TMC Questionnaire with Explanation
You are called to examine an acutely dyspneic and hypotensive patient and you note the
following: reduced chest expansion on the left side, hyperresonant percussion note and tactile
fremitus on the left side, absent breath sounds on the left side, and a tracheal shift to the right.
What do these findings suggest?
A. Pleural effusion on the left side
B. Pneumothorax on the left side
C. Atelectasis on the left side
D. Consolidation on the left side - answer✔✔By assessing this patient, you can quickly
determine that the correct answer is a left-sided pneumothorax.
The unilateral findings of reduced chest expansion, a hyperresonant percussion note, absent
breath sounds and tactile fremitus all on the left side. That to go along with a tracheal shift to the
right — this indicates that the patient has most likely suffered a large pneumothorax on the left
side.
Remember, for a pneumothorax, the trachea will shift away from the affected side. You can rule
out left-sided atelectasis because the trachea would shift to that side. And also, if the
pneumothorax is severe enough, it can disrupt cardiac function which can cause the blood
pressure to decrease. That explains why this patient is hypotensive.
The correct answer is: B. Pneumothorax on the left side
You are asked to assess a 39-year-old man that was admitted through the emergency department
with an abrupt onset of fever and chills. The man shows signs of bilateral rhonchi with a
productive cough and his SpO2 is 88% on room air. What should you recommend?
A. Intubate and provide mechanical ventilation with 40% oxygen
B. Provide noninvasive positive pressure ventilation using a full face mask
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,C. Implement postural drainage and percussion with directed coughing
D. Provide oxygen therapy, give an antibiotic, and obtain a sputum sample for Culture and
Sensitivity - answer✔✔Based on the information provided, we can easily figure out that D is the
correct answer.
The likely problem is some type bacterial pneumonia because it tells us that the patient has fever
and chills. That is why you would want to obtain a sputum sample.
Antibiotics and oxygen therapy would be the proper initial treatment in this case, and the sputum
sample is needed to help identify the type of organism.
Intubation nor NPPV is indicated in this case. And postural drainage and percussion are not
recommended either. So we know that there can only be one correct answers, and it's D.
120The correct answer is: D. Provide oxygen therapy, give an antibiotic, and obtain a sputum
sample for Culture and Sensitivity
A 50-year-old man is intubated and receiving mechanical ventilation with a size8.0 mm
endotracheal tube that is secured in place. The patient's cuff pressure is measured at 36 cm H2O.
What would you recommend in this situation?
A. Withdraw the tube 1-2 cm and reassess the patient's breath sounds
B. Recommend reintubation with a smaller endotracheal tube
C. Lower the cuff pressure to < 30 cm H2O and assess for leaks
D. Recommend ventilation via a tracheotomy instead - answer✔✔In order to answer this one
correctly, you have to know what the normal values for cuff pressure. And in this case, you must
know that 36 cm H2O is way too high and could cause tracheal damage.
So your first action should be to lower the cuff pressure to < 30 cm H2O and check to make sure
that there are not any leaks.
There is no indication to withdraw the tube, and using a smaller tube would only cause the
patient's peak pressure to increase, which is something that we do not want. And there is no
indication for the insertion of a trach, so we know that the correct answer has to be C.
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,The correct answer is: C. Lower the cuff pressure to < 30 cm H2O and assess for leaks
While making a routine equipment check, you hear the patient's bubble humidifier is making a
whistling noise. Which of the following is the most likely cause of this problem?
A. There is an obstruction in the delivery tube
B. There is a rise in the patient's ventilation
C. There is a clogged system diffuser
D. The wall outlet pressure is set too high - answer✔✔If you've ever accidentally stepped on the
tubing when a bubble humidifier is being used, then you will automatically know that the answer
is A.
The relief valve of a humidifier sounds when the pressure in the reservoir container exceeds the
valve's threshold pressure. And of course, the most common reason for this to occur is when
there is a downstream obstruction to outflow.
Flowmeter restriction prevents high wall outlet pressures from affecting pressure in the
humidifier because it is limited at 50 psig. Changes in patient ventilation would have no effect on
pressure in the humidifier. So we know that there can only be one correct answers, and it's A.
The correct answer is: A. There is an obstruction in the delivery tube
A forced expiratory measurement obtained after the administration of a bronchodilator shows an
increase in the patient's FEV1 from 60% to 80% of the predicted value. What does this indicate?
A. A fixed airway obstruction
B. A reversible airway obstruction
C. A normal diffusion capacity
D. A restrictive process - answer✔✔As we can see, the patient's airway obstruction was relieved,
but was it enough to classify it a reversible obstruction?
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, In order to achieve clinical significance, the post-bronchodilator FVC, FEV1 and/or
FEV1/FVC% should be at least 12-15% greater than the pre-bronchodilator value.
So yes, the increase was enough and this indicates that there is a reversible airway obstruction.
The correct answer is: B. A reversible airway obstruction
You are called to assess an intubated patient that is breathing asynchronously with the ventilator.
Her breath sounds are absent on the left, with dullness to percussion and a left shift of the
trachea. Which of the following is the most likely explanation for the problem?
A. A tracheoesophageal fistula has developed
B. A tension pneumothorax has developed on the lefts ide
C. The endotracheal tube is in the right mainstem bronchus
D. The patient is experiencing diffuse bronchospasm - answer✔✔This is a question that we can
determine the correct answer right away by looking at the information that they give us in the
question.
It states that the patient has a dull percussion note on the left side, tracheal shift toward the left
side, and absent breath sounds on the left side. These are all signs of atelectasis!
So now you have to think, "What would cause atelectasis?" In this instance, slippage of the
endotracheal tube into the right mainstem bronchus would be the most likely cause left-sided
atelectasis.
Diffuse bronchospasm would cause bilateral wheezing and a left-sided pneumothorax would
cause a hyperresonant percussion note, not a dull percussion note. So we know that there can
only be one correct answer, and it's C.
The correct answer is: C. The endotracheal tube is in the right mainstem bronchus
A 63-year-old female patient is receiving pressure controlled A/C mechanical ventilation. Which
of the following changes would occur if her compliance were to decrease?
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