressure ventilation?
A. To facilitate the removal of secretions
B. To decrease the airway resistance
C. To prevent gas leaks and aspiration
D. To decrease the work of breathing

63
In general, an endotracheal tube with a cuff in needed when
providing long-term positive pressure ventilation because it
prevent leaks and protects the lungs against aspiration.

The cuff does not help with the removal of secretions and it does
not decrease airway resistance. Also, it does not decrease the
work of breathing either.

So by using the process of elimination, we could easily determine

that the correct answer has to be C.

The correct answer is: C. To prevent gas leaks and aspiration

14. You collected an ABG on a 30-week gestational age infant

that is receiving oxygen via oxyhood at 60%. The results are
as follows:
pH 7.36
PaO2 47 torr
PaCO2 44 torr
After reviewing the results, which of the following would you
recommend?
A. Nasal CPAP at 4 cm H2O
B. Intubate and provide mechanical ventilation
C. Switch the infant to a nonrebreather mask
D. Increase the oxygen to 70%

To get this one correct, you have to be able to interpret the ABG
results of the infant and make the necessary changes.

A PaO2 of 47 torr is extremely low, so you should automatically

know that you need to improve the infant’s oxygenation. Since
they are already hypoxemic on 60%, increasing the FiO2 to 70%
probably isn’t going to do any good.

64
A nonrebreather definitely isn’t the best action to take either.
Also, in this case, intubation and mechanical ventilation are not
indicated yet.

Nasal CPAP with a pressure of 4 cm H20 is the most appropriate

action to take at this time. Most infants with moderate hypoxemia
respond well to nasal CPAP. After a trial of nasal CPAP, if the
infant’s PaO2 does not improve, then mechanical ventilation
would be indicated.

So by using what we know about treating neonates, as well as the

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

The correct answer is: A. Nasal CPAP at 4 cm H2O

15. Which of the following is a disadvantage of using a pulse

oximeter for monitoring the oxygenation status of a patient?
A. Pressure sores at the measuring site
B. False results leading to incorrect decisions
C. Electrical shock at the measuring site
D. Skin burns due to using incompatible probes

After reading the answer choices, you should be able to quickly

determine that the correct answer is B.

There are several factors that you must be aware of that can
cause a pulse oximeter to give incorrect results. Some of them
include:

• Motion artifact – make sure the probe is secure and limit

movement as much as possible.
• Low perfusion – if the patient lacks circulation in the finger,
you may have to try a different site, like the earlobe or
forehead.

65
 • Presence of COHb – If the patient has been exposed to
carbon monoxide, as we discussed, their SpO2 will read
falsely high.
• Darkly pigmented skin – Patient’s with dark skin will yield
results that read falsely high.
• Painted fingernails – Patient’s with dark, painted nails will
yield results that read falsely high.

And of course, these false readings can lead to incorrect decisions.

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. False results leading to incorrect

decisions

16. While assessing 50-year-old male patient, you notice that his
trachea is not positioned in the midline. Which of the
following conditions would be the mostly likely cause of this
finding?
A. Lobar collapse
B. Pulmonary edema
C. Pulmonary fibrosis
D. Chronic bronchitis

Observing the position of the trachea can help you determine a

patient’s condition.

The trachea can be pulled toward an area of decreased lung

volume — like atelectasis or lobar collapse. The trachea is pushed
away from areas with excess air or fluid — like a pneumothorax or
pleural effusion.

Chronic bronchitis and pulmonary fibrosis do not normally cause

a shift in the mediastinum and trachea, so we can rule them out.

66
So taking what we know about a tracheal or mediastinal shift, we
can see that only one of the answer choices would cause the
trachea not to be positioned in the midline. The correct answer
has to be A.

The correct answer is: A. Lobar collapse

17. You are instructing a patient on how to perform an FVC

maneuver. After looking at the results of an attempt, you
determine that the back extrapolated volume is excessive.
Before another attempt, 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.”

The question tells us that the back extrapolated volume is

excessive, which means that there is a hesitation at the beginning
of the patient’s breath. This, of course, can cause invalid results.

In this case, you should simply instruct the patient not to hesitate
at the beginning of the forced exhalation. This will fix the
problem.

Taking a deeper breath will not fix the issue and the patient
doesn’t seem to have a problem about blasting the air out fast
enough. Blowing out longer isn’t going to fix the issue either. So
we know that the correct answer has to be B.

The correct answer is: B. “Don’t hesitate.”

67
18. A 63-year-old male patient is receiving volume controlled
ventilation with a PEEP of 5 cm H2O. Over a 3-hour period,
his peak pressure has been steadily increasing while his
plateau pressure has remained the same. No ventilator
setting changes have been made. What is the most likely
cause?
A. The patient is developing pneumonia
B. The patient is developing bronchospasm
C. The patient is developing atelectasis
D. The patient’s lung compliance is decreasing

The question tells us that the peak pressure has been increasing
at a steady rate while the plateau pressure remained the same.
The means that the patient’s airway resistance is increasing.

Now you just need to look at the answer choices to determine

which one would cause an increase in airway resistance.

Bronchospasm affects the airways and causes and increased

airway resistance, which tells us that B has to be the correct
answer.

All of the other answer choices suggest a decreased lung

compliance which is why we can rule them out.

The correct answer is: B. The patient is developing bronchospasm

19. A carbon monoxide reading was taken on a 64-year-old

female patient with COPD. Her results were 5 ppm. This
finding indicates which of the following:
A. The patient has abstained for more than 12 hours
B. The patient can be classified as a non-smoker
C. The patient has smoked within the past 24 hours
D. The patient has been exposed to secondhand smoke

68
Exhaled Carbon Monoxide Testing is used to monitor a patient’s
smoking status. In order to get this one correct, you needed to
know how to assess the results of an exhaled CO test.

The results can be interpreted as follows:

• Heavy smokers: > 20 ppm

• Moderate smokers: 11 – 20 ppm
• Light smokers: 7 – 10 ppm
• Non-smokers: < 7 ppm

With an expired CO analysis of 5 ppm, you can conclude that the

patient is a non-smoker, so you know that the correct answer has
to be B.

The correct answer is: B. The patient can be classified as a non-

smoker

20. You have a patient that is receiving scheduled aerosol

treatments with albuterol every four hours. The patient does
not take breathing treatments at home and has no history of
smoking. Upon assessment, you note clear breath sounds
that are equal bilaterally. Which of the following would you
recommend for this patient?
A. Continue the treatments as ordered
B. Discontinue the aerosol treatments
C. Perform postural drainage and percussion
D. Switch to an MDI with albuterol

After reading the question, you should be able to determine that

this patient has normal airways and does not need bronchodilator
treatments.

Bronchodilators, like albuterol, are indicated to treat

bronchoconstriction. This patient is not showing any signs of

69
bronchoconstriction, therefore, the treatments should be
discontinued.

Moreover, there is no need for postural drainage and percussion

in this case. We know that the correct answer has to be B.

The correct answer is: B. Discontinue the aerosol treatments

21. You just obtained a peak flow measurement of 3.7 L/sec on a

39-year-old male who is 5 feet 9 inches tall. What is the
interpretation of this test result?
A. The patient has poor gas distribution
B. The patient has decreased lung compliance
C. The patient’s peak flow is normal
D. The patient has an airflow obstruction

The first thing you need to do is determine if the peak flow

measurement is normal, high or low. And to do that, you have to
know the normal range.

The normal range for peak flows in adults is 6–12 L/second.

So clearly, this patient’s peak flow measurement is below normal

which means that the patient has an airflow obstruction. The
peak flow test does not assess lung compliance and has nothing
to with gas distribution. So we know that the correct answer has
to be D.

The correct answer is: D. The patient has an airflow obstruction

22. While reviewing the results of a forced vital capacity

maneuver of an adult male patient, you note that an ‘S’

70
 shaped curve appears on the flow-volume graph. This most
likely indicates which of the following?
A. The patient stopped exhalation too soon
B. The patient was coughing during the attempt
C. The patients was breathing too fast during the attempt
D. The patient gave poor effort at the start of the breath

After a patient performs an FVC maneuver, if you see an S-shaped

curve on the flow-volume loop graph, this indicates that the
patient gave a poor effort at the start of the breath.

If you think about it, it’s an S-shape because the flow starts out
low with poor effort, then it increases in the middle of the
maneuver and then plateaus toward the end of the breath.

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

The correct answer is: D. The patient gave poor effort at the start
of the breath

23. A 70-year-old female patient with a progressive

neuromuscular condition needs mechanical ventilation. All of
the following measurements would be useful EXCEPT:
A. Airway resistance
B. Maximum inspiratory pressure
C. Maximum expiratory pressure
D. Vital capacity

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

understanding of neuromuscular disorders.

Remember, as a Respiratory Therapist, you must be familiar with

neuromuscular disorders because they cause respiratory muscle
weakness which leads to respiratory failure.

71
And in order to assess a patient’s respiratory muscle strength, you
can measure the patient’s MIP and MEP. Vital capacity is also a
useful measurement when it comes to assessing respiratory
mechanics.

Airway resistance is the measure of the impedance to ventilation

caused by the movement of gas through the airways. It’s not
usual when it comes to measuring respiratory muscle strength,
so you know that the correct answer has to be A.

The correct answer is: A. Airway resistance

24. An ABG was collected on a 59-year-old female patient with

the following results:
pH = 7.52
PaCO2 = 44 torr
HCO3 = 36 mEq/L
PaO2 = 85 torr
The acid-base interpretation can be classified as which of the
following?
A. Acute (uncompensated) respiratory alkalosis
B. Acute (uncompensated) metabolic alkalosis
C. Combined respiratory and metabolic alkalosis
D. Fully compensated respiratory alkalosis

To get this one correct, you just needed to know how to interpret
the ABG results.

The pH is increased and the PCO2 is in the normal range. The

HCO3 is increased which tells us that the patient has primary
metabolic alkalosis.

Since the PCO2 is normal, that means that there is no

compensation and the problem is an acute or uncompensated
metabolic alkalosis.

72
The correct answer is: B. Acute (uncompensated) metabolic
alkalosis

25. Which of the following patients should you avoid the

insertion of an oropharyngeal airway?
A. A patient that has a foreign body obstruction
B. A patient that requires manual ventilation
C. A patient that is unconscious
D. A patient that is less than 12-years-old

For the exam, you must remember that oropharyngeal airways

should not be used on patients that are conscious because they
will have an active gag reflex, which could cause gagging and
vomiting.

Also, when a foreign body is already obstructing the oropharynx,

you wouldn’t want to use an oropharyngeal airway in this case
either. That tells us that the correct answer is A.

Oropharyngeal airways are often used during bag-valve-mask

ventilation and as long as you use the correct size, they can be
used in children as well. And again, you only want to use this type
of airway on patient’s that are unconscious. So we know that the
correct answer has to be A.

The correct answer is: A. A patient that has a foreign body

obstruction

26. A 3-year-old boy has arrived to the emergency department

having an asthma attack. Which of the following drugs
would you NOT recommend for the initial management of
an acute asthma attack for a child?
A. Epinephrine

73
 B. Albuterol (Proventil)
C. Terbutaline (Brethaire)
D. Cromolyn sodium (Intal)

To get this one correct, you just need to know which drugs should
and should not be given for an acute asthma attack.

For patients having an asthma attack, you need to provide a

short-acting beta-agonist bronchodilator like albuterol or
terbutaline. Also, Epinephrine is an ultra-short acting
bronchodilator that could potentially be used to treat an asthma
attack in children.

Remember that cromolyn sodium is a controller medication that

is used to prevent asthma attacks. It is only a preventative
medication for asthma which means that it will do nothing to
treat an acute attack.

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 D.

The correct answer is: D. Cromolyn sodium (Intal)

27. A new patient just finished a cardiothoracic surgery

procedure. Upon assessment, you noticed that the patient
has a paradoxical pulse. Which of the following conditions is
most likely?
A. Pericarditis
B. COPD exacerbation
C. Myocardial infarction
D. Cardiac tamponade

To get this one right, first, you have to know exactly what is a
paradoxical pulse.

74
A paradoxical pulse, aka pulsus paradoxus, is when the pulse or
blood pressure varies or changes during inhalation and
exhalation. It is most often seen during a tension pneumothorax
or cardiac tamponade and often occurs when the patient has a
flail chest.

Cardiac tamponade is an accumulation of fluid within the

pericardial sac. One of the most common side effects of cardiac
tamponade is a paradoxical pulse.

So on the TMC Exam, if you get a question where the patient has
a chest trauma injury, be sure to remember that a pneumothorax,
flail chest, cardiac tamponade, and thus pulsus paradoxus may
occur.

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. Cardiac tamponade

28. While assessing a 71-year-old male patient, you note that

their chest has a barrel-shaped appearance. This indicates
that the patient most likely has which of the following?
A. Pectus excavatum
B. Pectus carinatum
C. Signs of air trapping
D. Normal chest anatomy

To get this one correct, you simply just needed to have an

understanding of the typical findings for obstructive diseases.

A barrel-shaped appearance means that the patient has an

increased AP diameter of the lungs. This results from air trapping
which is a common finding in patients with COPD — particularly
emphysema.

75
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. Signs of air trapping

29. While assessing a 63-year-old male patient via chest

palpitation, you note that there is less movement on the
patient’s right side compared to the left side. This is an
indication for which of the following conditions?
A. Left-sided chronic bronchitis
B. Right-sided chronic bronchitis
C. Left-sided pneumothorax
D. Right-sided pneumothorax

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

understanding of the pathology of the conditions that are listed
in the answer choices.

If you were to palpate the chest of a patient with chronic

bronchitis, you would not expect to find a one-sided change in
movement. That means we can rule out A and B right away.

With a pneumothorax, on the other hand, you would expect a

unilateral change of the affected side. The question tells us that
there is less movement on the right side, so we know that the
correct answer has to be D.

The correct answer is: D. Right-sided pneumothorax

30. An EKG was taken on a dyspneic 54-year-old male patient in

the emergency department. In which of the following results
should cardioversion be performed?
A. Ventricular fibrillation

76
 B. Atrial flutter
C. Second-degree heart block
D. Ventricular tachycardia with a pulse

For the TMC Exam, you have to know when it’s appropriate to
perform a shock on a patient with an irregular heart rhythm. First,
let’s discuss when unsynchronized defibrillation is required.

There are two shockable rhythms for defibrillation:

• Ventricular Fibrillation
• Pulseless Ventricular Tachycardia

Cardioversion, on the other hand, is a synchronized shockable

rhythm. Here’s when to recommend cardioversion:

• Supraventricular Tachycardia
• Ventricular Tachycardia with a Pulse

So for the patient mentioned in the question, with V-tach with a

pulse, cardioversion should be initiated as soon as possible to
restore normal sinus rhythm.

