Entry-Level Exam Review for Respiratory Care PDF

 E N T R Y- L E V E L EXAM REVIEW F O R R E S P I R AT O R Y CARE: GUIDELINES FOR SUCCESS SECOND EDITION WILLIAM V. WOJCIECHOWSKI A u s t r a l i a C a n a d a M e x i c o S i n g a p o r e S p a i...

 E N T R Y- L E V E L EXAM REVIEW F O R R E S P I R AT O R Y CARE: GUIDELINES FOR SUCCESS SECOND EDITION WILLIAM V. WOJCIECHOWSKI A u s t r a l i a C a n a d a M e x i c o S i n g a p o r e S p a i n U n i t e d K i n g d o m U n i t e d S t a t e s  Entry-Level Exam Review for Respiratory Care: Guidelines for Success by William V. Wojciechowski Business Unit Director: Project Editor: William Brottmiller Stacy Prus DISCLAIMER Acquisitions Editor: Production Coordinator: The author, contributors, and publisher make no claim Candice Janco John Mickelbank that persons using this review book are guaranteed success on the National Board for Respiratory Care (NBRC) Entry-Level (CRTT) Examination. The National Development Editor: Art/Design Coordinator: Board for Respiratory Care does not endorse this Patricia A. Gaworecki Mary Colleen Liburdi publication. The NBRC has merely granted permission to Delmar Publications, Inc. to use the Entry-Level (CRTT) Examination Matrix in this publication. The examination Editorial Assistant: Cover Design: items and analyses contained in this publication have Elizabeth O’Keefe TDB Publishing Service been written by the author and contributors based solely on their own education, experience, and knowledge of the profession of respiratory care. The NBRC offers no Executive Marketing Manager: opinion or endorsements of these examination items and Dawn F. Gerrain analyses. COPYRIGHT © 2001 by Delmar, ALL RIGHTS RESERVED. No part of this Library of Congress Cataloging-in- a division of Thomson Learning, Inc. Thom- work covered by the copyright hereon may Publication Data son Learning™ is a trademark used herein be reproduced or used in any form or by any Wojciechowski, William V. under license means—graphic, electronic, or mechanical, Entry-level exam review for respiratory care: including photocopying, recording, taping, guidelines for success/Wojciechowski, Printed in Canada Web distribution or information storage and William V.—2nd ed. 1 2 3 4 5 XXX 05 04 02 01 00 retrieval systems—without written permis- p. ; cm. sion of the publisher. Includes bibliographical references. For more information contact Delmar, ISBN 0-7668-0779-7 3 Columbia Circle, PO Box 15015, For permission to use material from this text 1. Respiratory therapy—Examinations, Albany, NY 12212-5015. or product, contact us by questions, etc. I. Title Tel (800) 730-2214 [DNLM: 1. Respiratory Therapy— Or find us on the World Wide Web at Fax (800) 730-2215 Examination Questions. WB 18.2 http://www.delmar.com www.thomsonrights.com W847e2001] RC735.I5 W644 2001 615.8'36'076—dc21 00-030686 NOTICE TO THE READER Publisher does not warrant or guarantee any of the products described herein or perform any independent analysis in connection with any of the product information contained herein. Publisher does not assume, and expressly disclaims, any obligation to ob- tain and include information other than that provided to it by the manufacturer. The reader is expressly warned to consider and adopt all safety precautions that might be indicated by the activities herein and to avoid all potential hazards. By following the instructions contained herein, the reader willingly assumes all risks in connection with such instructions. 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The publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or part, from the readers’ use of, or reliance upon, this material.  Dedication To my children, Alison, Maria, and Matthew, who raise more questions than are found in this book, and whose answers are found in no book.  