NCE PRACTICE EXAM

Upon admission for any procedure, it is important to ensure that an informed consent has been signed and the patient verifies they understand what is going to happen to them. DNR status/Advance Directives are also important to verify as they will determine what actions will be taken if something were to happen to the patient during the procedure.

The orders should be the first thing checked to be sure the patient is receiving the appropriate levels of oxygen and any treatments that need to be given immediately. The key word is STABLE. If the patient were in difficulty, it would be more important to check the Oximetry first.

Tactile Rhonchi is felt through the skin as a "rumble" or "bubbling" feeling beneath the hands. Tactile Fremitus is a palpable increase in vocal vibrations transmitted through the chest wall. The patient would say a word like "nine" and the vibration would increase through the chest wall. Crepitus is a crackling feeling beneath the skin when your fingertips press on an area. A "normal" chest wall would have no feelings of bubbling, cracking or vibration with speech beneath your hands or fingers.

The CXR will give you important information and should be obtained. However, the CXR takes time to order and to get the results back. When you have a patient arrive in the ER you want to perform initial assessment procedures that take little time and give you valuable data almost immediately. Pulse Oximetry, Breath Sounds and the Cardiac Monitor can give you vital information that gives you a baseline assessment of oxygen status, heart rhythm and breath sounds quickly.

To determine the tube size, divide the gestational age by 10. This is the quick method to determine size. You can also select the uncuffed ET tube with an internal diameter of 2.5 mm tube for infants less than 1 kg weight, 3.5 mm for neonates up to 1 year of age. An internal diameter of 3.0 mm should be used for neonates over 3.5 kg and less than a year old.

All the above. You need to determine if the patient has or had a history of cardiac issues, heart attacks or some form of lung disorder. Smoking history will help to determine if they have a contributing factor to cardiac and lung disease.

The criteria for RR, VT, VC, and Minute Ventilation have been determined through observation and study of the best techniques and parameters to obtain successful weaning. The Standard Weaning Criteria (SWC) uses the respiratory muscle strength and endurance by using the negative inspiratory force (NIF) and positive expiratory pressure (PEP) to determine how well a patient will do when weaned from the ventilator. The RSBI which is the Respiratory Shallow Breathing Index is used as well. As the patient tires the spontaneous breathing rate becomes rapid and shallow and it is necessary to evaluate muscle fatigue. RSBI =(f/VT) which helps to identify the breathing pattern associated with an unsuccessful weaning. The ratio of success is considered--

The symptoms in options a, b, and c are the most frequently seen in this scenario as well as drooling, sitting forward, sweating. A neck X-ray will show a column of air around the epiglottis and a "thumbs up sign."

The normal I:E ratio for an infant with normal lung compliance and an infant with obstructive lung disease is the same: 1:1.5 to 1: 2. An I:E ratio of 1:1 I:E ratio is used in infants with impaired Dynamic Compliance to ensure maximum alveolar recruitment.

Oxygen and Atropine are the initial drugs of choice for the treatment of Sinus Bradycardia. If the Bradycardia persists or devolves to a heart block you may consider placing transthoracic pacing pads along with medication and oxygen.

A Spiral/Helical CT takes less than 30 minutes to complete. If you have an unstable patient, it is important to get the information you need quickly. The V/Q scan is considered the second-best option. The CT Angiogram is the last choice as it is expensive and takes longer to accomplish. The CXR will not be sensitive enough to give you the information you need.

Obstructive Lung Disease will cause a higher than predicted increase in values of FRC, RV and TLC. Obstructive Lung Disease causes an increase in chest expansion.

Capnography gives you the most immediate information. Breath sounds and Bilateral Chest Expansion can be considered subjective. Oximetry is also a device that gives you data, but it is on Oxygen, not End Tidal CO2.

This is an example of an uncompensated respiratory acidosis. The PH is acidic-less than 7.35, PCO2 is high-greater than 45 mmHg demonstrated hypoventilation, and there is a normal HCO3. The kidneys have not started to adjust the Bicarb level by holding onto it.