The correct answer is: D. Ventricular tachycardia with a pulse

31. The doctors requested for an oropharyngeal airway to be

inserted on 46-year-old male patient. This airway type is
useful in supporting which of the following?
A. Aerosol drug therapy
B. Frequent suctioning
C. Bag-mask ventilation
D. Incentive spirometry

77
For the exam, you need to know the difference between a
nasopharyngeal and oropharyngeal airway for the exam.

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.

The correct answer is: C. Bag-mask ventilation

32. A 49-year-old male patient has a vital capacity of 3400 mL, a

functional residual capacity of 4600 mL and expiratory
reserve volume of 1400 mL. What is his residual volume?
A. 8700 mL
B. 2100 mL
C. 3200 mL
D. 5800 mL

You may see a calculation such as this on the exam, but don’t
panic! This is a very simple calculation. To get this one right, you
must know that FRC = RV + ERV.

You can use the Lung Box to remember this. We share our
strategy about the Lung Box inside of our Hacking the TMC Exam
video course, if you’re interested.

So using the same formula, it also means that RV = FRC – ERV.

4600 – 1400 = 3200 mL

78
So by performing this simple subtraction, we calculated that the
patient’s residual volume is 3200 mL, which means that the
correct answer is C.

The correct answer is: C. 3200 mL

33. You were called by the nurse to assist with the assessment of
a newborn infant in the NICU. Which of the following signs is
an indication that the infant is in respiratory distress?
A. Pallor
B. Cyanosis
C. Grunting
D. Digital clubbing

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

The most common signs include:

• Tachypnea
• Nasal flaring
• Grunting
• Chest wall retractions

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

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. Grunting

79
34. Which of the following would you expect to see during
inspiration to indicate normal diaphragm activity?
A. An inward motion of the abdomen
B. An outward motion of the abdomen
C. Supraclavicular retractions
D. Intercostal retractions

During normal breathing, when the diaphragm contracts during

inspiration, it drops and pushes the abdominal contents outward.

If the diaphragm does not contract and descend properly, this

normally indicates that a neuromuscular disorder is present. This
could also be seen in advanced COPD or emphysema when there
is a flattened diaphragm, which would indicate an increased work
of breathing or muscle fatigue.

Retractions and an inward motion of the abdomen would be

considered abnormal findings during inspiration. The correct
answer is B.

The correct answer is: B. An outward motion of the abdomen

35. While assessing a female patient’s breathing pattern, you

see that her tidal volumes go from small to large to small and
then stop for 10 seconds before starting again. Which of the
following would best describe this breathing pattern?
A. Cheyne-stokes breathing
B. Kussmaul breathing
C. Obstructed expiration
D. Eupnea

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

80
When you have a patient that is breathing deep and shallow
breaths with periods of apnea, this is the Cheyne-stokes
breathing pattern. The most important thing that I want you to
remember about this pattern is that it is seen in stroke and head
trauma patients.

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.
• Kussmaul – Deep and fast. An increased respiratory rate and
depth, with an irregular rhythm. It is usually associated with
diabetic ketoacidosis.
• 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, you can quickly determine

that this one has to be A.

The correct answer is: A. Cheyne-stokes breathing

36. A 57-year-old male patient with a hemothorax recently had a

chest tube and pleural drainage system inserted. Upon
assessment, you note that the drainage level has stayed the
same over a 2-hour period. Which of the following would you
recommend?
A. Withdraw the chest tube about 3-4 cm
B. Check the connecting tubing for kinks
C. Add water to the water seal chamber
D. Add water to the suction control chamber

81
For the TMC Exam, you need to be familiar with chest tubes and
pleural drainage systems. Here are a few tidbits that you should
remember:

• If there is no bubbling in the suction chamber, that means

that there could be a leak in the system, or you may just
need to increase the vacuum suction pressure.
• On the other hand, if there is bubbling in the water seal
chamber, this is normal when a pneumothorax is present.
This lets you know that the air is being drained properly.
• However, the bubbling in the water seal chamber should not
be continuous. It should be sporadic. If there is continuous
bubbling, that means that a new leak has developed. You
should check for a loose connection.
• If the collection chamber becomes full, you should clamp
the chest tube and exchange the system with an empty
chamber.
• If there has been no change in drainage, there may be a kink
in the tubing.

The correct answer is: B. Check the connecting tubing for kinks

37. You are called to the emergency department to help

extubate an adult female patient who is orally intubated. All
of the following equipment should be available for
extubation EXCEPT:
A. New endotracheal tube
B. Suction equipment
C. Bag-valve mask
D. Arterial blood gas kit

As a Respiratory Therapist, before extubating a patient, there is

certain equipment that is required for the procedure. You would
need the following:

82
 • Suction equipment
• Oxygen and aerosol therapy setups
• Manual resuscitator with bag valve mask
• A new intubation kit

A new ET tube, which would be included in a new intubation kit,

is needed in case rapid reintubation is required. Suction
equipment is always needed during extubation in case of excess
secretions. A manual resuscitator is always needed as well.

An ABG kit is not required for extubation. If the patient were to

deteriorate, then an ABG may be necessary. But it’s not required
at bedside in order to perform an extubation.

The correct answer is: D. Arterial blood gas kit

38. The physician asks for your opinion on whether or not to

initiate IPPB on a new post-operative adult patient. Which of
the following is an absolute contraindication for this
treatment modality?
A. Acute atelectasis
B. Hemoptysis
C. Congestive heart failure
D. Bacterial pneumonia

To get this one correct, you simply just needed to know when
NOT to recommend IPPB therapy. The contraindications are:

• An untreated tension pneumothorax

• Hemoptysis
• Lack skilled personnel to operate the machine
• Availability of simpler therapies like incentive spirometry

IPPB, or Intermittent Positive Pressure Ventilation, is essentially a

positive pressure ventilator that uses a mouthpiece.

83
As a general rule, incentive spirometry is always preferred over
IPPB as long as the patient can perform it with proper technique.

If they can’t, for example, if they’re too sedated after surgery, then
IPPB would be indicated.

The correct answer is: B. Hemoptysis

39. You are called to assist with the delivery of a high-risk infant.
After being evaluated, the infant is given a five-minute Apgar
score of 8. What should you recommend at this time?
A. Give the infant supplemental oxygen
B. Begin bag/mask rescue breathing on the infant
C. Give the infant to the mother for bonding
D. Give the mother supplemental oxygen

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

the Apgar score ranges.

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

immediately after birth, and should be performed 1 minute and 5
minutes after birth.

• Appearance
• Pulse
• Grimace
• Activity
• Respirations

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

84
So in this question, the infant has an Apgar score of 8 which
indicates that the newborn is in good condition and can be given
to the mother for bonding.

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. Give the infant to the mother for
bonding

40. You are about to perform pulmonary function tests on a 52-

year-old male patient. Before you begin, the patient
mentioned that he smoked 3 cigarettes in the past two
hours. Which of the following tests would be affected by this
finding?
A. FVC
B. FRC
C. Raw
D. Lung Diffusion

By looking at the answer choices, you can determine that the

FVC, FRC, and Raw would not be affected (in the short term) by
cigarette smoking. So that means that the correct answer has to
be lung diffusion.

In a lung diffusion test, the carbon monoxide from the cigarettes

would adversely affect the results. The correct answer is D.

The correct answer is: D. Lung Diffusion

41. A male patient arrives to the emergency department in

excruciating pain after a motor vehicle accident. The patient
is screaming and appears to have multiple broken bones in

85
 his legs. Which of the following medications would you
recommend for sedation?
A. Ibuprofen
B. Ipratropium bromide
C. Morphine sulfate
D. Succinylcholine

To get this one correct, you simply just needed to have a basic
understanding of the medications that are listed in the answer
choices.

Ibuprofen is not indicated for severe pain. Succinylcholine is a

paralyzing agent, not a sedative. Ipratropium bromide, aka
Atrovent, is an anticholinergic agent.

Morphine is a sedative that is used to relive severe acute pain,

which of course tells us that the correct answer has to be C.

The correct answer is: C. Morphine sulfate

42. You are called to access a 72-year-old female patient in the

acute phase of ARDS. Which of the following would you
expect to find?
A. Metabolic alkalosis
B. Increased compliance
C. Increased lung volumes
D. Refractory hypoxemia

Hopefully you were able to determine the correct answer

immediately for this one. Remember, refractory hypoxemia and
ARDs always go hand in hand. On the exam, whenever you see a
patient with refractory hypoxemia, you should automatically think
ARDS.

86
ARDS essentially causes a decrease in lung volumes and
compliance. This increases the patient’s spontaneous work of
breathing which results in dyspnea and tachypnea.

In addition, physiologic shunting causes severe hypoxemia that

does not respond well to increases in FIO2, i.e. refractory
hypoxemia.

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. Refractory hypoxemia

43. What is the primary cause of the S1 heart sound?

A. The opening of the semilunar valves
B. The opening of the atrioventricular valves
C. The closing of the semilunar valves
D. The closing of the atrioventricular valves

Remember, the normal heart sounds can be heard when the

heart valves close. That means we can rule out the first two
answer choices right away.

The first or S1 heart sound is produced by the closure of the mitral

and tricuspid valves during ventricular contraction. So you
needed to know that the mitral and tricuspid valves are known as
the atrioventricular valves.

Also note that when systole ends, the semilunar valves close,
creating the second or S2 heart sound. Remember, the pulmonic
and aortic valves are known as the semilunar valves.

The correct answer is: D. The closing of the atrioventricular valves

87
44. While interpreting a patient’s ABG results, you note a PaCO2
of 24 torr, a Base Excess of -11 mEq/L, and a pH of 7.36. How
would you interpret these results?
A. Acute respiratory alkalosis
B. Acute metabolic acidosis
C. Compensated respiratory alkalosis
D. Compensated metabolic acidosis

This is your typical ABG interpretation question. Let’s break this

one down.

The pH is in the normal range. The PaCO2 is decreased, and the

Base Excess is decreased. When you have abnormal values but
yet a normal pH, this tells us immediately that there is come
compensation going on.

The pH is on the low end of the normal range, meaning that it is

less than 7.40. This tells us that the primary problem is acidosis.
And since the Base Excess is severely low, we know that there is a
metabolic issue. The PaCO2 is also low because the body is
compensating for the low Base Excess in order to bring the pH
back into the normal range.

So now we know that the correct answer has to be D.

The correct answer is: D. Compensated metabolic acidosis

45. A patient arrives in the emergency department intubated

with a King LT airway. After being admitted, you are asked to
exchange the patient’s current airway with an endotracheal
tube. In order to make the switch, you would recommend
which of the following?
A. Insert the ET tube under the King LT
B. Remove the King LT and temporarily apply NIPPV
C. Use an airway exchange catheter

88
 D. Insert the ET tube on top of the King LT

A King Laryngeal Tube airway is a tube that is typically easy to

insert. It is recommended only for short-term ventilation and is
often inserted by paramedics in the field when they are unable to
insert an endotracheal tube. So in cases like this, you should
switch the patient to an ET tube as soon as possible.

And in order to make the switch, you will need an airway

exchange catheter. It is inserted through the King tube, and then
you can remove the King tube while keeping the catheter in
place. Then, you can insert the ET tube through the catheter until
it is threaded into place. Then the catheter is removed from
within the ET tube.

None of the other answer choices would be recommended in this

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

The correct answer is: C. Use an airway exchange catheter

46. The most likely cause of stridor in an adult patient would be

which of the following?
A. Croup
B. Asthma
C. Epiglottitis
D. Post-extubation edema

To get this one right, you must know what stridor is and when it
occurs.

Stridor is a high-pitched sound that is heard during inhalation in

patients with an upper airway obstruction.

89
Stridor is common with croup and epiglottitis in children, but the
question tells us that the patient is an adult. That’s the key to
getting this one right.

In adults, stridor is a common complication of endotracheal

extubation caused by edema of the vocal cords.

So after breaking it all down, we can easily determine that the

correct answer is D.

The correct answer is: D. Post-extubation edema

47. The nurse calls and requests for you to suction a pediatric
patient with excess secretions. What is the normal range of
negative pressure that should be used when suctioning the
child?
A. -60 to -80 mm Hg
B. -80 to -100 mm Hg
C. -100 to -120 mm Hg
D. -150 to -200 mm Hg

No matter if you’re suctioning a child or an adult, it’s important to

use the proper pressure in order to help avoid atelectasis and
airway trauma. Here’s what you need to remember:

• For adults, you should use a negative pressure of -100 to -120

cm H2O.
• For children, you should use a negative pressure of -80 to -
100 cm H2O.
• For infants, you should use a negative pressure of -60 to -80
cm H2O.

Do keep in mind, thicker secretions may require more negative

pressure, and thinner secretions may require less. So the pressure
can be adjusted as needed.

90
Taking this into consideration, you know that the correct answer
has to be B.

The correct answer is: B. -80 to -100 mm Hg

48. You were called by the physician to perform a Tensilon test

on a new patient. This test is commonly used to confirm the
diagnosis for which of the following conditions?
A. Myasthenia gravis
B. Guillain-Barré syndrome
C. Multiple sclerosis
D. Poliomyelitis

In order to get this one right, you simply had to know what a
Tensilon test is used for.

A Tensilon Challenge Test is used to diagnose patients with

myasthenia gravis. A patient with myasthenia gravis will show a
dramatic improvement in muscle strength within one minute of
the administration of Tensilon.

If you knew this, then you knew that the correct answer has to be
A. Please remember this because you will probably see it again on
the TMC Exam.

The correct answer is: A. Myasthenia gravis

49. While assessing a 72-year-old postoperative patient, you

noted distinct wheezing in both lung fields. Which of the
following would recommend for this condition?
A. Give the patient a bronchodilator
B. Administer incentive spirometry
C. Giver the patient a mucolytic agent

91
 D. Administer chest physiotherapy

I just created a new rule that if you miss this one, you cannot
become a Respiratory Therapist. Okay, I’m totally kidding!

But seriously — after reading the question, you should

immediately know that when a patient has bilateral wheezing,
they need a bronchodilator to reverse the narrowing of the
airways.

They tried to trick you in the question because, in general, you

would want to recommend incentive spirometry to a post-op
patient in order to prevent atelectasis. However, the BEST answer
in this case is to treat the patient’s wheezing.

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. Give the patient a bronchodilator

50. A 62-year-old male patient is receiving volume control

ventilation and you note that the endotracheal tube has
become obstructed. Which of the following findings would
you expect?
A. Increased peak pressure
B. Decreased peak pressure
C. High volume alarm
D. Decreased lung compliance

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

understanding of mechanical ventilation and the settings.

Whenever there is an obstruction of the ET tube during volume

control ventilation, you can expect the peak pressure to increase.

92
With an increased peak pressure, this will cause the patient to
reach the pressure limit early which results in a decrease in
delivered tidal volume. This would cause a low volume alarm.