Contents CHAPTER-MATRIX TABLE vii PREFACE ix ACKNOWLEDGMENTS xi CONTRIBUTORS xiii INTRODUCTION 1 TEXT OBJECTIVES 1 ORGANIZATION OF BOOK CONTENT 1 HOW TO USE EACH CHAPTER 1 ENTRY-LEVEL EXAMINATION STRUCTURE 3 ENTRY-LEVEL EXAMINATION MATRIX 3 NBRC CERTIFICATION EXAMINATION FOR ENTRY-LEVEL CERTIFIED RESPIRATORY THERAPISTS (CRTS) 4 LEVEL OF QUESTIONS 12 ENTRY-LEVEL EXAMINATION ITEM FORMAT 13 MULTIPLE TRUE-FALSE (K-TYPE) QUESTIONS 13 GENERAL ENTRY-LEVEL EXAMINATION INFORMATION 14 ENTRY-LEVEL EXAMINATION PREPARATION 14 CHAPTER 1 TEST PREPARATION 17 THE APPLICATION 17 THE MATRIX AND CLINICAL PRACTICE 18 STUDY HINTS 19 THE WEEK OF THE EXAMINATION 21 THE DAY BEFORE THE EXAMINATION 21 THE DAY OF THE EXAMINATION 21 EXPECT TO PASS 22 CHAPTER 2 PRETEST 23 PRETEST ASSESSMENT 27 CHAPTER 2 PRETEST: MATRIX CATEGORIES 46 PRETEST ANSWERS AND ANALYSES 48 REFERENCES 82 CHAPTER 3 CLINICAL DATA 83 CLINICAL DATA ASSESSMENT 90 CHAPTER 3: MATRIX CATEGORIES 132 CLINICAL DATA ANSWERS AND ANALYSES 134 v  REFERENCES 192 CHAPTER 4 EQUIPMENT 193 EQUIPMENT ASSESSMENT 199 MATRIX CATEGORIES 233 EQUIPMENT ANSWERS, ANALYSES, AND REFERENCES 235 REFERENCES 279 CHAPTER 5 THERAPEUTIC PROCEDURES 280 THERAPEUTIC PROCEDURES ASSESSMENT 288 MATRIX CATEGORIES 329 THERAPEUTIC PROCEDURES—ANSWERS AND ANALYSES 331 REFERENCES 382 CHAPTER 6 POSTTEST 383 POSTTEST ASSESSMENT 387 POSTTEST: MATRIX CATEGORIES 405 POSTTEST ANSWERS AND ANALYSES 407 REFERENCES 437 APPENDIX 1 QUICK REFERENCE MATERIAL—CLINICAL DATA 439 APPENDIX 2 QUICK REFERENCE MATERIAL—SPIROGRAM, 446 ECG, PULMONARY ARTERY CATHETER, AND CAPNOGRAPHY APPENDIX 3 QUICK REFERENCE MATERIAL—MECHANICAL 453 VENTILATION WAVEFORMS vi  Chapter-Matrix Table Chapter Matrix Section Pages/Questions Pages/Analyses 2 All matrix sections 27–45/1–140 48–81/1–140 3 IA1 to IA2 90–101/1–95 134–158/1–95 3 IB1 to IB10 104–119/96–210 158–182/96–210 3 IC1 to IB2 123–129/211–250 182–191/211–250 4 IIA1 to IA2 199–212/1–111 235–256/1–111 4 IIB1 to IIB3 215–229/112–211 257–278/112–211 5 IIIA1 to IIID10 288–303/1–110 331–354/1–110 5 IIIE1 to IIIG2 307–325/111–235 354–381/111–235 6 All matrix sections 387–404/1–140 407–436/1–140 Chapters 3, 4, and 5 have been restructured. The questions are no longer randomly interspersed throughout each chapter, as in the first edition. In this edition, questions and analyses are presented in sequential order ac- cording to the Entry-Level Examination Matrix. For example, Chapter Three, “Clinical Data,” has three sections: IA, IB, and IC. All the questions referring to the matrix category IA appear in sequence. No questions from matrix categories IB or IC are included in that portion of the chapter. Each matrix area is segregated within its corresponding chap- ter. The analyses pertaining to the questions are also sequenced in the same manner. vii  Preface The purpose of the second edition of The Entry-Level Exam Review for Respiratory Care: Guidelines for Suc- cess is to assist Entry-Level Examination candidates to prepare for the credentialing exam based on the expanded matrix introduced in July 1999. Every five years, the National Board for Respiratory Care (NBRC) conducts a job analysis for the Entry-Level and Advanced Practitioner Examinations. Respiratory therapists, department heads, educators, and physicians throughout the United States complete thousands of job-analysis surveys. These surveys ascertain the specific tasks performed by certified and registered respiratory therapists. The questions, therefore, are job related. The job analysis also ensures the content validity of the credentialing examinations. Each five-year cycle results in more application and analysis questions, with fewer recall questions appearing on the exam. First- time technicians taking the 1999 revised Entry-Level Examination had only a 46.5% pass rate (refer to the table on page x). This new edition can help you prepare for a better exam performance with these features: Organization is centered on the 1999 NBRC Exam Matrix in a question/answer format that provides the stu- dent with analyses for each answer. Pretest and posttest evaluations identify baseline competencies and areas of continued remediation. Matrix scoring forms appear in every chapter, along with the complete NBRC examination content outline for reference and review. CD-ROM software provides a practice test environment that simulates the actual computerized NBRC exam. Students are able to take the test in learning or test modes, with answers and analyses provided. A timing function is also available to more closely resemble the actual exam. There is no substitute for preparation and practice. This book has been designed as a tool to help you progress through the credentialing process. Good luck in your professional endeavors. ix  NBRC Entry-Level Exam Data 100 90 Average ELE 1st-time technician pass rate 1990 - March 1999 = 69.4% 80 70 Percent Pass Rate (%) % * 60 50 4 6 * * 40 30 20 10 0 1994 1994 1999 1990 1991 1992 1993 March July/Nov 1995 1996 1997 1998 March 1999 First-Time Technicians 70.6 71.1 72.2 73.6 72.7 66.6 68.47 67.83 66.8 67 66.9 46 Repeat Technicians 28.4 27.2 25.4 27.3 20 19.9 24.2 23 20 26.1 26.9 6.2 Repeat Therapists 35.7 37.6 31.8 36.3 27.2 29.8 34.8 31.2 34 37 39.9 7.8 *ELE exam revised based on 1993 job analysis: 1st-time technician pass rate: 65.1% *ELE exam revised based on 1997 job analysis: 1st-time technician pass rate: 46%.  