Depth of Clinical Judgment practice questions

Answer: A) Coordinate analgesia timing with nursing, teach incisional splinting, then coach the session

After upper abdominal surgery, incisional pain causes splinting, shallow breathing and atelectasis. Well-timed analgesia, incisional splinting and coached deep breathing are the first step.

• ACorrect. Pain-related splinting causes shallow breathing and atelectasis. Timing analgesia before therapy and teaching the patient to splint the incision with a pillow allows deeper breaths, so the incentive spirometry coaching works.
• BIncorrect. Postoperative atelectasis develops within about 72 hours. Waiting for the pain to go away allows atelectasis to progress, so therapy should continue after surgery.
• CIncorrect. The patient has mild hypoxemia and no ventilatory failure. High-pressure continuous NIV is not warranted and does not address the cause, which is pain-limited inspiration.
• DIncorrect. Nothing suggests bronchospasm, such as wheezing or a history of reactive airways. The volumes are limited by pain, which a bronchodilator does not treat.

Answer: A) Explain that nighttime NIV can relieve symptoms, review later tracheostomy ventilation, and encourage the patient to share wishes with family and the team

In ALS with early respiratory muscle weakness, the RT should explain NIV and the possibility of later tracheostomy ventilation, and support the patient in making and documenting informed choices about ventilation.

• ACorrect. ALS has no cure, and respiratory muscle weakness is the usual cause of death. Bilevel NIV can ease hypoventilation symptoms. Invasive ventilation through a tracheostomy is a later option some patients choose. Because cognition is intact, the patient should make an informed choice and document wishes about ventilation with family and providers.
• BIncorrect. Waiting until respiratory failure develops risks emergency intubation that does not reflect the patient's wishes. With orthopnea and a declining FVC, the patient needs these discussions and advance planning now.
• CIncorrect. Mild bulbar weakness does not rule out a trial of NIV, which is the usual first-line support. Tracheostomy ventilation is a major personal decision with a heavy caregiver burden, and it is not routinely recommended at this stage.
• DIncorrect. ALS hypoventilation comes from respiratory muscle weakness. Oxygen alone does not improve ventilation and can worsen CO2 retention. Ventilatory support such as bilevel NIV is what is needed.

Answer: C) Preoxygenate and keep each suction pass short

• AIncorrect. That worsens hypoxemia.
• BIncorrect. That worsens desaturation.
• CCorrect. Closed suction can also help.
• DIncorrect. That can cause injury.

Answer: D) 6

• AIncorrect. The infant has a heart rate.
• BIncorrect. Recheck each component.
• CIncorrect. Several components are reduced.
• DCorrect. HR 2, respiration 1, tone 1, reflex 1, color 1.

Answer: A) Keep the current settings and accept the hypercapnia

Low-VT ventilation in ARDS often raises PaCO2. This permissive hypercapnia is accepted while pH stays at or above about 7.20, so plateau pressure and VT can stay within protective limits.

• ACorrect. This is permissive hypercapnia. The pH is above about 7.20, oxygenation is adequate, plateau pressure is under 30 cm H2O, and the rate is already at its maximum, so the lung-protective settings should stay.
• BIncorrect. A larger VT would push plateau pressure above 30 cm H2O and give up the volume limit that lowers mortality in ARDS.
• CIncorrect. PEEP is set for oxygenation and alveolar recruitment. Cutting it would risk derecruitment and hypoxemia and is not how hypercapnia is treated.
• DIncorrect. ECMO is considered for severe ARDS with refractory hypoxemia or hypercapnic acidosis with pH below about 7.20. A pH of 7.28 with adequate oxygenation does not meet that threshold.

Answer: B) Clean the connector with an alcohol pad, reconnect the tube, and notify the team

When a chest tube comes off an intact drainage system, quickly restore the closed system: clean the connector if time allows, reconnect, and notify the team. Avoid prolonged clamping or leaving the tube open to air.