Also, in cases such as this, you likely will not be able to pass a
suction catheter. This would confirm that an obstruction is
present.

The correct answer is: A. Increased peak pressure

51. An adult patient is receiving volume-controlled ventilation in

the ICU. Upon assessment, you note a sudden drop in the
peak inspiratory pressure. Which of the following is most
likely the cause of this problem?
A. Mucous plug
B. Tension pneumothorax
C. Copious airway secretions
D. Exhalation valve leak

For the TMC Exam, you should be familiar with the basic reasons
that would cause the PIP to drop in volume-controlled ventilation.
Those reasons are:

• A leak is present
• There was a decrease in either the volume or flow setting
• Decreased airway resistance
• Increased lung/thorax compliance

A mucous plug and airway secretions would increase the PIP. A

tension pneumothorax would cause the lung compliance to
decrease, which would increase the PIP as well. A valve leak
would definitely cause a sudden drop in peak pressure.

93
So by using what we know about PIP and volume-control
ventilation, as well as the process of elimination, you can
determine that the correct answer is D.

The correct answer is: D. Exhalation valve leak

52. A 60 kg postoperative female patient is intubated and the

physician orders volume control A/C ventilation. Which of the
following settings would you choose for this patient?
A. Tidal Volume 250 mL; Rate 10/min; PEEP 10
B. Tidal Volume 300 mL; Rate 22/min; PEEP 5
C. Tidal Volume 350 mL; Rate 12/min; PEEP 10
D. Tidal Volume 450 mL; Rate 12/min; PEEP 5

To get this one correct, you simply needed to know the normal
ranges for initial ventilator settings:

• Tidal volume 5 – 10 mL/kg of IBW

• PIP 20 – 30 cm H2O
• Respiratory rate 10 – 20 breaths/min
• FiO2 40 – 60% (or set to the level prior to ventilation)
• PEEP 2 – 6 cmH20
• I:E Ratio ≤ 1:2

Now all you have to do is look through the answer choices to

select the one where all the values are within the normal
parameters.

The correct answer is: D. Tidal Volume 450 mL; Rate 12/min; PEEP
5

94
53. It is noted that a 61-year-old female patient with pneumonia
has consolidation in the left lung. Which of the following
positions would you recommend for postural drainage?
A. Right lateral decubitus position
B. Left lateral decubitus position
C. Prone position with a pillow under the hips
D. Trendelenburg position with a pillow under the hips

You will see a question about the postural drainage positions on

the TMC Exam. The good news is, you will likely only see one of
these questions. Here are a few tidbits for you to remember:

• Supine – Drains the anterior segment of the upper lobes.

• Prone – Drains the superior segments and posterior basal
segments of the lower lobes.
• Trendelenburg – Drains the basal segments of the lower
lobes. Both the anterior and posterior.
• Lateral decubitus position – Used when there is
consolidation in one lung. Remember “good lung up.” For
example, to drain the right lung, you would recommend the
right lateral decubitus position.

So for this patient, we could determine that the correct answer

has to be B.

The correct answer is: B. Left lateral decubitus position

54. In which of the scenarios would it be appropriate to select

and HME during mechanical ventilation instead of a heated
wick humidifier?
A. A patient with a high fever
B. A patient intubated via the nasal route
C. A patient without thick secretions
D. A patient needing lung protective strategies

95
To get this one correct, you needed to be familiar with the
different types of humidification devices.

An HME (Heat and Moisture Exchanger) is typically the first choice

to provide humidification during mechanical ventilation. What I
want you to remember is that the HME may become obstructed
if the patient has really thick secretions and this will cause an
increase in peak pressure.

In such a case, you should remove the HME and replace it with a
heated wick humidifier. These are the only humidification devices
that can condition gas to 100% body humidity (44 mg/L).

Other HME contraindications include: hypothermia, large tidal

volumes, and large system leaks. Also note that heated
humidifiers should be used over an HME whenever lung
protective strategies are needed.

The correct answer is: C. A patient without thick secretions

55. A 62-year-old male patient is receiving pressure control A/C

mechanical ventilation. Which of the following would you
recommend in order to help prevent ventilator-associated
pneumonia?
A. Use heated humidification
B. Provide daily oral care
C. Use disposable circuit components
D. Change the ventilator circuit every 24 hours

In order to get this one correct, you needed to be familiar with the
best practices that are used to prevent VAP and nosocomial
infections.

96
VAP is pneumonia that occurs while the patient has been on the
ventilator for more than 48 hours. This means that it is usually the
medical personnel’s fault.

Here are some VAP prevention strategies that you should

remember:

• Only change the circuit when it when it is visibly soiled

• Always use standard precautions
• Elevate the head of the patient’s bed 30 –45 degrees
• Implement SBTs daily or when indicated
• Provide daily oral care
• Use a closed suction catheter system

The correct answer is: B. Provide daily oral care

56. A 57-year-old male patient is receiving oxygen via a

nonrebreathing mask. Upon assessment, you note that the
reservoir bag collapses all the way during inspiration. Which
of the following is the most likely cause of this problem?
A. The patient is a nose-breather
B. The patient is a mouth-breather
C. The oxygen flowmeter setting is too low
D. The mask is not tight enough on the face

For the TMC Exam, you will likely see a question about the
reservoir bag of a nonrebreathing mask. There are two things to
keep in mind:

• If the reservoir bag collapses all the way during inspiration,

you can troubleshoot by increasing the flow.
• If the reservoir bag does not deflate at all during inspiration,
it means that the mask is too loose on the patient’s face. You
can troubleshoot by tightening the mask.

97
The flow for a nonrebreathing mask should be > 10 L/min in order
to keep the bag from collapsing. With a loose mask, that means
air is leaking in from the sides of the mask and explains why there
is no change in the volume of the reservoir bag. This would cause
a decrease in FiO2 as well.

Additionally, with this type of mask, it does not matter if the

patient breathes through the nose or mouth.

The correct answer is: C. The oxygen flowmeter setting is too low

57. While inspecting a 64-year-old female patient, you note that

her sternum appear to have a caved-in appearance. This best
describes which of the following?
A. Kyphosis
B. Scoliosis
C. Kyphoscoliosis
D. Pectus excavatum

For the TMC Exam, you must be familiar with the spine
abnormalities. You will likely only see one question on the exam,
but you never know which one they’ll ask. That is why you must
know them all.

Here they are:

• Kyphosis – an abnormal AP curvature of the spine

• Scoliosis – an abnormal lateral curvature of the spine
• Kyphoscoliosis – a combination of kyphosis and scoliosis
which may produce a severe restrictive lung defect
• Pectus carinatum – abnormal anterior protrusion of the
sternum, i.e. the sternum pokes out.
• Pectus excavatum – depression of part or all of the sternum,
i.e. the sternum caves in.

98
Once you know this information, you can easily determine that
the correct answer is D.

The correct answer is: D. Pectus excavatum

58. You are called to give an aerosolized breathing treatment

with albuterol to a 41-year-old male patient. If the patient’s
heart rate were to increase during the treatment, that would
be a result of which of the following?
A. Alpha only
B. Beta 1 only
C. Beta 2 only
D. Beta 1 and Beta 2

You have to remember all the way back to the beginning of your
Pharmacology course to know the correct answer for this one.

When there is an increase in the patient’s heart rate after the

administration of an adrenergic bronchodilator, it is primarily due
to Beta 1 receptor stimulation.

None of the other answer choices are correct in this situation, so

you know that the correct answer has to be B.

The correct answer is: B. Beta 1 only

59. While assessing a 54-year-old male patient, you note that he

has diminished breath sounds in the right lower lobe with a
trachea that has shifted to the right. What is most likely the
cause of these findings?
A. Pneumothorax on the left side
B. Pneumonia on the left side
C. Pneumothorax on the right side

99
 D. Atelectasis on the right side

To get this one right, you have to be able to use the information
that is given in the question to interpret which disease is present.

Since the trachea has shifted to the right, by looking at the

answer choices, you know that it has to either be a left-sided
pneumothorax or right-sided atelectasis.

Remember, for a pneumothorax, the trachea will shift away from

the affected side. For atelectasis, the trachea will shift towards the
affected side.
It also says in the question that the patient has diminished breath
sounds on the right side. This tells us that the disease is on the
right, so you know that the correct answer has to be D.

The correct answer is: D. Atelectasis on the right side

60. An unresponsive 21-year-old male patient has arrived to the

emergency department. His family states that he was
dealing with depression and an overdose is suspected.
Which of the following medications would you recommend?
A. Naloxone
B. Fentanyl
C. Indomethacin
D. Vecuronium

In order to get this one correct, you simply just needed to know
what medication is given to reverse a narcotic drug overdose.
And that drug is Naloxone.

You’ve probably heard it referred to as Narcan, which is the brand

name. So you needed to know that Naloxone and Narcan are the
same thing.

100
Narcan is given to reverse an overdose on narcotic drugs such as
heroin and morphine. As a Respiratory Therapist, whenever a
patient arrives to the ER with an apparent drug overdose, you
always want to recommend Narcan in cases such as this.

You will definitely see a question similar to this one on the TMC
Exam. None of the other drugs would be helpful in this case, so
you know that the correct answer has to be A.

The correct answer is: A. Naloxone

61. A 52-year-old male patient has arrived in the ER with severe

upper airway trauma. After multiple failed endotracheal
intubation attempts, you are beginning to find it difficult to
ventilate the patient using a bag mask resuscitator. Which of
the following would you recommend?
A. Nasotracheal intubation
B. Cricothyrotomy
C. Laryngeal mask airway
D. Esophageal-tracheal tube

To get this one correct, you needed to recognize that this is a

medical emergency. The question states that it’s becoming
difficult to ventilate the patient using an bag-valve mask,
therefore, something has to be done immediately.

A cricothyrotomy would be indicated in this case. It’s an

emergency surgical procedure where an incision is made
through the skin and cricothyroid membrane in order to access
the trachea so that ventilation can occur. It’s the last step in a
'cannot-intubate-cannot-ventilate' scenario.

None of the other answer choices really make sense in this

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

101
The correct answer is: B. Cricothyrotomy

62. A 24-year-old female patient who was admitted to the

emergency department is showing signs of respiratory
distress. You would expect to find all of the following except:
A. Diaphoresis
B. A normal respiratory rate
C. Accessory muscle usage
D. Intercostal retractions

Diaphoresis, accessory muscle usage, and intercostal retractions

are all signs of respiratory distress.

For a patient in respiratory distress, you would not expect them to

have a normal respiratory rate. Instead, you would expect them to
show signs of tachypnea.

So with that said, you should easily be able to determine that the
correct answer is B.

The correct answer is: B. A normal respiratory rate

63. The administration of theophylline would pose the greatest

risk for a patient with which of the following conditions?
A. Emphysema
B. Chronic asthma
C. Chronic bronchitis
D. Sinus tachycardia

To get this one correct, you simply just needed to have a basic
understanding of the indications and contraindications of the
drug theophylline.

102
Theophylline is a methylxanthine medication that serves as a
bronchodilator in patients with asthma and COPD. It provides
anti-inflammatory effects that decreases work of breathing and
increases the contractility of the diaphragm.

Knowing this alone can help you select the correct answer
because three of the answer choices are types of obstructive
diseases. However, it should be noted that theophylline should be
used with caution in patients with cardiac arrhythmias

The correct answer is: D. Sinus tachycardia

64. A 72-year-old female patient who was diagnosed with severe

COPD is in for a visit with the pulmonologist. It is noted that
the patient has pulmonary hypertension and cor pulmonale.
Which of the following would you recommend for this
patient?
A. Corticosteroid therapy
B. Systemic vasodilators
C. Long-term oxygen therapy
D. Long-acting beta agonist therapy

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

understanding of the management of patients with COPD.

Since the patient shows signs of pulmonary hypertension and cor

pulmonale, this indicates that chronic hypoxemia is present
which is common in patients with severe COPD.

So in this case, the patient needs long-term oxygen therapy, likely

at a low FiO2, in order to help with the hypoxemia.

The correct answer is: C. Long-term oxygen therapy

103
65. A 6-month-old infant with cystic fibrosis was admitted to the
emergency department with retained secretions. Which of
the following airway clearance techniques would you
recommend for this patient?
A. Autogenic drainage
B. Postural drainage with percussion
C. Intrapulmonary percussive ventilation
D. Positive expiratory pressure

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

understanding of the airway clearance techniques that are listed
in the answer choices. If you knew them, along with some
common sense, you could easily select the correct answer.

When treating an infant, you have to take into consideration that

they will not be able to perform active types of therapy. Because,
obviously, they’re an infant, so they can’t understand or follow
instructions. So that means you can immediately rule out PEP
therapy, IPV, and autogenic drainage.

Postural drainage, on the other hand, can be performed by you,

the Respiratory Therapist. It does not require any effort by the
infant which means that the correct answer has to be B.

The correct answer is: B. Postural drainage with percussion

66. Which of the following is true regarding the synchronous

intermittent mandatory ventilation mode of mechanical
ventilation?
A. Machine breaths cannot be pressure controlled
B. The patient contributes to minute ventilation
C. Asynchrony is prevented during machine breaths
D. Only partial ventilatory support can be provided

104
To answer this one correctly, obviously, you must know about the
SIMV mode of ventilation.

SIMV allows the patient to take spontaneous breaths between

the machine breaths. This means that they have an effect on the
rate of breathing and do contribute to the total minute
ventilation in this mode.
SIMV provides full ventilatory support at normal rates and partial
support when the rate is set lower.

Machine breaths can be pressure controlled and asynchronous

breathing still can occur during machine breaths. So with that
said, we know that the correct answer has to be B.

The correct answer is: B. The patient contributes to minute

ventilation

67. Noninvasive positive pressure ventilation would be indicated

for acute respiratory failure in which of the following
conditions?
A. Narcotic drug overdose
B. Smoke inhalation injuries
C. Cardiogenic pulmonary edema
D. Acute respiratory distress syndrome

To get this one correct, you simply needed to know the

indications for NPPV:

• Acute exacerbations of COPD or asthma

• CHF or pulmonary edema (cardiogenic)
• Severe dyspnea episodes
• When a Do Not Intubate order is in place

105
Patients with ARDS, drug overdose, and smoke inhalation will like
need full ventilatory support which means that the correct
answer has to be C.

The correct answer is: C. Cardiogenic pulmonary edema

68. A patient who has developed a sudden upper airway

obstruction would display all of the following signs EXCEPT:
A. Intercostal retractions
B. Inspiratory crackles
C. Increased levels of anxiety
D. Usage of accessory muscles

If a patient were to develop a sudden upper airway obstruction,

you would expect to see signs of an increased work of breathing.

Intercostal retractions, increased anxiety, and the use of accessory

muscles are signs of dyspnea, which means that they are signs of
an upper airway obstruction as well.