Acknowledgments I wish to take this opportunity to extend my appreciation to my colleagues who contributed to the writing of The Entry-Level Examination Review for Respiratory Care: Guidelines for Success second edition. I am certain that the composite of their clinical experiences and educational expertise will greatly benefit the candidates who use this book to prepare for the NBRC Entry-Level Examination. Sincere thanks and gratitude are extended to Deanna Winn for her painstaking efforts and patience that she dis- played throughout the typing of the manuscript. The fact that she maintained an amiable attitude despite the hard- ships was inspirational. Her amiability is now a known attribute of her character. How she relishes compiling an art manuscript amazes me further (inside joke). Special thanks to Fred Hill, MA, RRT for meticulously reviewing the entire manuscript and making insightful suggestions. Special thanks is also extended to Helen A. Jones, RRT, for contributing Chapter 1, which sets the tempo for the remainder of the book. I am also grateful for the professional assistance provided by Patty Gaworecki, Tara Carter, Doris Smith, and Dawn Gerrain of Delmar Thomson Learning. Lastly, I welcome suggestions and critiques of all varieties from the reading audience in an effort to enhance the utility of this book. W. V. W. xi  Contributors Karen M. Boudin, MA, RRT Fred Hill, MA, RRT Inservice Instructor Assistant Professor Department of Respiratory Therapy Department of Cardiorespiratory Care Stanford University Hospital University of South Alabama Stanford, CA Mobile, AL Kim Cavanagh, MEd, RRT Bradley A. Leidich, MSEd, RRT Technical Director Associate Professor/Director Respiratory Therapy Department Respiratory Care Programs Mercy Medical Harrisburg Area Community College Daphne, AL Harrisburg, PA Robert P. DeLorme, MEd, RRT Nancy Jane Deck-Lorance, BS, RRT Program Director Program Director Respiratory Therapy Technology Respiratory Therapist Program Gwinnett Technical Institute Rose State College Lawrenceville, GA Midwest City, OK Larry Arnson, MS, RRT Anna W. Parkman, MBA, RRT Director of Clinical Education/Instructor Program Director Respiratory Therapy Technology Program Respiratory Care Program Gwinnett Technical Institute University of Charleston Lawrenceville, GA Charleston, WV F. Herbert Douce, MS, RRT Glenda Jean Fisher, BA, RRT Assistant Professor/Director of Respiratory Therapy Director of Clinical Education Respiratory Therapy Division Respiratory Care Program The Ohio State University University of Charleston Columbus, OH Charleston, WV Charles M. Fatta, MBA, RRT Leslee Harris Smith, MS, RRT Albuquerque Technical-Vocational Institute Respiratory Therapy Program Head/ Albuquerque, NM Assistant Professor Northern Virginia Community College Marie A. Fenske, EdD, RRT Annandale, VA Program Director Respiratory Care Steve Wehrman, RRT Gateway Community College Assistant Professor/Program Director Phoenix, AZ University of Hawaii Kapiolani Community College Robert R. Fluck, Jr., MS, RRT Honolulu, HI Associate Professor Department of Respiratory Care and Theodore R. Wiberg, PhD, RRT Cardiorespiratory Sciences Chairman of Health Sciences State University of New York Richard A. Henson School of Science and Technology Health Science Center–Syracuse Salisbury State University Syracuse, NY Salisbury, MD Bill Galvin, MSED, RRT, CPFT David N. Yonutas, MS, RRT Assistant Professor, Division of Allied Health Program Coordinator Program Director, Respiratory Care Program Health Sciences Gwynedd Mercy College Santa Fe Community College Gwynedd, PA Gainesville, FL Lezli Heyland, BS, RRT Francis Tuttle Vocational Technical Center Oklahoma City, OK xiii  INTRODUCTION Text Objectives Chapter 2: Pretest Chapter 3: Clinical Data The objectives of this text are as follows: Chapter 4: Equipment 1. preparing candidates for the National Board of Chapter 5: Therapeutic