• AIncorrect. Leaving the tube clamped stops air and fluid from escaping the pleural space and can cause a tension pneumothorax. Any clamping during a disconnection should be very brief.
• BCorrect. The drainage unit is still intact. Guidance says to clean the tube with an alcohol wipe if time allows, reconnect it to the drainage system, and notify the primary team right away.
• CIncorrect. An open chest tube lets air into the pleural space during inspiration and can worsen a pneumothorax. More oxygen does not fix the loss of the one-way water seal.
• DIncorrect. Removing a chest tube needs a physician's order and a check that the pleural air or fluid has resolved. A disconnection is fixed by restoring the closed drainage system, not by removing the tube.

Answer: C) Obtain an ABG and notify the physician of a likely need for ventilatory support

An acceptable SpO2 can hide impending ventilatory failure. A respiratory rate above 30/min, accessory muscle use and fatigue call for an ABG and prompt escalation toward ventilatory support.

• AIncorrect. SpO2 is within range, but the patient shows tachypnea, accessory muscle use and fatigue, which are signs of respiratory failure. Weaning oxygen ignores the rising work of breathing.
• BIncorrect. A respiratory rate above 30/min with respiratory muscle fatigue calls for prompt evaluation. Waiting several hours risks sudden decompensation.
• CCorrect. Pulse oximetry can't detect rising PaCO2 or acidosis. An ABG measures both, and tachypnea plus muscle fatigue suggest the patient may need HFNC, NIV or intubation.
• DIncorrect. Incentive spirometry adds work for a patient who is already fatigued and tachypneic. It doesn't treat impending respiratory failure.

Answer: C) Intubate and start mechanical ventilation, then transfer to intensive care

An infant with bronchiolitis who has repeated apnea needing bag-mask ventilation and acute respiratory acidosis on high-flow nasal cannula has failed that therapy. Intubation and mechanical ventilation are indicated, rather than more oxygen, less support, or bronchodilators.

• AIncorrect. More oxygen does not treat apnea or hypoventilation. The respiratory acidosis shows that ventilation is failing, and that needs ventilatory support.
• BIncorrect. This lowers support in an infant who is already failing high-flow therapy, so apnea and hypercapnia would likely get worse.
• CCorrect. Repeated apnea that needs bag-mask ventilation, together with acute respiratory acidosis, means high-flow therapy has failed and the infant is in respiratory failure. Intubation and mechanical ventilation are indicated.
• DIncorrect. Bronchodilators are not recommended for routine bronchiolitis care and do not treat apnea. Waiting an hour is unsafe when episodes already need bag-mask ventilation.

Answer: A) Continue NIV and monitor

• ACorrect. The patient is responding.
• BIncorrect. The patient is improving.
• CIncorrect. It's still needed.
• DIncorrect. That isn't needed.

Answer: B) Nebulized hypertonic saline followed by an oscillating PEP device

When conventional chest physiotherapy fails to clear thick bronchiectatic secretions, adding a mucoactive agent such as hypertonic saline and an oscillating PEP device improves airway clearance. Corticosteroids, incentive spirometry and oxygen do not mobilize mucus.

• AIncorrect. An inhaled corticosteroid targets airway inflammation. It does not thin or move retained secretions, so it does not address the problem of mucus that is too thick to clear.
• BCorrect. Hypertonic saline hydrates the airway surface and makes mucus less viscous. An oscillating PEP device then vibrates the airway walls and splints the airways open, which loosens and moves the mucus. Together they improve clearance when postural drainage and percussion alone are not enough.
• CIncorrect. Incentive spirometry encourages deep breaths to prevent or treat atelectasis. It does nothing to thin or loosen thick, retained bronchial secretions.
• DIncorrect. Supplemental oxygen treats hypoxemia. It does not thin or mobilize secretions, and nothing in the scenario points to a need for oxygen.