Inspiratory crackles, on the other hand, are heard as air passes

through secretions and are often seen in patient with CHF or
pulmonary edema — not an upper airway obstruction.

The correct answer is: B. Inspiratory crackles

69. A 2-year-old boy was admitted to the emergency

department showing signs of respiratory distress. Upon
assessment, you note wheezes in the right lung and with
normal lung sounds heard on the left side. Which of the
following would you recommend?
A. Intubation and mechanical ventilation
B. Albuterol via small volume nebulizer

106
 C. Epinephrine via small volume nebulizer
D. Rigid bronchoscopy

To get this one correct, you needed to know the causes of the
different types of wheezing.

• Bilateral wheezing typically indicates bronchospasm and

can be treated with a short-acting bronchodilator.
• If the patient is wheezing due to fluid overload, giving a
bronchodilator is not going to do any good. You should
recommend a diuretic medication instead.
• Unilateral wheezing is an indication of a foreign body
obstruction. In this case, you should recommend a
bronchoscopy.

The young child most likely has either aspirated or swallowed an

object which explains why wheezing is only heard on the right
side.

The correct answer is: D. Rigid bronchoscopy

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

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

To get this one correct, you need to have an understanding of the

volume and pressure control modes of ventilation.

107
Since the patient is receiving pressure controlled ventilation, you
would expect an increase in delivered volume once secretions are
cleared. That is because, clearing secretions decreases airway
resistance which means that the set pressure limit won’t be
reached as quickly, thus increasing the delivered tidal volume.

On the other hand, during volume control ventilation, retained

secretions will increase the patient’s peak airway pressure. So if
you were to clear the secretions via suctioning, that should
decrease the PIP in that mode. But this patient is in the pressure
control mode, so we know that the correct answer has to be A.

The correct answer is: A. An increased tidal volume

71. 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 with a pleural effusion
C. A patient with a thick neck
D. A patient with ventilator-associated pneumonia

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 C.

108
The correct answer is: C. A patient with a thick neck

72. A newly admitted 70-year-old female patient with

pneumonia has an oxygen saturation of 86% on a nasal
cannula at 2 L/min. Which of the following is a potential
cause the patient’s hypoxemia?
A. Fever and chills
B. Diffusion defect
C. Capillary shunting
D. Hypoventilation

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.

Hypoxemia in patients with pneumonia is often related to

capillary shunting. That is because, if the alveoli are filled with
fluid (consolidation), perfusion will not occur as the oxygen passes
through, which is what causes hypoxemia.

Also, for the TMC Exam, I want you to always remember that
consolidation is associated with pneumonia. So if you read a
question that says a patient has consolidation, you automatically
associate that with pneumonia.

But for this question, after breaking it down, you can determine
that the correct answer has to be C.

The correct answer is: C. Capillary shunting

109
73. A 57-year-old female patient has been admitted and
diagnosed with Myasthenia Gravis. 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. Peak inspiratory flow
C. Expiratory reserve volume
D. Inspiratory capacity

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 Myasthenia Gravis. 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.

None of the other answer choices are critically important in

regards to monitoring a patient with Myasthenia Gravis, so we
know that the correct answer has to be D.

The correct answer is: D. Inspiratory capacity

74. While reviewing the medical record of a 59-year-old male

patient, you note that his FEV1/FVC ratio was reported as
being severely decreased. Which of the following conditions
would you expect with this finding?
A. Pneumonia
B. Chronic asthma

110
 C. Morbid obesity
D. Pulmonary hypertension

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.

Using the CBABE mnemonic, you can quickly determine that the
correct answer is B. We actually 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: B. Chronic asthma

75. A 58-year-old male patient who in orally intubated is

undergoing a spontaneous breathing trial. Which of the
following would indicate that you need to stop the trial and
return the patient back to full ventilatory support?
A. A decrease in SpO2 from 95% to 91%
B. An increase in heart rate from 91 to 116/min
C. An increase in respiratory rate from 16 to 27/min
D. An increase in arterial PCO2 from 44 to 56 torr

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

111
 • 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 patient’s oxygen saturation decreased as well, but again, not

enough for there to be a huge concern.

The PaCO2, on the other hand, increased significantly. More

specifically, it increased by more than 10 torr which is an
indication that the SBT should be stopped and the patient should
be returned back to full ventilatory support.

The correct answer is: D. An increase in arterial PCO2 from 44 to

56 torr

76. A 58-year-old female patient was intubated and auscultation

reveals that she has no breath sounds over the left lung. Her
SpO2 has decreased from 96% to 81% and her PIP has
increased from 33 to 53 cm H2O. It was noted that the tube
length marking is 26 cm at the lip. What action should you
take at this time?
A. Recommend a stat chest X-ray
B. Increase the FiO2 and the flow rate
C. Withdraw the ET tube 2-3 cm and reassess
D. Administrator a bronchodilator

After reading the question, you should be able to interpret that all
signs point to a right mainstem intubation. This means that the
ET tube was inserted too far and has slipped into the right
mainstem bronchus.

112
The giveaway was the fact that there are no breath sounds on the
patient’s left side. Also, the decrease in SpO2 and increased in PIP
help support the suspicion as well.

And to top it all off, the tube marking of 26 cm at the lip also tells
you that the tube is inserted too far. Remember that, in adults,
the ET tube should be inserted 21–24 cm at the patient’s lip, which
you can verify by the markings on the tube.

This one is still tricky because a chest x-ray would help us confirm
that the tube was inserted too far into the right mainstem
bronchus. However, you have to select the BEST answer. And in
this case, before requesting an x-ray, you simply just need to
withdraw the tube 2–3 cm and reassess the patient.

The correct answer is: C. Withdraw the ET tube 2-3 cm and

reassess

77. A 62-year-old male was admitted to the emergency

department showing signs of dyspnea and shortness of
breath. Lab tests were ordered to check his troponin and
BNP levels but the results were negative. Additionally, his
ABG results displayed acute respiratory acidosis with
moderate hypoxemia. Which of the following is the most
likely problem for this patient?
A. Pneumonia
B. CHF
C. COPD
D. Myocardial infarction

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

question, take everything they give you, and put all the pieces
together. Let’s break it down.

113
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.

Now we need to look at the patient’s ABG results. COPD patients

typically show respiratory acidosis with some type of
compensation going on due to CO2 retention. Normally, it’s
common to see full compensation but during an acute
exacerbation, you would expect to see partially compensated
respiratory acidosis.

In this case, due to the fact that no compensation is present,

pneumonia is the most likely issue which means that the correct
answer has to be A.

The correct answer is: A. Pneumonia

78. Which of the following tidal volume settings for mechanical

ventilation would be most appropriate for a 6'2" male patient
with normal lungs?
A. 300 mL
B. 500 mL
C. 700 mL
D. 900 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 = 78 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 390 to 780 mL.

114
Now we can rule out A and D right away because they fall outside
of this range. 500 mL is closer to the middle of the range and is
the most appropriate tidal volume (of the choices) for this patient.

The correct answer is: B. 500 mL

79. You are called to administer acetylcysteine to a 66-year-old

female patient. This drug can be helpful in treating which of
the following conditions?
A. Bronchospasm
B. Mucous plugs
C. Pleural effusion
D. Pulmonary hypertension

To get this one right, you simply just had to know that
acetylcysteine is another name for Mucomyst.

And of course, Mucomyst breaks down the disulfide bonds of

mucus which thins and helps mobilize secretions in patients with
mucus plugs.

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. Mucous plugs

80. The physician has ordered mechanical ventilation in the

volume control A/C mode for a 60 kg postoperative female
patient. Which of the following initial settings would you
choose?
A. Tidal volume = 400 cmH2O; Rate = 30/min; Inspiratory
time = 1 second

115
 B. Tidal volume = 650 cmH2O; Rate = 12/min; Inspiratory
time = 2 seconds
C. Tidal volume = 500 cmH2O; Rate = 22/min; Inspiratory
time = 1 second
D. Tidal volume = 450 cmH2O; Rate = 12/min; Inspiratory
time = 1 second

In order to get this one correct, you needed to know the normal
ranges for the initial ventilator settings of an adult patient. 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:

• Tidal Volume: 5-10 mL/kg of Ideal Body Weight

• Rate: 8-20/min
• I:E ratio of less than or equal to 1:2

So if you take the patient’s weight, which was given in the

question, and multiple it by 5 and by 10, this tells us that the tidal
volume should be set between the range of 300-600 mL.

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. Tidal volume = 450 cmH2O; Rate =

12/min; Inspiratory time = 1 second

81. A high-flow nasal cannula has been ordered for a 54-year-old

male patient. In order to set up this device, you would need
all of the following EXCEPT?
A. Blender
B. Bubble humidifier
C. Sterile water

116
 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

A bubble humidifier is used with a regular nasal cannula, not a

high-flow nasal cannula. A high-flow nasal cannula does require a
heated humidifier, just not a bubble-type humidifier.

The correct answer is: B. Bubble humidifier

82. A 61-year-old male patient is receiving volume-controlled A/C

mechanical ventilation with an FiO2 of 60% and a PEEP of 5
cmH2O. Over the past hour, his SpO2 has decreased from
95% to 82%. Which of the following would you recommend
FIRST?
A. Change to SIMV
B. Increase the PEEP
C. Increase the FiO2
D. Increase the flow

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.

117
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
patient’s FiO2 is already at 60%, in this case, you should increase
the level of PEEP and reassess the patient.

The correct answer is: B. Increase the PEEP

83. 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. Hyperlucency of the patient’s right side
was noted as well. These findings indicate which of the
following?
A. Diffuse pulmonary emphysema
B. Right-sided pleural effusion
C. Pneumothorax in the right lung
D. Atelectasis of the left lung

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.

For a pleural effusion, the key finding on a chest x-ray is blunting

of the costophrenic angle, which is not occurring here, so we can

118
rule that one out as well. This means that the correct answer has
to be either C or D.

If atelectasis were present, there would be opacification of the

affected side. Instead, there is hyperlucency of the patient’s right
side, so we can rule out atelectasis.

When a pneumothorax is present, the trachea will shift away from

the affected side. This indicates that a pneumothorax is present
on the right side which explains why there is a tracheal shift to
the left and hyperlucency on the opposite side.

The correct answer is: C. Pneumothorax in the right lung

84. While assisting with the care of an adult patient with no IV

access who is in cardiac and pulmonary arrest, the physician
requests a medication for direct instillation into the
endotracheal tube. Which of the following would you
recommend?
A. Epinephrine
B. Liquid Heparin
C. Ipratropium bromide
D. Saline

There are two ways that could help you determine the correct
answer.

First, if you have a basic understanding of ACLS, 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.

• N – Narcan

119
 • A – Atropine
• V – Valium/Versed
• E – Epinephrine
• L – Lidocaine

Epinephrine is commonly given during ACLS. Also, it’s the only

answer choice that is 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. Epinephrine

85. High-frequency oscillatory ventilation has been ordered for

an adult patient in the ICU. All of the following are required
for this type of therapy EXCEPT:
A. Humidifier
B. Circuit tubing
C. High-pressure oxygen source
D. Spirometer to measure tidal volume

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

understanding of high-frequency oscillatory ventilation (HFOV).

Basically, it’s a mode of ventilation that delivers very small tidal

volumes at an extremely fast rate. The rate is so fast and the
breaths are so small that it would be impossible to measure with
a spirometer.

A high-pressure oxygen and air source are required, along with

the ventilator, humidifier, and circuit. Of the answer choices that
are listed, only a spirometer is not necessary.

The correct answer is: D. Spirometer to measure tidal volume

120
86. A 72-year-old male patient states that he has had a
productive cough for at least four months a year for the past
two years. This describes which of the following conditions?
A. Chronic bronchitis
B. Status asthmaticus
C. Panlobular emphysema
D. Centrilobular emphysema

To get this one correct, you needed to be familiar with the

conditions that are listed in the answer choices.

Chronic bronchitis is a type of COPD that is characterized by

increased mucus production in the trachea and bronchi that
results in a productive cough which occurs for at least three
months of the year for more than two consecutive years.

None of the other answer choices fit this description which

confirms that the correct answer has to be A.

The correct answer is: A. Chronic bronchitis

87. A 70-year-old male patient with ARDS is receiving

mechanical ventilation in a pressure-controlled mode.
During a routine ventilator check, it was noted that the
plateau pressure was increased. In order to prevent
barotrauma, which of the following modes would you
recommend?
A. Volume control ventilation
B. Pressure support ventilation
C. Continuous positive airway pressure
D. Airway pressure release ventilation

121
To get this one correct, you needed to be familiar with the
ventilator modes that are appropriate for patients with ARDS.

Airway Pressure Release Ventilation (APRV) is a mode of

mechanical ventilation is which two levels continuous positive
airway pressure are applied with an intermittent release phase for
spontaneous breaths.

This mode is often recommended to improve oxygenation and treat

refractory hypoxemia which means that it’s good for patients with
ARDS.

The correct answer is: D. Airway pressure release ventilation

88. A 65-year-old female patient was admitted with cardiogenic

pulmonary edema. What is the primary goal of treating this
condition?
A. To increase the venous return to the heart
B. To increase the pulmonary fluid and blood volume
C. To decrease the right heart and systemic venous
pressures
D. To decrease the left heart and pulmonary vascular
pressures

Cardiogenic pulmonary edema is a certain type of pulmonary

edema that is caused by increased pressures in the heart and is
associated with congestive heart failure. It results from an
inadequate left ventricle that isn't able to pump out enough of
the blood it receives from the lungs.

The primary goal in treating this condition is to decrease left heart

and pulmonary vascular pressures to try to restore normal heart
function.

122
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. To decrease left heart and pulmonary

vascular pressures

89. Which of the following patients would you not recommend

the use noninvasive positive pressure ventilation?
A. Trauma and burns to the face
B. The need for moderate sedation
C. The need for suctioning of secretions
D. The need for an FiO2 greater than 40%

To get this one correct, you needed to know the indications and
contraindications of noninvasive positive pressure ventilation.

Some of the absolute contraindications for using NPPV include:

• The need for immediate intubation

• Hemodynamic instability
• Active cardiac arrhythmias
• Active upper GI bleeding
• Uncooperative patients
• Facial burns or trauma
• The need for airway protection

NPPV would be okay to use in all of the answer choices except for
a patient with facial burns or trauma. That is because, the mask
would likely cause too much pain while being worn.

The correct answer is: A. Trauma and burns to the face

123
90. A 61-year-old male patient with emphysema is receiving
oxygen via air-entrainment mask at 45%. One hour after
oxygen therapy was initiated, the patient appears lethargic
and obtunded. Which of the following is the most likely
cause in the change of the patient’s status?
A. Hypotension
B. Refractory hypoxemia
C. Respiratory muscle fatigue
D. Oxygen-induced hypoventilation

You first needed to recognize that emphysema in an obstructive

disease that is classified as a type of COPD. Patients with COPD
are typically chronic CO2 retainers which means that their ABG
results would show compensated respiratory acidosis.