Procedures Respiratory Care (NBRC) Entry-Level Exami- Chapter 6: Posttest nation 2. providing Entry-Level Examination candidates the opportunity to complete a computer-based How to Use Each Chapter practice examination Introduction 3. assisting respiratory care students in entry-level and advanced practitioner programs to prepare The introduction provides the following information: (1) for course examinations states this text’s objectives, (2) explains how to use this 4. preparing practitioners for legal credentialing review book, (3) describes the makeup and content areas (state) examinations contained in the NBRC Entry-Level Examination, (4) 5. streamlining the credentialing examination provides information on how to prepare for the Entry- preparation process by focusing the candidate’s Level Examination, and (5) describes the three levels of attention on the Entry-Level Examination Matrix questions contained on the Entry-Level Examination. 6. determining entry-level content areas requiring Refer to the matrix of the examination to be familiar remediation with the concepts that are presented on the credentialing 7. presenting an organized approach to examina- examination. You should focus on the specific material tion preparation described in each matrix item. Doing so will make your study time more efficient. Do not neglect this critical 8. reinforcing learning by providing several cross- step in the credentialing examination review process. To references for each question assist you with this task, all the questions in this book 9. clarifying theoretical and clinical aspects of have been categorized into their content areas via the entry-level respiratory care via analysis of each Entry-Level Examination Matrix Scoring Form located question in Chapters 2 through 6. You should use the scoring of 10. providing a self-assessment mechanism for your results on these forms to develop a prescription for credentialed respiratory care practitioners study. Collate your results, and focus your attention on 11. supplementing hospital in-service programs the areas that require remediation. 12. assisting respiratory care educators with devel- oping evaluation instruments for course exami- Chapter 1 Test Preparation nations Embarking on a credentialing examination review process 13. assisting respiratory care educators with the requires a positive attitude. The content of the first chapter development of Entry-Level Examination in this review book focuses your attention on the task review sessions at hand. As formidable an undertaking as the review process seems, a number of practical and relatively easy plans of action are presented to help alleviate your Organization of Book Content anxiety and stress. Suggestions are provided for orga- This book consists of six chapters: nizing a realistic timetable for using the examination review material presented in this text. You are encour- Introduction aged to make the effort to implement the strategies pro- Chapter 1: Examination Preparation vided for your use. 1 Chapter 2 Pretest (140 Items, Analyses, you read material in the references. After you have thor- and References) oughly reviewed the questions, analyses, matrix desig- nations, and references, proceed to the next chapter. The pretest should be performed without the benefit of advance preparation. You should simply take the pretest Chapter 3 Clinical Data (250 Items, to establish a baseline for the measurement of your Analyses, and References) progress through this study guide. Make sure that you allow yourself three hours of uninterrupted time to Chapter 3 enables you to evaluate your knowledge in complete the pretest. That length of time is provided by the four categories within this content area: the NBRC for this credentialing examination. Place A. Reviewing patient records and recommending yourself in a quiet, well-lit, ventilated area. Be seated diagnostic procedures on a chair with a back support at a desk or table. B. Collecting and evaluating clinical information The pretest offers you the opportunity to identify Entry-Level Examination content areas that might re- C. Performing procedures and interpreting results quire remediation. The pretest parallels the Entry-Level D. Assessing and developing a therapeutic plan Examination. The items on the pretest match the testing and recommending modifications categories