0.7 - 1.3 mg/dL. Creatinine is a waste by-product of the metabolizing of creatine phosphate which is a result of the breakdown of skeletal muscle. There are four reasons why Creatinine is used to determine kidney function: the rate of production is fairly constant; it is eliminated only by the kidneys; it is not-protein bound so it is easily filtered by the kidneys and the rate of elimination is almost the same as the glomerular filtration rate. The importance of this is that creatinine is secreted and reabsorbed by the tubules in a limited amount.

Patient safety always comes first. If the dosage is incorrect, you must call the Provider and ask for clarification of the order. You do not give a medication order that is not correct. You do not give the "correct" dose and then confirm the order afterwards. All orders must be verified before administration. You do not just "skip" a treatment because the order is incorrect. Make sure the order error is corrected and the treatment given to the patient.

Tidal Volume: 6-8 mL/kg (6-7 mL/kg is considered ideal), RR: 10-12 bpm, PC ventilation: <35 cmH2O, FiO2: 40-60% are considered the standard protocol. The exceptions are ARDS, ALI, Asthma where the ARDS Net protocol 4-6 mL/kg and 4 mL/kg for Asthmatics should be used. When calculating the VT, calculate a high and low VT for ARDS.

If your FiO2 is over 60% and your PEEP is over 5, lower the PEEP first. The reasoning is that if your P/F ratio PaO2/FiO2 cannot be maintained as you lower the Peep as you may have an underlying problem with ARDS.

Compliance = Change in Volume/Change in Pressure. Remember that the lungs are normally compliant. They adjust to changes in volume and pressure relatively easy. As the lungs become less compliant, less volume can be accommodated, thus increasing the pressure in the lungs as lung volumes are trying to be maintained.

The only name that is not used to describe auto-PEEP is Stiff Lung. A non-compliant lung can contribute to Auto PEEP occurring.

Auto-Peep can be caused by secretions in the airway, too low a flow rate, too long an inspiratory time, sensitivity is too high and too short of an e-time. By increasing the flow rate, you can decrease the I: Time. Bronchodilators and suctioning remove obstruction of the airway due to secretions or edema. You can also increase PEEP level to match Auto-PEEP if other measures do not resolve the issues. This will increase sensitivity decreasing the work of breathing. Changing the flow patter by changing the wave to a square pattern may decrease auto-peep versus a decelerating wave form which may not give sufficient exhalation time. Increasing the E: Time allows for a longer period of time for the patient to exhale air from the lungs.

Too high a level of PEEP can cause a decrease in Cardiac Output by decreasing Venous return to the heart and decreases Urine Output due to the decrease in Cardiac Output. Too high a PEEP can decrease lung compliance as the lung cannot properly deflate.

If the FiO2 is already 60% or over, then gradually increase the PEEP. If the FiO2 is not 60% or over then increase the FiO2 first until you reach 60%, then adjust your PEEP.

Bronchoconstriction, Kinked ETT and Secretions are three common, easy to fix issues that affect Dynamic Compliance. Cdyn= Vt/(PIP-PEEP).

Keep RR high to keep PaCO2 levels between 25 and 30 mmHg and PIP below 30 cmH2O to avoid suctioning and causing coughing which raises ICP.

Administer Acetylcysteine Concentrations of 10-20% via a nebulizer after pre-treating the patient with a bronchodilator. In the clinical setting you often mix the bronchodilator and the Acetylcysteine together.

Increasing the I-Time increases the time the flow is entering the lungs which will increase the airway pressure. Increasing the Pressure Limit allows for the increase in MAP.

When a patient's equipment is broken it is important to have both of you speak to the patient's case manager to arrange procuring a new one for home use. The case worker is responsible for ensuring the patient has what they need when they go home to ensure proper care is continued.

Acetic Acid soak for 20 minutes. Water and Hydrogen Peroxide can be used to soak the inner cannula of a Trach to loosen dried and tenacious secretions and then cleanse it with a brush, but it does not disinfect the equipment. Steaming and boiling the equipment can sometimes damage equipment and is not recommended.

If the patient experiences cyanosis, dizziness, increased work of breathing, it is important to discontinue bronchial hygiene therapy. Any of these symptoms can cause severe problems and potentially death.