These patient are prone to oxygen-induced hypoventilation

which means that receiving high levels of oxygen can affect their
ventilation-to-perfusion balance in the lungs. It causes an
increase in deadspace ventilation and, thus, an increase in PaCO2.

For COPD patients, it is recommend to provide an FiO2 that is low

enough to keep their PaO2 in the 50-60 torr range, which is
equivalent to an SpO2 85-90%. With that said, you should NEVER
deprive oxygen from a patient in need just because they are a
CO2 retainer.

The correct answer is: D. Oxygen-induced hypoventilation

91. A 33-year-old female patient has arrived to the emergency

department in the early stages of an asthma attack. Which of
the following would you expect for this patient?
A. Respiratory alkalosis
B. Moderate hypoxemia
C. Decreased expiratory flow rates
D. No response to beta adrenergic medications

124
To get this one correct, you needed to be familiar with the
pathophysiology of asthma.

When a patient is in the early stages of an asthma attack, they will

typically exhibit decreased expiratory flow rates due to the fact
that their airways are beginning to constrict.

Respiratory alkalosis and moderate hypoxemia are possibilities

but they usually occur in the middle or late stages of an asthma
attack — not in the early stages. Most asthmatic will respond to
beta adrenergic bronchodilator treatments, so we can rule that
one out as well.

The correct answer is: C. Decreased expiratory flow rates

92. A pulmonary artery catheter was inserted on a 68-year-old

male patient who is receiving mechanical ventilatory
support. Five minutes after insertion, the patient appears to
be rapidly deteriorating and the high pressure alarm is
sounding. The patient is now hypotensive and has decreased
breath sounds on the right side. Which of the following
conditions is most consistent with these findings?
A. Pulmonary edema
B. Pulmonary embolism
C. Tension pneumothorax
D. Acute Respiratory Distress Syndrome

To get this one correct, you needed to take everything that was
provided in the question and break it all down.

In general, one of the common complications of the insertion of a

pulmonary artery catheter is a pneumothorax. And since the
patient is receiving positive pressure ventilation, this results in a
tension pneumothorax.

125
After reading the question and seeing rapid deterioration and
unilateral breath sounds, this should immediately tell you that a
pneumothorax is likely present. That, to go along with
hypotension, should be a dead giveaway.

In this case, to treat the patient, they likely need immediate

decompression via needle thoracostomy followed by the insertion
of a chest tube.

The correct answer is: C. Tension pneumothorax

93. Intubation is indicated for a 62-year-old female patient in the

emergency department. After three failed endotracheal
attempts, your efforts to ventilate the patient using a bag-
valve-mask are beginning to fail. Which of the following
would you recommend?
A. Perform one more endotracheal intubation attempt
B. Stop intubation efforts and continue bagging
C. Insert a laryngeal mask airway
D. Perform a percutaneous tracheotomy procedure

Whenever there is a “can’t intubate, can’t ventilate” scenario, this

is considered to be an emergency situation.

In this case, since ventilation with bag-valve mask is beginning to

fail, you would not want to keep attempting that. Other measures
are needed. Three failed intubation attempts have already been
unsuccessful, so trying one more likely isn’t the best option either.

A Laryngeal Mask Airway (LMA) is an airway that is indicated for

short-term ventilation when normal ET tube intubation attempts
are 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

126
laryngeal and tracheal trauma. It’s the best option in this
scenarios which means that the correct answer has to be C.

The correct answer is: C. Insert a laryngeal mask airway

94. A 61-year-old male patient was administered lidocaine prior

to a fiberoptic bronchoscopy procedure. Which of the
following is the primary reason for administering this drug?
A. To provide moderate sedation
B. To provide topical anesthesia
C. To decrease vagal responses
D. To provide bronchodilation

To get this one correct, you needed to be familiar with the drug
lidocaine as well as the basic steps of performing a bronchoscopy.

Lidocaine is a topical anesthetic that is nebulized before a

bronchoscopy procedure to obtain airway mucosal anesthesia for
relaxation and to decrease the cough rate.

Lidocaine is not a sedative and is not typically used to decrease

vagal responses nor to promote bronchodilation.

The correct answer is: B. To provide topical anesthesia

95. A 70-year-old male patient was admitted to the emergency

department receiving oxygen via nonrebreathing mask with
unstable atrial flutter. After an initial shock via cardioversion,
the patient’s SpO2 drops to 82% and his breathing rate has
become slow and shallow. His heart rate is now 84/min with
normal sinus rhythm. Which of the following would you
recommend?
A. Direct instillation of naloxone (Narcan)

127
 B. Deliver an additional synchronized shock
C. Intubate and initiate mechanical ventilation
D. Ventilate the airway with 100% oxygen via bag valve
mask

To get this one correct, you needed to gather all of the

information that was given in the question and make the best
clinical decision for the patient.

Narcan is a drug given for a narcotic overdose, so we can rule that

one out right away. The question states that the patient’s heart
rate has normalized after the shock and is now a normal sinus
rhythm. This means that no additional shock is needed.

While there was a sharp decline in the SpO2, this is not an

indication for intubation and mechanical ventilation. Instead, the
most immediate action should be to open the patient’s airway
and provide ventilation and oxygenation via bag valve mask.

The correct answer is: D. Ventilate the airway with 100% oxygen
via bag valve mask

96. An indwelling arterial catheter was just inserted on a 69-

year-old female patient in the ICU. The physician asks for you
to confirm that the catheter was successfully placed into the
artery. Which of the following would you assess?
A. Adequate blood return
B. A positive modified Allen test
C. Proper blood pressure and waveform
D. The ability to flush the line

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

understanding of the process of inserting an arterial catheter.

128
First of all, the modified Allen test is only performed to assess for
collateral circulation of the radial artery and is performed before
insertion. So you can rule that one out right away.

Adequate blood return and ability to flush the line can occur even
if the catheter has been inserted into a vein. So neither can be
used for confirmation of arterial insertion.

The best way to confirm that the line has been inserted properly
into an artery is by looking at the measured pressure values as
well as the waveform on the monitor. If the waveform looks
normal and there are consistent blood pressure readings, you
know that the line was inserted properly.

The correct answer is: C. Proper blood pressure and waveform

97. A cardiopulmonary exercise test is being performed on a 58-

year-old female patient. During the test, her heart rate, SpO2,
and EKG are being monitored. What additional value would
you recommend for monitoring?
A. The physiologic deadspace
B. The peak expiratory flow rate
C. The maximum inspiratory pressure
D. The patient’s perceived level of exertion

During a cardiopulmonary exercise test, it’s important to monitor

the following objective data:

• Respiratory rate
• Heart rate
• Blood pressure
• EKG
• SpO2

129
With that said, you should also monitor the patient’s subjective
response to the test as well. For example, the patient could let
you know if they experience uncomfortable shortness of breath,
leg cramps, or angina.

Lastly, the perceived level of exertion should be monitored using

the Borg scale in order to keep an eye on the intensity level of the
test. The deadspace, PEFR, and MIP values are not required at this
time.

The correct answer is: D. The patient’s perceived level of exertion

98. The following bedside spirometry measurements were

obtained on an adult patient:
Respiratory rate = 12
Tidal volume = 450 mL
Dead space = 147 mL
Vital capacity = 1.2 L
Based on this data, what is the alveolar minute ventilation?
A. 2.6 L/min
B. 3.6 L/min
C. 4.6 L/min
D. 5.4 L/min

To get this one correct, you simply just needed to know the
formula. Remember, to calculate minute ventilation, you can
multiply the rate by the tidal volume.
But the question specifically asks for the alveolar minutes
ventilation, which means that you need to subtract the
deadspace. The formula looks like this:

VA = (Tidal Volume – Deadspace) x Respiratory Rate

Now you can simply just plug the numbers in to calculate the
correct answer.

130
VA = (450 – 147) x 12

VA = 3,636 mL/min

Then you can divide by 1,000 in order to convert mL to L.

We share our unique strategy for the calculations on the TMC

Exam inside of our Hacking the TMC Exam video course, so check
that out if you want to learn more.

The correct answer is: B. 3.6 L/min

99. A 69-year-old female patient was discharged with orders for

IPPB therapy with oxygen twice per day while at home. A
pneumatically powered machine has been provided. Which
of the following gas sources would you recommend power
the device?
A. An oxygen concentrator
B. A liquid oxygen reservoir
C. A high-pressure air cylinder
D. A high-pressure oxygen cylinder

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

understanding of the functionality of respiratory care equipment.

An IPPB is a pneumatically powered device that requires a high-

pressure source of at least 50 psi. Oxygen concentrators and
liquid oxygen reservoirs are both low-pressure systems which
means that they cannot be used in this case.

When a high-pressure source is needed in the home setting, a

high-pressure cylinder with a reducing valve is the best option.

131
And the question states that the therapy must be delivered with
oxygen.

The correct answer is: D. A high-pressure oxygen cylinder

100. You are called to help obtain a cardiac index measurement

using a Swan-Ganz catheter. Before the measurement is
taken, the physician asks, “what is the normal range for
cardiac index?” Which of the following would you select?
A. 2 - 6 mmHg
B. 4 - 12 mmHg
C. 4 - 8 L/min
D. 2 - 4 L/min/m2

For the TMC Exam, you must be familiar with the normal values
for hemodynamics.

Here are a few that you should remember:

• CVP 2 - 6 mmHg
• MAP 93 - 95 mmHg
• PCWP 4 - 12 mmHg
• CO 4 - 8 L/min
• CI 2 - 4 L/min/m2

So as long as you know the hemodynamic normal values, you

could easily determine that the correct answer is D.
The correct answer is: D. 2 - 4 L/min/m2

101. It is suspected that a patient has excess fluid around the

lungs in the pleural space. Which of the following would
you recommend in order to further inspect this patient?

132
 A. CT scan of the chest
B. Fiberoptic bronchoscopy
C. Ultrasound
D. Lung Biopsy

To get this one right, you needed to recognize that a pleural

effusion is present and have a basic understanding of what to
recommend as a Respiratory Therapist.

A pleural effusion can be found when the patient has a dull

percussion note along with diminished breath sounds and a
tracheal shift away from the affected side.

An ultrasound can be used to find and inspect a pleural effusion,

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

The patient’s x-ray findings with a lateral decubitus view will show
blunted costophrenic angles, so please remember this for the
exam.

Also, for a pleural effusion, you should always recommend a

thoracentesis in order to remove fluid from the pleural space.

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. Ultrasound

102. A patient arrived to the emergency room after a motor

vehicle accident with chest trauma. The doctor stated that
subcutaneous emphysema was present. Which of the
following would you expect to find?
A. Mucus plug
B. Crepitus
C. Expiratory wheezes

133
 D. Tactile fremitus

All you needed to know in order to get this one correct is the
meaning of subcutaneous emphysema.

Subcutaneous emphysema basically means that air bubbles can

be felt under the skin when palpitated.

Crepitus is grating, crackling or popping sound that is heard

when subcutaneous emphysema 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.

The correct answer is: B. Crepitus

103. What is the total amount of gas left in the lungs after a
resting expiration?
A. FVC
B. FRC
C. IRV
D. ERV

To get this one correct, you simply just need 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.

134
 • 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.
• FRC – the total amount of gas left in the lungs after a resting
expiration.
• FVC – the maximum volume of gas that can be exhaled as
forcefully and quickly as possible.
• TLC – the total amount of gas in the lungs after a maximum
inspiration.

For this one, you should automatically know that the correct
answer is B.

The correct answer is: B. FRC

104. On physical examination of a patient with pulmonary

emphysema, which of the following would you expect to
find?
A. Increased sputum production
B. Decreased AP chest diameter
C. Signs of cor pulmonale
D. Productive cough

To get this one correct, you simply just needed to know the signs
of a patient with emphysema upon physical examination.

135
A patient with emphysema will have air trapping which means
that they will have an overdistention of the thorax — in other
words, an increased AP diameter.

Patients with chronic bronchitis will have a productive cough,

increased sputum production, and show signs of cor pulmonale,
but not those those with emphysema.

So by using what we know about chronic bronchitis and

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

The correct answer is: B. Decreased AP chest diameter

105. A 58-year-old female patient is receiving mechanical

ventilation in the CPAP mode. In this mode, a breath will be
triggered in response to which of the following?
A. The patient’s inspiratory efforts only
B. Either the patient’s inspiratory efforts or a timing
mechanism
C. The timing mechanism of the ventilator only
D. The timing mechanism and the pressure settings on
the ventilator

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

understanding of the CPAP mode on the ventilator.

CPAP, or continuous positive airway pressure, is a mode that is

often used for weaning and no mandatory breaths are given. This
means that the patient MUST be breathing spontaneously in
order for this mode to be used.

136
The patient’s own inspiratory efforts are the only way that a
breath can be triggered in this mode, which tells us that the
correct answer has to be A.

The correct answer is: A. The patient’s inspiratory efforts only

106. The physician is considering initiating pressure-controlled

ventilation on a 62-year-old female patient. How would you
describe this mode of ventilation?
A. “Inspiration begins after a specific pressure is inhaled.”
B. “Expiration ends after a pre-set pressure is delivered.”
C. “Inspiration ends after a pre-set pressure limit is
reached.”
D. “Inspiration ends after the patient exhales a pre-set
pressure.”

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

understanding of the common modes of mechanical ventilation.

• Volume Controlled Ventilation – the tidal volume is pre-set.

The machine will cycle off after a pre-set volume in delivered.
• Pressure Controlled Ventilation – the pressure is pre-set. The
machine will deliver volume until the pre-set pressure limit
is reached.

So, of course, during pressure control, inspiration ends after the

pre-set pressure limit is reached. None of the other answer
choices describe pressure controlled ventilation, so you know that
the correct answer has to be C.

The correct answer is: C. “Inspiration ends after a pre-set pressure

limit is reached.”

137
107. A patient is receiving 2 L/min of oxygen from an H-cylinder
at 1500 psi. What is the approximate duration of flow?
A. 22 hours, 43 minutes
B. 27 hours, 20 minutes
C. 39 hours, 15 minutes
D. 45 hours, 35 minutes

For the TMC Exam, you need to know how to calculate the
duration left in a cylinder tank. Here’s the formula:

Duration = (gauge pressure X tank factor) / liter flow

As you can see, all the numbers that we need to get the answer
were given to us in the question — everything except the tank
factor. This is a value that you’ll have to memorize!

There are several different sizes of tanks, and each one has a
different tank factor. However, we’re going to simplify it for you
and let you in on a little secret. You really only need to remember
(2) cylinder size tank factors:

• E cylinder – 0.28
• H cylinder – 3.14

That’s because, these are the only ones that the NBRC tends to
use on the exam. You can thank me later. Now back to the
calculation:

Duration = (1500 x 3.14) / 2

Duration = 2,355 minutes

Then, just divide 60 to convert minutes to hours.