found on the Entry-Level Examination. Among the four categories encountered in the con- Table I-1 indicates the content areas and the item dis- tent area of clinical data, there are 68 matrix designa- tribution comprising the pretest. tions. Twenty-five of these matrix items are included on Table I-1: Pretest Content Areas and Item Distribution the NBRC Entry-Level Examination. Content Areas Number of Items Because there is no way to determine which 25 items relating to clinical data will appear on the Entry-Level Ex- I. Clinical Data 25 amination, the candidate needs to experience questions II. Equipment 36 from each matrix item. This chapter provides you with III. Therapeutic Procedures 79 practice questions that encompass virtually all the possible TOTAL 140 types that might be encountered on the actual examination. After completing the pretest, use the answer sheet In addition to thoroughly studying the questions, provided in the book to determine your score. Use the analyses, and references for the questions that were ei- Entry-Level Examination Matrix Scoring Form, located ther incorrectly answered or answered correctly by after the analyses, to score each content category and de- guessing, you are encouraged to note the matrix desig- termine content areas that require remediation. Review nation of those questions and refer to the Entry-Level and study the analyses of the questions you have an- Examination Matrix for a clear description of the con- swered incorrectly, as well as the analyses of the ques- cept being tested. Remember to use the Entry-Level tions that you might have gotten correct by answering Examination Matrix Scoring Form associated with this with an “educated” guess. In other words, also review chapter to help identify areas of strength and weakness the analyses of any questions of which you are unsure. regarding Clinical Data. After studying each question and analysis, refer to Again, as with all the other chapters, use the answer the Entry-Level Examination Matrix located within sheet provided at the beginning of each assessment. Chapter 2. The matrix outlines all the tasks that fall You should strive to achieve a score of 75% in this within the purview of the Entry-Level Examination. chapter, or 187 correct answers. You must become familiar with the range of knowledge Chapter 4 Equipment (211 Items, and cognitive areas for which you are responsible on Analyses, and References) this credentialing examination. The manner in which to achieve this familiarity is to study the Entry-Level Ex- This chapter offers you the opportunity to evaluate your un- amination Matrix, as well. derstanding of the two categories within this content area: When you have reviewed the appropriate matrix cat- A. Selecting, obtaining, and assuring equipment egories, read and study the material indicated by the ref- cleanliness erences. The references are provided to offer you a more B. Assembling, checking, and correcting equip- detailed account of the concept associated with each ment malfunctions; performing quality control question and analysis. By reading the matrix designa- tion before proceeding to the references, you will be These two categories are represented by 90 matrix more focused on the information pertinent to the matrix designations. Only 36 items from this section appear on category and will be less likely to go off on tangents as the Entry-Level Examination. 2 Introduction  This chapter offers you the opportunity to sample the exhaustive review of the Entry-Level Examination Ma- entire gamut of matrix items, because the assessment trix. The posttest content areas and item distribution are presented here contains 211 items regarding equipment. listed in Table I-2. Again, you are urged to completely review the materials Table I-2: Posttest Content Areas and Item Distribution that require remediation and cross-reference the items to the Entry-Level Examination Matrix. Use the answer Content Areas Number of Items sheet located in front of the test, and employ the Entry- I. Clinical Data 25 Level Examination Matrix Scoring Form found after the II. Equipment 36 analyses. A score of 75% would result from correctly III. Therapeutic Procedures 79 answering 158 of the 211 items presented. TOTAL 140 Chapter 5 Therapeutic Procedures (235 Items, Analyses, and References) The posttest should indicate the degree of