The correct answer is: C. 39 hours, 15 minutes

138
108. It has been determined that a 64-year-old male patient has
bronchiectasis. This disorder can be classified as which of
the following?
A. A restrictive disorder
B. An obstructive disorder
C. Both a restrictive and obstructive disorder
D. Neither a restrictive or obstructive disorder

For the TMC Exam, you MUST know the difference between the
obstructive and restrictive diseases! The best trick I know is this,
none other than: CBABE.

You can remember this little mnemonic for all of the obstructive
diseases.

• C – Cystic Fibrosis
• B – Bronchiectasis
• A – Asthma
• B – Bronchitis (Chronic)
• E – Emphysema

Those are your obstructive diseases. ANY other disease that you
see on the TMC Exam can be considered a restrictive disease.

So just to recap: On the exam, whatever disorder is mentioned, if

it’s not in the CBABE mnemonic, you can go ahead and interpret
it as a restrictive disorder for treatment purposes.

For this question, bronchiectasis is one of the diseases in the

CBABE mnemonic, so you automatically know it’s an obstructive
disorder and the correct answer has to be B.

The correct answer is: B. An obstructive disorder

139
109. A 62-year-old female patient is receiving therapy with a
pressure-cycled ventilator via mouthpiece. In order to
increase the inspiratory time, you can do which of the
following?
A. Increase the flow
B. Decrease the flow
C. Increase the sensitivity
D. Decrease the sensitivity

You will definitely see a question about making adjustments to

IPPB settings in order to get a desired outcome. Since the new
version of the exam was released, you may not see the term IPPB
any longer. It could be referred to as a pressure-cycled ventilator
instead.

But in general, this is what you should remember about making

adjustments to this type of machine:

• To give a larger tidal volume, increase the pressure setting.

• To give a smaller tidal volume, decrease the pressure setting.
• To give a faster breath, you must decrease the inspiratory
time. You can do that by increasing the flow.
• To give a slower breath, you must increase the inspiratory
time. You can do that by decreasing the flow.

The correct answer is: B. Decrease the flow

110. What size suction catheter is most appropriate for an infant

that is intubated with a size 3.0 mm endotracheal tube?
A. 5 Fr
B. 6 Fr
C. 8 Fr
D. 10 Fr

140
For the TMC Exam, you must know the guidelines for what size
catheter to use, depending on the size of the patient’s ET tube.
Here is the general rule:

The outer diameter of the suction catheter should be no more

than one-half of the inner diameter of the ET tube. This ensures
that there is enough space for gas from the ventilator to flow
around the catheter.

Here’s an easy way for selecting the appropriate catheter size:

Take the size of the ET tube and double it. Then use the next
smallest catheter size.

So for this infant, they are intubated with a size 3 ET tube.

According to the rule we just learned, you should take the size of
the ET tube and double it.

So 3 x 2 = 6

Then, you should go one size down. The next smallest size is 5,
which means that the correct answer has to be A.

The correct answer is: A. 5 Fr

111. A 48-year-old male patient is receiving volume-control

SIMV with 40% oxygen and has following ABG results:
pH 7.51
PaCO2 27 torr
PaO2 85 torr
HCO3 24 mEq/L
BE -1
The patient’s blood gas results indicate which of the
following?
A. Acute respiratory alkalosis

141
 B. Acute respiratory acidosis
C. Acute metabolic alkalosis
D. Acute hypoxemic failure

To get this one right, you have to be able to interpret the ABG
results. Let’s break this one down.

The pH is increased which means alkalosis. The Bicarb and Base

Excess values are in the normal range and the PaCO2 is
decreased. This tells us that there is respiratory acidosis.

There is no compensation going on here, since the Bicarb level is

normal and the pH is outside of the normal range. Also note, the
oxygenation status is normal as well, which we know this because
the PaO2 is normal.

The results show uncompensated respiratory alkalosis, so we

know that the correct answer has to be A.

The correct answer is: A. Acute respiratory alkalosis

112. What is the maximum time in seconds that can be devoted

to an intubation attempt before you need to return the
patient back to manual ventilation?
A. 30 seconds
B. 45 seconds
C. 60 seconds
D. 90 seconds

Usually when intubation is indicated, this means that the patient

is often apneic or in some form of respiratory distress. That means
that you will be providing ventilation and 100% oxygenation via a
bag-valve-mask resuscitator.

142
An intubation attempt should last no more than 30 seconds. If the
attempt fails, you should immediately begin to ventilate and
oxygenate the patient for up to 5 minutes before another attempt
is made.

To get this one right, you simply just had to know the maximum
time between intubation attempts. The correct answer is A.

The correct answer is: A. 30 seconds

113. An 8-year-old child is in need of immediate intubation and

mechanical ventilation. Which of the following
endotracheal tube sizes would you select for this patient?
A. 4.0 mm
B. 5.0 mm
C. 6.0 mm
D. 7.0 mm

You need to know how to estimate the appropriate ET tube size

for children in order to get this one correct.

You can use the following formula to estimate ET tube sizes:

ET Tube size = (age in years + 16) ÷ 4

So since the question tells us that the patient is 8 years old, you
just plug that number into the formula.

(8 + 16) ÷ 4

For an 8-year-old, a size 6 ET tube would be appropriate, so you

know that the correct answer is C.

The correct answer is: C. 6.0 mm

143
114. 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 1100 dyn/s/cm-5
C. Cardiac Index of 3.3 L/min/m2
D. CVP of 11 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 D.

The correct answer is: D. CVP of 11 cmH2O

115. A 62-year-old male patient with CHF was inadvertently

given 1500 mL of IV fluids instead of the ordered amount of
150 mL. Which of the following would you expect to see in
this case?
A. Increased PaO2
B. Increased PAP
C. Decreased PCWP
D. Decreased lung markings on the chest x-ray

144
To get this one correct, you needed to have a basic
understanding of hemodynamics and what to expect when the
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.

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 B.

The correct answer is: B. Increased PAP

116. A 59-year-old male home care patient states that he does

not feel any oxygen coming from the prongs of the nasal
cannula and is unsure if it is functioning properly. You
should recommend all of the following EXCEPT:
A. Tighten up all connections
B. Refill the humidifier with sterile water
C. Place the cannula under water to check for bubbles
D. Switch the patient from his concentrator to his tank

For this patient, you would want to recommend that they check
for leaks and tighten up all connections. And if no gas is coming
out, they should switch from the concentrator to the tank.

An easy way to check is to place the prongs of the nasal cannula

under water to see if bubbling can be seen. If so, then you know
that it’s functioning properly.

145
The water level in the humidifier bottle will not have any effect on
the flow of oxygen, so you know that the correct answer has to be
B.

The correct answer is: B. Refill the humidifier with sterile water

117. A 61-year-old adult patient is receiving bronchodilator

therapy during mechanical ventilation. Which of the
following ventilator graphics would you recommend in
order to assess the patient’s response to the
bronchodilator?
A. Volume vs Time
B. Flow vs Volume
C. Flow vs Time
D. Pressure vs Volume

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

understanding of ventilator graphics — even though an actual
graphic is not shown in the question.

When it comes to assessing a patient’s response to a

bronchodilator, the Flow-Volume loop would be the best choice
because the flow increases when the airways open up.

Flow-Volume loops also can be used to detect leaks and the

presence of auto-PEEP.

The correct answer is: B. Flow vs Volume

118. A 60-year-old female patient has been admitted to the

emergency department with the following ABG results:
pH 7.48

146
 PaCO2 41 torr
PaO2 98 torr
HCO3- 52 mEq/L
These results of this ABG can be interpreted as:
A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Metabolic acidosis

This is just a classic ABG interpretation question. You likely won’t

see many of these on the TMC Exam because at this point, the
NBRC will assume that you already know how to interpret ABGs.
Otherwise, you wouldn’t have made it this far.

With that said, you still absolutely MUST know how to interpret
them because you will be required to do so for SEVERAL
questions on the exam.

So let’s go ahead and break this one down. The pH is increased

which means that alkalosis is present. The PaCO2 is in the normal
range and the bicarb level is increased. So this ABG can be
interpreted as metabolic alkalosis, which means that the correct
answer is C.

The correct answer is: C. Metabolic alkalosis

119. While performing a 12-lead EKG on a patient, you are

unable obtain an electrical reading. The device is fully
charged and working properly. Which of the following is the
most likely cause of this problem?
A. Motion artifact
B. Improper filtering
C. A missing lead
D. The patient has too much adipose tissue

147
While motion artifact and improper filtering could be potential
problems when performing an EKG, you would still be able to
obtain electrical readings. And for obese patients with excess fat
tissue, the technology will still be able to obtain reading through
the tissue.

However, if there is a missing lead, the heart rhythm waveform

will not show up on the screen, so you know that the correct
answer has to be C.

The correct answer is: C. A missing lead

120. Which of the following would you assess for during

inspiration to indicate normal diaphragm activity?
A. Supraclavicular retractions
B. Intercostal retractions
C. Inward motion of the abdomen
D. Outward motion of the abdomen

As a (future) Respiratory Therapist, it’s probably a good idea for

you to know the basic physiology of taking a breath. During
normal breathing, as the diaphragm contract during inspiration,
it drops and causes the abdominal wall to move outward.

If this outward movement does not occur with inspiration, it

usually means that an abnormality is present. Two causes of this
abnormality would be a neuromuscular disorder or emphysema.

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. Outward motion of the abdomen

148
121. During the assessment of a 67-year-old female patient, you
note peripheral edema and wheezing. Which of the
following is the most likely cause of this finding?
A. Emphysema
B. Dehydration
C. Hypertension
D. Fluid overload

To get this one correct, you simply needed to recognize that the
finding is a sign that the patient is fluid overload. In fact, you must
know all of the signs of fluid overload for the TMC Exam:

• Peripheral edema
• Jugular venous distention
• Crackles on auscultation
• Shortness of breath

In this case, the patient needs a diuretic, such as Lasix. None of

the other answer choices really make sense in this situation, so
we know that the correct answer has to be D.

One more note to remember:

If the patient is wheezing due to fluid overload, giving a

bronchodilator is not going to do any good. You should
recommend a diuretic medication instead.

The correct answer is: D. Fluid overload

122. A 57-year-old patient with a history of CHF presents to the

emergency room with dyspnea, shortness of breath, and
wheezing. Which of the following would you recommend?
A. Aerosolized albuterol
B. Aerosolized pulmicort

149
 C. Furosemide (Lasix)
D. Rigid bronchoscopy

To get this one correct, you needed to understand the different

types and causes of wheezing.

• Bilateral wheezing typically indicates bronchospasm and

can be treated with a short-acting bronchodilator.
• If the patient is wheezing due to fluid overload, giving a
bronchodilator is not going to do any good. You should
recommend a diuretic medication instead.
• Unilateral wheezing is an indication of a foreign body
obstruction. In this case, you should recommend a
bronchoscopy.

Inhaled steroids, such as Pulmicort, are not typically used to treat

wheezing in any case, so you can rule that one out right away.

For a patient with a history of CHF, it likely means that they are
fluid overloaded which is causing dyspnea and wheezing. In this
case, you should recommend a diuretic such as Lasix.

The correct answer is: C. Furosemide (Lasix)

123. A 49-year-old post-operative patient is showing signs of

atelectasis. The patient awake and receiving oxygen via
nasal cannula at 2 L/min. Which of the following would you
recommend in order to improve the patient’s ventilation?
A. Incentive spirometry
B. IPPB
C. Flutter
D. Nasotracheal suctioning

150
When a post-operative patient has atelectasis, there are two
treatment modalities to choose from:

• Incentive spirometry
• IPPB

The key to making the right choice is that the question tells us
that the patient is conscious.

As a general rule, incentive spirometry is always preferred over

IPPB, as long as the patient can perform it with proper technique.
In cases where a patient is unconscious or too sedated, then IPPB
would be indicated.

But for this patient, since they are awake and conscious, you
would simply recommend incentive spirometry first.

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. Incentive spirometry

124. A 53-year-old female patient that is receiving volume

control ventilation had a sudden increase in peak
inspiratory pressure. All of the following could be a possible
cause EXCEPT:
A. Kinking of the endotracheal tube
B. Patient-ventilator asynchrony
C. A mucous plug
D. Bronchodilation

To get this one correct, you simply just needed to know the
causes of a sudden increase in peak inspiratory pressure (PIP).
The key word here is a “sudden” increase.

151
Here are the causes that you should be familiar with:

• Coughing
• Increased secretions or mucous plugging
• Kinked circuit tubing
• Kinked ET tube
• Tube displacement into the right mainstem bronchus
• Patient-ventilator asynchrony
• Bronchospasm
• Presence of a pneumothorax

Bronchodilation would cause the PIP to decrease, not increase. All

of the other answer choices would cause a sudden increase in the
patient’s peak inspiratory pressure, so we know that the correct
answer has to be D.

The correct answer is: D. Bronchodilation

125. A patient in the emergency department is receiving

oxygen via a nonrebreather at 15 L/min. There ABG results
are as follows:
pH 7.21
PaCO2 38 torr
PaO2 569 torr
SpO2 100%
HCO3 23 mEq/L
BE -1
Which of the following is the best interpretation for these
results?
A. Respiratory acidosis
B. Metabolic acidosis
C. Laboratory error
D. Large physiologic shunt

152
This appears to be a typical ABG interpretation question, but after
looking at the results, one major value should stand out like a sore
thumb.

Before you even attempt to interpret the acid-base status, you

should automatically know that a PaO2 of 569 torr on 100%
oxygen is not only possible.

The PaCO2 and the Bicarb values are both in the normal ranges.
That means that the pH should be normal as well, but it’s not—
it’s decreased.

So taking everything into consideration, you know that the only

possibility here is a laboratory error. The correct answer has to be
C.

The correct answer is: C. Laboratory error

126. What purpose does the pilot balloon of an endotracheal or

tracheostomy tube serve during intubation and airway
management?
A. To minimize mucosal trauma during insertion
B. To protect the airway against aspiration
C. To monitor cuff integrity and pressure
D. To help with proper tube positioning

The cuffs of ET tubes and trach tubes help to seal the airway for
protection and provide positive pressure ventilation. But coming
from the cuff is the pilot balloon, which is used to monitor cuff
integrity and pressure once the tube is in place.

It also has a valve in which a syringe is attached for the inflation

and deflation of the cuff. It doesn’t help with tube positioning,
preventing aspiration, or minimizing trauma.

153
So by using the process of elimination, we can determine that the
correct answer is C.

The correct answer is: C. To monitor cuff integrity and pressure

127. Upon entering the patient’s room, you heard the physician
instruct the patient to “inhale as deeply as possible and
then blow out all of the air as hard as you can.” Which
pulmonary function test is being performed?
A. IC
B. TLC
C. MVV
D. FVC

To get this one right, you have to know the PFT abbreviations as
well and the differences between the different pulmonary
function tests.

When a patient takes a maximum inhalation followed by a forced

maximum exhalation, you should automatically know that this is
a forced vital capacity maneuver, or an FVC as abbreviated in the
question. The correct answer is D.

The correct answer is: D. FVC

128. Your patient is a healthy male with average body size. What
would be considered the normal vital capacity range for this
patient?
A. 2000 – 3000 mL
B. 3000 – 4000 mL
C. 4000 – 5000 mL
D. 5000 – 6000 mL

154
The normal range for vital capacity is 4000–5000 mL, or 65–75
mL/kg. This represents about 80% of the total lung capacity.

Normal values can vary significantly depending on the patient’s

age and sex. With that said, weight is not a factor in predicting
normal values.

To get this one right, you simply had to know the normal value
range for vital capacity. For the TMC Exam, be sure to know all of
the PFT normal values. The correct answer is C.

The correct answer is: C. 4000 – 5000 mL

129. A one-week-old neonate in the NICU is receiving gas via

nebulizer into an oxyhood. Which of the following could be
a potential problem for this patient?
A. The production of harmful noise levels
B. An increased potential for CO2 accumulation
C. Difficulty in maintaining stable high FIO2s
D. Difficulty in maintaining adequate humidification

Something that you should remember is that, in general, loud

noises can damage an infant’s hearing. This is something that we
obviously want to avoid.

When a nebulizer is delivering gas into an oxyhood, it generates

high noise levels through the delivery tubing.

You can avoid this problem by using a blender with heated

humidification to deliver oxygen to the hood. You should keep
the flow set at the minimum level that is needed to maintain the
FIO2 — usually 5 - 7 L/min.

None of the other answer choices really make sense in this

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

155
The correct answer is: A. The production of harmful noise levels

130. An adult patient is about to be intubated in the emergency

department. How far should the endotracheal tube should
be advanced into the trachea during the oral intubation
procedure?
A. Until the cuff has passed the vocal cords by 3–4 inches
B. Until the cuff has passed the vocal cords by 3–4
centimeters
C. Until the proximal end of the tube is at the teeth
D. Just far enough so that the tube cuff is no longer visible

You will see a question about inserting and verifying proper ET

tube placement. Here’s how:

• 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 above the carina. This can be verified with a chest x-
ray.

Now that you know where the ET tube should be placed, do you
know how verify that it’s in the correct position? Here’s how:

• Auscultation to check for bilateral breath sounds

• Look for a rising SpO2. If the patient’s oxygen saturation is
increasing, this is a sign that the tube is in the trachea
• Look for condensation on the inside of the ET tube
• Verify color change on exhalation with a CO2 detector
• Look for symmetric chest expansion on exhalation
• Use capnography to verify exhaled CO2

156
 • And as we already mentioned, confirm proper placement
with a chest radiograph

We cover this topic in more detail inside of our Hacking the TMC
Exam video course. Definitely check it out if you want to learn
more! So by using what we know about intubation and proper ET
tube placement, we can determine that the correct answer is B.

The correct answer is: B. Until the cuff has passed the vocal cords
by 3–4 centimeters

131. A 67-year-old female 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. An increased usage of the scalene muscles during
breathing
B. An increase in heart rate from 97 to 136/min
C. A decrease in the systolic blood pressure from 115 to 76
mm Hg
D. A decrease in SpO2 from 95% to 90%

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 mm Hg and > 90 mm Hg
• Respiratory rate ≤ 30/min
• No accessory muscle usage

157
So after reviewing the answer choices, we can see that only one
would be deemed acceptable while weaning.

Scalene muscle usage during breathing means that the patient is

using their accessory muscles which is a sign of respiratory
distress. A systolic blood pressure of 76 is dangerously low, so we
can rule that one out as well.

During an SBT, it’s typical for the heart rate to increase some, but
a jump from 97 to 136/min is far too much. A decrease in SpO2
from 95-90% is nothing to be alarmed about as the value is still
within the normal range.

The correct answer is: D. A decrease in SpO2 from 95% to 90%

132. A 42-year-old female patient with dyspnea and wheezing

for the past 24 hours has not responded to bronchodilator
therapy. This describes which of the following conditions?
A. Chronic bronchitis
B. Status asthmaticus
C. Pulmonary embolism
D. Emphysema

To get this one correct, you needed to be familiar with the

conditions that are listed in the answer choices.

Status asthmaticus is a severe asthma attack or episode that does

not respond to bronchodilator therapy that lasts for more than 24
hours. In cases such as this, if the patient’s condition doesn’t
improve, intubation and mechanical ventilation may be indicated
for ventilatory failure.

None of the other answer choices fit this description which

confirms that the correct answer has to be B.

158
The correct answer is: B. Status asthmaticus

133. A bronchodilator treatment was administered to a 67-year-

old male patient with COPD. Afterwards, the following PFT
data was obtained:
FEV1/FVC = 68%
FEV1 = 83% predicted
The stage of the patient’s COPD can be classified as which
of the following?
A. Mild
B. Moderate
C. Severe
D. Very severe

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

understanding of COPD and how to interpret PFT results.

You can interpret that an irreversible airflow obstruction is

present when a patient’s FEV1/FVC ratio after a bronchodilator
treatment is less than 70% of predicted. With that said, the stage
of COPD is determined by looking at the FEV1 results compared
to the predicted value.

If the patient’s FEV1 is ≥ 80% of the predicted value and there is no

significant dyspnea, as is the case with this patient, the stage of
COPD can be classified as mild.

The correct answer is: A. Mild

134. A 47-year-old female patient who was admitted for an

acute asthma attack is being treated with bronchodilators
and oxygen therapy. An ABG was obtained and you note an

159
 increased in their PaCO2 to 50 mmHg with a pH of 7.27. The
patient appears to be anxious but otherwise is alert and
cooperative. Which of the following would you
recommend?
A. Administer nebulized corticosteroids
B. Administer a CNS respiratory depressant
C. Intubate and provide mechanical ventilation
D. Maintain their current therapy and continue to monitor
closely

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

understanding of ABG interpretation and how to treat patients
with asthma.

Mechanical ventilation is a common treatment modality in

patients with asthma once the PaCO2 increases and the pH
decreases out of the normal ranges. With that said, since the
patient is alert and cooperative, in the case, it would be best to
avoid intubation if possible.

You should first give the oxygen and bronchodilator therapy a

chance to improve the patient’s status. If the patient continues to
deteriorate, then intubation would be indicated.

Nebulized corticosteroids are maintenance drugs which means

that they are useless for an acute attack, and a CNS respiratory
depressant is not indicated at this time either.

The correct answer is: D. Maintain their current therapy and

continue to monitor closely

135. A 29-year-old male patient with a history of bronchiectasis

was admitted with signs of purulent sputum and has an
SpO2 of 93% on 3 L/min. Upon assessment, auscultation

160
 reveals course rhonchi and wheezing in the right lower
lobes. A chest X-ray shows infiltrates in the same area.
Which of the following would you recommend?
A. Epinephrine via small volume nebulizer
C. Incentive spirometry with 12 breaths/hour
D. Nonrebreathing mask at 12 L/min
D. Intrapulmonary percussive ventilation (IPV)

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

understanding of airway clearance therapy. In general, airway
clearance therapy is indicated in patients who are producing
large amounts of sputum greater than 20-30 mL/day.

While the question doesn’t specifically tell us the amount, it does

say that the patient has purulent sputum with a history of
bronchiectasis. This should tell you right away that airway
clearance therapy is needed.

Now, all you need to do is look through the answer choices to

select a form of this therapy. Examples of airway clearance
therapy include:

• Postural drainage
• PEP therapy
• Intrapulmonary percussive ventilation (IPV)
• High-frequency chest wall compression (HFCW)

In general, the technique does not matter and depends on the

patient’s preference. The most important thing is to select a cost-
effective method that patient will adhere to.

Antibiotic medications would also be indicated for this patient

along with mucokinetic agents.

The correct answer is: D. Intrapulmonary percussive ventilation

(IPV)

161
136. A 69-year-old male has arrived to emergency department
complaining of chest tightness and radiating left shoulder
pain. He has a 25-pack per year smoking history and shows
physical signs of COPD. Which of the following would you
recommend FIRST?
A. Collect an arterial blood gas sample
B. Recommend a STAT chest radiograph
C. Initiate oxygen therapy via nasal cannula
D. Initiate oxygen therapy via nonrebreathing mask

To get this one correct, you needed to recognize that the patient
is showing signs of a possible heart attack. And as a Respiratory
Therapist, whenever this is the case, the FIRST thing that you
should ALWAYS do is provide as much oxygen as possible.

That is because, a high FiO2 can help improve the oxygenation of

the cardiac tissues and prevent further injury. So in this case,
since a nonrebreather provides a higher FiO2 than a nasal
cannula, it’s the best option of the answer choices.

An ABG and chest x-ray would be indicated, however, the FIRST

thing that you should do is initiate oxygen therapy.

The correct answer is: D. Initiate oxygen therapy via

nonrebreathing mask

137. After entering the room of a 66-year-old female patient,

you found that she is unresponsive and without pulse. You
called for help and requested a defibrillator but no one
responds. Which of the following actions would you take?
A. Intubate and initiate mechanical ventilation
B. Check the patient’s advance directive order
C. Immediately begin giving chest compressions

162
 D. Wait for the defibrillator to arrive

If you were to find a patient in cardiac arrest with no defibrillator

available, you should immediately begin CPR and starting with
giving chest compressions until help arrives.

You’re not going to be able to intubate and initiate mechanical

ventilation on your own without the proper equipment, and also
this would require an order from the physician.

You should already know your patient’s advance directive order

beforehand — i.e. you should already know if they are a DNR. This
situation is a medical emergency so now is not the time to leave
the patient to dive into their medical records.

During cardiac arrest, it’s crucial to begin compressions as early as

possible which is why you wouldn’t want to wait for help or for a
defibrillator to arrive.

The correct answer is: C. Immediately begin giving chest

compressions

138. A 60-year-old male patient is receiving therapy via a

pressure-controlled mouthpiece ventilator. Their tidal
volume goal is 750 mL but they are only exhaling 550 mL
and there is no air leak. Which of the following would you
recommend in order to deliver a larger tidal volume?
A. Increase the flow setting
B. Increase the pressure setting
C. Use a sealed mouthpiece
D. Instruct the patient to inhale more forcefully

To get this one correct, you needed to have basic knowledge of

how pressure-controlled mouthpiece ventilators work (e.g. IPPB).

163
If you understand the settings, you would know that in order to
deliver a larger tidal volume, you need to deliver more pressure to
the lungs. Increasing the flow setting will deliver the volume at a
faster rate. This would lower the inspiratory time but it would not
increase the tidal volume.

The question states that no leak is present so a sealed

mouthpiece is not indicated. And if the patient inhales more
forcefully, this will only increase the work of breathing because
the flow setting would be inadequate.

The correct answer is: B. Increase the pressure setting

139. An adult patient who receiving mechanical ventilation has

a PIP of 30 cmH2O and a plateau pressure of 10 cmH2O
with a set flow rate of 60 L/min. What is the airway
resistance?
A. 20 cm H2O/L/sec
B. 24 cm H2O/L/sec
C. 30 cm H2O/L/sec
D. 24 cm H2O/L/sec

To get this one correct, you simply just needed to know the
formula for airway resistance. If you did, you can simply just plug
the formula in to calculate the correct answer. The formula looks
like this:

Raw = (PIP – Plateau pressure) / Flow

Raw = (30 – 10) / 1

Raw = 20 cm H2O/L/sec

164
We share our unique strategy for the calculations on the TMC
Exam inside of our Hacking the TMC Exam video course, so check
that out if you want to learn more.

The correct answer is: A. 20 cm H2O/L/sec

140. Cardiopulmonary resuscitation is being performed on a 56-

year-old male patient in the emergency department. The
doctor orders an ABG to be collected. Which of the
following sample sites would you recommend?
A. Radial artery
B. Brachial artery
C. Carotid artery
D. Femoral artery

In general, the radial artery is the recommended sample site for a

patient who is alert, awake, and in stable condition. If you are
unable to collect a sample from the radial artery, then an attempt
can be made in the brachial artery. Again, this is under normal
conditions.

But during CPR, the femoral artery is the recommended sample

site because it’s larger and should be relatively easy to stick.
Another reason is because it’s farther away from the patient’s
chest which is important to consider while chest compressions
are being performed.

You should not puncture the carotid artery, especially during CPR.

The correct answer is: D. Femoral artery

165
141. A sputum sample via Lukens trap has been ordered for a
64-year-old male patient. All of the following are true
regarding this device EXCEPT:
A. The use of a vacuum source is required
B. The use of a suction catheter is required
C. It is indicated for a patient with a productive cough
D. All connections must be tight for it to work properly

To get this one right, you simply needed to know what a Lukens
trap is and what it’s used for.

A Lukens trap is a collection tube that is used during the

suctioning procedure in order to obtain a sputum sample from a
patient who CANNOT cough productively.

That is the key. If the patient has a productive cough, a Lukens

trap wouldn’t be needed because they can just cough up the
sample and spit it into a cup.

The device is connected to a vacuum source for suctioning and

uses a catheter to collect the sample. All connections must be
tight for it to work properly.

The correct answer is: C. It is indicated for a patient with a

productive cough

142. A neonate was born with meconium aspiration syndrome

and is receiving ventilatory support. The attending
physician wants to increase the pressure limit but doing so
would increase the risk of which of the following?
A. Pneumothorax
B. Oxygen toxicity
C. Tracheoesophageal fistula
D. Retinopathy of prematurity

166
To get this one correct, you needed to have an understanding of
the basic concepts of mechanical ventilation.

If you increase the pressure limit setting on a ventilator, this will

cause an increase in tidal volume. And since we’re talking about a
newborn infant here, an increased tidal volume increases the
chances of barotrauma and over-inflation which could result in a
pneumothorax.

The pressure limit setting has no effect on the oxygen toxicity,

retinopathy of prematurity, or a tracheoesophageal fistula, so we
can rule those out right away.

The correct answer is: A. Pneumothorax

143. A 67-year-old female patient with emphysema is receiving

ventilatory support with an HME in place. Immediately after
an aerosolized breathing treatment was administered, the
patient begins to cough secretions into the HME and their
high-pressure alarm begins to sound. Which of the
following would you recommend?
A. Suction the patient
B. Replace the HME
C. Increase the high-pressure alarm
D. Provide an additional breathing treatment

In general, whenever an HME becomes soiled or obstructed with

secretions, it should be replaced. And once it has been replaced,
the high peak-pressure should drop back down to normal and
the alarm will stop sounding.