progress you have made while studying this review book. The This chapter enables you to evaluate your comprehen- posttest should be approached seriously and with con- sion of the seven categories within this content area: fidence, which should have developed over the last few A. Educating patients and maintaining records, weeks. As with the pretest, the posttest should also be communication, and infection control graded immediately, and, for the final time, remedia- tion (questions, analyses, and matrix) and cross- B. Maintaining an airway and removing bron- referencing must follow. chopulmonary secretions C. Assuring ventilation and oxygenation Entry-Level Examination D. Assessing patient response E. Modifying therapy/making recommendations Structure based on patient’s response; recommending The examination matrix is a detailed content outline pharmacologic agents describing the content categories that will appear on the F. Resuscitating in various emergency situations Entry-Level Examination. You should become famil- G. Assisting physician; conducting pulmonary re- iarized with the examination matrix. Keep in mind that habilitation and home care the items appearing on the credentialing examination have been developed from this outline. Chapter 5 provides you with 235 sample questions The Entry-Level Examination Matrix provides you from this content area. Therefore, to achieve a score with the information that is evaluated on this creden- (75%) on this assessment, you must minimally answer tialing examination. The matrix of this test helps eval- 176 questions correctly. The Entry-Level Examination uate whether the candidate possesses the cognitive Matrix contains 90 matrix designations from the seven skills necessary to function as a Certified Respiratory content categories found with Therapeutic Procedures. Technician (CRT) at the entry level. Only 79 items appear on the NBRC Entry-Level Ex- amination, however. As before, careful attention to the remediation process and cross-referencing the ques- Entry-Level Examination tions to the Entry-Level Examination Matrix should Matrix prepare you well for this content area. The Entry-Level Examination Matrix is composed of Chapter 6 Posttest (140 Items, Analyses, three major content areas: and References) I. Clinical Data The posttest is intended to provide you with feedback re- II. Equipment lated to the remediation performed in response to the re- III. Therapeutic Procedures sults obtained on the pretest. The posttest is structured to parallel the NBRC Entry Level Examination in terms of Each of these content areas is divided into a number content area and item distribution. The following table of subcategories. The subcategories are subdivided into demonstrates the organization of the posttest. more specific content elements. The complete Entry- Chapter 6 contains a posttest tailored after the Entry- Level Examination Matrix follows in Table I-3. Be- Level Examination. This evaluation tool represents the come familiar with this matrix as you prepare for the culmination of a substantial effort on your part and an examination. Introduction 3 NBRC Certification Examination for Entry-Level Certified Respiratory Therapists (CRTs) APP APP ANA ANA LIC LIC REC REC ATI ATI LYS LYS ALL ALL ON ON Content Outline—Effective July 1999 IS IS N N N N (4) dead space to tidal volume ratio I. Select, Review, Obtain, (VD/VT) x (5) non-invasive monitoring [e.g., and Interpret Data capnography, pulse oximetry, SETTING: In any patient care set- transcutaneous O2/CO2] x ting, the respiratory care practi- g. results of cardiovascular monitoring tioner reviews existing clinical data (1) ECG, blood pressure, heart rate x and collects or recommends ob- (2) hemodynamic monitoring [e.g., taining additional pertinent clinical central venous pressure, cardiac data. The practitioner interprets all output, pulmonary capillary wedge data to determine the appropriate- pressure, pulmonary artery pressures, ness of the prescribed respiratory mixed venous O2, C(a-v̄)O2, shunt care plan and participates in the studies (Q̇s/Q̇t)] x development of the plan. h. maternal and perinatal/neonatal history 7 14 4 and data [e.g., Apgar scores, gestational age, L/S ratio, pre/post-ductal A. Review existing data in patient record, oxygenation studies] x x and recommend diagnostic procedures. 