This one is a bit confusing because usually when there are

secretions with a high-pressure alarm, the first thing that usually
comes to mind is to suction the patient. But remember,

167
suctioning is only indicated if the patient is not able cough out
the secretions. In this case, the question tells us that they are able
to cough adequately.

There is no indication to increase the high-pressure alarm setting,

nor is there an indication to give another breathing treatment.

The correct answer is: B. Replace the HME

144. A V/Q scan was performed on a 69-year-old male patient

for analysis. Which of the following findings would suggest
that a pulmonary embolism is present?
A. Areas with normal ventilation and normal perfusion
B. Areas with no ventilation and no perfusion
C. Areas with normal ventilation but no perfusion
D. Areas with no ventilation but normal perfusion

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

understanding of what a V/Q scan is, as well as the pathology of a
pulmonary embolism.

A V/Q scan is a type of imaging test that uses a radiographic

substance to assess the ventilation and perfusion in the lungs.

For the TMC Exam, you should know that a V/Q scan is always
indicated when a pulmonary embolism is suspected. If you see a
patient with a normal ventilation scan but an abnormal perfusion
scan, this confirms that a pulmonary embolism is present.

The correct answer is: C. Areas with normal ventilation but no

perfusion

168
145. A 67-year-old male patient with a history of smoking was
admitted for shortness of breath. A chest radiograph shows
depressed hemidiaphragms and an increased
anteroposterior diameter of the chest. Which of the
following conditions is most likely present?
A. Left-ventricular failure
B. Pneumothorax
C. Pulmonary fibrosis
D. Emphysema

To get this one correct, you needed to have an understanding of

the conditions that are listed in the answer choices.

Emphysema is an obstructive disease that results in increased

lung expansion due to air trapping. It causes irreversible damage
to the alveolar walls which causes permanent enlargement of the
air spaces distal to the terminal bronchioles.

For patients with emphysema, their chest x-ray would show an

increased AP diameter, depressed hemidiaphragms, and
widened intercostal spaces. Someone with pulmonary fibrosis
would have decreased lung compliance and smaller lungs, no
overinflated lungs.

Also note that these radiographic findings are not consistent with
a pneumothorax or left-ventricular failure, so we can rule those
out as well.

The correct answer is: D. Emphysema

146. A 51-year-old female patient who is intubated has been

transported from the emergency room to the intensive care
unit. The physician is concerned that the endotracheal tube

169
 has moved out of the correct position. Which of the
following is the best way to determine its location?
A. Auscultate the stomach
B. Palpate the larynx
C. Order a chest radiograph
D. Perform percussion to the chest

In general, the best way to assess the position of an endotracheal

tube is to is to obtain a chest x-ray. It will provide a visual of
exactly where the tip of the tube is located.

Remember, when looking at a chest radiograph, a properly

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

None of the other answer choices are useful in assessing the

positioning of the ET tube.

The correct answer is: C. Order a chest radiograph

147. A series of pulmonary function tests were performed on a

60-year-old female patient with the following results:
Vital Capacity = 3,500 mL
Functional Residual Capacity = 4,500 mL
Expiratory Reserve Volume = 1,400 mL
What is the patient’s residual volume?
A. 1,000 mL
B. 3,100 mL

170
 C. 4,900 mL
D. 5,900 mL

To get this one correct, you simply just need to be able to

calculate the Residual Volume using the date that is given. This is
where the ‘Lung Box’ would come in handy. If you’re not familiar,
no worries — we cover it in more detail inside of our Hacking the
TMC Exam course.

For this one, you needed to know that the Residual Volume can
be calculated by subtracting the Expiratory Reserve Volume from
the Functional Residual Capacity:

RV = FRC - ERV

RV = 4500 – 1400 mL

The correct answer is: B. 3,100 mL

148. A 52-year-old male patient has a P/F ratio of 425. This value
indicates which of the following?
A. Mild ARDS
B. Moderate ARDS
C. Severe ARDS
D. Normal oxygenation

For the TMC Exam, you must know and understand all of the
important normal values.

The P/F Ratio (PaO2/FiO2 Ratio) is a value that is used to assess a

patient’s oxygenation status and level of hypoxemia. It can be
calculated simply by dividing the PaO2 by the FiO2.

171
A P/F Ratio of > 380 is considered to be normal. The patient in this
question has a value of 425 which means that he has normal
oxygenation.

Once the P/F Ratio starts to decrease below 300, that is when ARDS
is a concern:

• Mild ARDS = 200 – 300

• Moderate ARDS = 100 – 200
• Severe ARDS = < 100

The correct answer is: D. Normal oxygenation

149. A 61-year-old male postoperative patient who is receiving

ventilatory support has started to awaken. The patient is
receiving an FiO2 of 40% with PEEP of 5. This indicates
which of the following?
A. The patient is at risk of oxygen toxicity
B. The patient has an increased PaO2/FiO2 Ratio
C. The patient has adequate oxygenation for weaning
D. The patient needs continued ventilatory support

For the TMC Exam, you must know when it’s appropriate to
consider weaning from mechanical ventilation. Specifically for
this question, you needed to know the oxygenation values.

Here are some indications that a patient has adequate

oxygenation for weaning:

• P/F > 150 – 200

• PEEP ≤ 8 cmH2O
• FiO2 ≤ 40 – 50%
• Arterial pH ≥ 7.25

172
Keep in mind, these are just the oxygenation parameters. Other
criteria must be met as well before weaning should be
considered.

An FiO2 of 40% and a PEEP of 5 is definitely adequate for

weaning. 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 patient has adequate oxygenation

for weaning

150. An upper airway inspection prior to the intubation of an

adult patient revealed that only the hard palate, soft palate,
and base of the uvula are visible. What is the Mallampati
classification?
A. Class 1
B. Class 2
C. Class 3
D. Class 4

A Mallampati Score is a test that is used to inspect the upper

airway in order to predict the ease of endotracheal intubation. It
uses four scoring levels to determine the classification.

Basically, the higher the score, the more the upper airway is
obstructed and the more difficult the intubation attempt will be.

Here are the classes that you should be familiar with:

• Class 1 – Fully visible, open, and normal upper airway.

• Class 2 – Somewhat obstructed with the hard palate, soft
palate, uvula, and tonsils visible.
• Class 3 – Only the hard palate, soft palate, and base of uvula
are visible.

173
 • Class 4 – No visibility of the soft palate. Only the hard palate
is visible.

For the patient in this question, since only the hard palate, soft
palate, and base of the uvula are visible, you should be able to
determine that the Mallampati score is 3.

The correct answer is: C. Class 3

151. A newborn infant in the has neonatal intensive care unit

has a Silverman score of 4. How should this be interpreted?
A. No respiratory distress
B. Moderate respiratory distress
C. Severe respiratory distress
D. Invasive suctioning is indicated

To get this one correct, you simply just needed to have a basic
understanding of the Silverman score.

It’s is a test that is used to determine an infant’s level of

respiratory distress by assessing the chest movement, intercostal
retractions, xiphoid retractions, nasal flaring, and expiratory
grunting.

You should remember the following scores:

• A score of 0 means that no respiratory distress is present.

• A score of 1 – 6 means that the infant is experiencing
mild/moderate respiratory distress.
• A score of ≥ 7 means that the infant is experiencing severe
respiratory distress and respiratory failure is a real concern.

If you were familiar with this scale, you would know that a score of
4 indicates moderate respiratory distress.

174
The correct answer is: B. Moderate respiratory distress

152. The pulmonologist wants to run tests on a 68-year-old male

patient with a history of smoking to assess for the possible
diagnosis of lung cancer. Which of the following imaging
techniques would you recommend?
A. Pulmonary Ventilation/Perfusion Scan
B. Barium Swallow
C. Magnetic Resonance Imaging
D. Positron Emission Tomography

For the TMC Exam, you need to be familiar with the indications
for the common radiological tests and how they apply to the field
of Respiratory Care.

A PET Scan, or Positron Emission Tomography, is a radiographic

test that uses radioactive substances to examine the metabolic
activity of various parts of the body. In Respiratory Care, it’s
typically recommended for diagnosis or evaluation of lung cancer
which lets us know that D is the correct answer.

A V/Q Scan is indicated to assess the patient’s ventilation and

perfusion and is useful to check for a pulmonary embolism. A
Barium Swallow is indicated to assess for abnormalities of the
esophagus and stomach.

An MRI can be used to assess the internal organs of the body but
it’s not the best choice to diagnose lung cancer.

The correct answer is: D. Positron Emission Tomography

175
153. A spontaneous breathing trial was performed on a 64-year-
old male patient to evaluate if he can be weaned from the
ventilator but the physician deemed the attempt
unsuccessful. Which of the following would you
recommend?
A. Attempt another spontaneous breathing trial in 1 hour
B. Attempt another spontaneous breathing trial in 6 hours
C. Attempt another spontaneous breathing trial in 12 hours
D. Allow the patient to rest for 24 hours before another
attempt is made

To get this one correct, you needed to know the basics of a

spontaneous breathing trial and weaning criteria.

In general, if a patient fails a spontaneous breathing trial, you

should return them back to full ventilatory support to give them
adequate time to rest. No additional attempts should be made for
24 hours.

The correct answer is: D. Allow the patient to rest for 24 hours
before another attempt is made

154. The physician has requested to switch an adult patient

from a standard tracheostomy tube over to a fenestrated
tracheostomy tube. What is the primary advantage of using
a fenestrated tube?
A. Fenestrated tubes reduce tracheal injuries
B. Fenestrated tubes help minimize secretions
C. Fenestrated tubes allow the patient to speak
D. Fenestrated tubes minimize the risk of infection

Fenestrated tracheostomy tubes have an opening above the cuff

which allows airflow to pass through so that the patient is able to
talk with the airway in place.

176
It allows the patient to communicate and that is the primary
advantage that I want you to remember for the TMC Exam.

The correct answer is: C. Fenestrated tubes allow the patient to

speak

155. During your shift in the neonatal ICU, the physician has
recommended hyperventilation as a method of treatment
for a newborn infant. For which of the following conditions
would this treatment modality typically be recommended?
A. Respiratory distress syndrome
B. Meconium aspiration
C. An infant with normal lung compliance
D. Persistent Pulmonary Hypertension of the Newborn

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

understanding of the neonatal conditions that are listed in the
answer choices.

PPHN is a condition in newborn infants that is characterized by

abnormally increased pulmonary hypertension caused by failed
circulatory adaptation at birth.

Hyperventilation is indicated for infants with PPHN because it

results in pulmonary vasodilation which will improve their
condition by increasing blood circulation for oxygenation.
There is no evidence that hyperventilation would be helpful in any
of the other conditions that are listed.

The correct answer is: D. Persistent Pulmonary Hypertension of

the Newborn

177
156. Which of the following patients would the application of a
heated humidifier would pose the greatest potential
hazard?
A. A patient with hyperthermia
B. A patient with hypothermia
C. A patient with thick secretions
D. A patient with hypovolemia

To get this one correct, you needed to know the indications and
contraindications for using a heated humidifier.

Heated humidity is recommended for patients with thick

secretions because it helps to thin them up for removal via
coughing or suctioning. It’s also indicated in hypothermia as well
because it can help elevate the body temperature.

On the other hand, it would not be recommended for a patient

with a fever because it would only cause the body temperature to
increase even more which definitely could be hazardous.

The correct answer is: A. A patient with hyperthermia

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

ventilatory support in the pressure controlled SIMV mode.
Upon assessment, you feel rhonchal fremitus on the chest
wall during inspiration and expiration. Which of the
following would you recommend?
A. Switch to volume controlled SIMV
B. Perform endobronchial suctioning
C. Administer a bronchodilator treatment
D. Decrease the pressure limit setting

178
Rhonchal Fremitus is a term that is used to describe coarse
vibrations that can be felt by palpitating the chest wall during
normal breathing.

It usually results from a partial airflow obstruction caused by

mucus or secretions in the airways. This means that suctioning
would be indicated in order to aid in the removal of the
secretions.

The correct answer is: B. Perform endobronchial suctioning

158. During the assessment of a patient 70-year-old female

patient, you noticed that her trachea is slightly positioned
to right side of the neck. Which of the following conditions
is most likely present?
A. Atelectasis
B. Pulmonary edema
C. Pulmonary fibrosis
D. Chronic bronchitis

The normal anatomical position of the trachea is in the midline.

So whenever there is a tracheal shift to either side, it means that
something is going on that’s causing this abnormal shift.

So for the TMC Exam, you should be familiar with the conditions
that cause the trachea to shift. Here are some examples:

• Atelectasis
• Surgical resection
• Pneumothorax
• Hemothorax
• Pleural effusion
• Mass lesions

179
Looking at these examples, you can see that they only effect one
side of the lungs, which explains why there is a tracheal shift. The
correct answer for this one is Atelectasis because it would cause
the trachea to shift towards the area of lobar collapse.

The other disorders listed in the answer choices affect the entire
lungs which generally would not cause a shift in the trachea.

The correct answer is: A. Atelectasis

159. The following data was obtained on a 63-year-old female

patient who is receiving ventilatory support:
Rate = 12/min
Tidal Volume = 450 mL
Inspiratory Time = 1.3 seconds
PIP = 25
PEEP = 5
What is the patient’s mean airway pressure?
A. 7.3 cmH2O
B. 9.4 cmH2O
C. 10.2 cmH2O
D. 13.7 cmH2O

To get this one correct, you simply just needed to know the
formula for mean airway pressure. If you did, you can simply just
plug the formula in to calculate the correct answer. The formula
looks like this:

Paw = ((Inspiratory Time x Frequency) / 60) x (PIP – PEEP) +PEEP

Paw = ((1.3 x 12) / 60) x (25 – 5) + 5

Paw = ((15.6) / 60) x (25 – 5) + 5

180
Paw = 0.26 x (25 – 5) + 5

Paw = 5.2 + 5

The correct answer is: C. 10.2 cmH2O

160. In addition to counseling, which of the following

prescription medications may be an effective modality to
help with smoking cessation?
A. Midazolam (Versed)
B. Buproprion (Zyban)
C. Beclomethasone (Vanceril)
D. Formoterol (Foradil)

For the TMC Exam, you need to be familiar with the drugs that are
recommended for smoking cessation. The drugs are:

• Varenicline (Chantix)
• Buproprion (Zyban)
• Clonidine (Catapres)

Midazolam is a sedative that is used before surgical procedures.

Beclomethasone is an inhaled steroid and Formoterol a long-
acting bronchodilator and midazolam a short-acting sedative.
None of these other agents are useful in smoking cessation
efforts.

The correct answer is: B. Buproprion (Zyban)

181
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 book. 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 in your inbox waiting for you.

If this is something that sounds interesting to you, definitely

consider signing up.

Click Here to Get Daily Practice Questions via Email

182
References

1. AARC Clinical Practice Guidelines, (2002-2019) 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.

183