2* 3 0 2. Recommend the following procedures to 1. Review existing data in patient record; obtain additional data: a. patient history [e.g., present illness, a. X-ray of chest and upper airway, CT admission notes, respiratory care scan, bronchoscopy, ventilation/ orders, progress notes] x** x perfusion lung scan, barium swallow x b. physical examination [e.g., vital signs, b. Gram stain, culture, and sensitivities x physical findings] x x c. spirometry before and/or after c. lab data [e.g., CBC, chemistries/ bronchodilator, maximum voluntary electrolytes, coagulation studies, ventilation, diffusing capacity, functional Gram stain, culture and sensitivities, residual capacity, flow-volume loops, urinalysis] x body plethysmography, nitrogen d. pulmonary function and blood gas washout distribution test, total lung results x capacity, CO2 response curve, closing e. radiologic studies [e.g., X-rays of volume, airway resistance, chest/upper airway, CT, MRI] x bronchoprovocation, maximum f. monitoring data inspiratory pressure (MIP), maximum (1) pulmonary mechanics [e.g., expiratory pressure (MEP) x maximum inspiratory pressure d. blood gas analysis, insertion of arterial, (MIP), vital capacity] x umbilical, and/or central venous (2) respiratory monitoring [e.g., rate, pulmonary artery monitoring lines x tidal volume, minute volume, I:E, e. lung compliance, airway resistance, inspiratory and expiratory lung mechanics, work of breathing x pressures; flow, volume, and f. ECG, echocardiography, pulse oximetry, pressure waveforms] x transcutaneous O2/CO2 monitoring x (3) lung compliance, airway resistance, work of breathing x B. Collect and evaluate clinical information. 3 7 0 1. Assess patient’s overall cardiopulmonary status by inspection to determine: *The number in each column is the number of item in that content area and the cognitive level contained in each examina- tion. For example, in category I.A., two items will be asked at the recall level, three items at the application level, and no items at the analysis level. The items could be asked relative to any tasks listed (1–2) under category I.A. **Note: An “x” denotes the examination does NOT contain items for the given task at the cognitive level indicated in the re- spective column (Recall, Application, and Analysis). 4 Introduction  APP APP ANA ANA LIC LIC REC REC ATI ATI LYS LYS ALL ALL ON ON IS IS N N N N a. general appearance, muscle wasting, b. presence of, or changes in, venous distention, peripheral edema, pneumothorax or subcutaneous diaphoresis, digital clubbing, cyanosis, emphysema, other extra-pulmonary air, capillary refill x consolidation and/or atelectasis, b. chest configuration, evidence of pulmonary infiltrates x diaphragmatic movement, breathing c. position of chest tube(s), nasogastric pattern, accessory muscle activity, and/or feeding tube, pulmonary artery asymmetrical chest movement, catheter (Swan-Ganz), pacemaker, intercostal and/or sternal retractions, CVP, and other catheters x x nasal flaring, character of cough, d. presence and position of foreign bodies x amount and character of sputum x e. position of, or changes in, c. transillumination of chest, Apgar score, hemidiaphragms, hyperinflation, pleural gestational age fluid, pulmonary edema, mediastinal 2. Assess patient’s overall cardiopulmonary shift, patency, and size of major airways x status by palpation to determine: 8. Review lateral neck X-ray to determine: a. heart rate, rhythm, force x a. presence of epiglottitis and subglottic b. asymmetrical chest movements, tactile edema x fremitus, crepitus, tenderness, secretions b. presence or position of foreign bodies x in the airway, tracheal deviation, c. airway narrowing x endotracheal tube placement x 9. Perform bedside procedures to determine: 3. Assess patient’s overall cardiopulmonary a. ECG, pulse oximetry, transcutaneous status by percussion to determine O2/CO2 monitoring, capnography, diaphragmatic excursion and areas of mass spectrometry x altered resonance x b. tidal volume, minute volume, I:E x 4. Assess patient’s overall cardiopulmonary c. blood gas analysis, P(A a)O2, alveolar status by auscultation to determine the ventilation, VD/VD, Q̇s/Q̇t, mixed venous presence of: sampling x a. breath sounds [e.g., normal, bilateral, d. peak flow, maximum inspiratory increased, decreased, absent, unequal, pressure (MIP), maximum expiratory rhonchi or crackles (rales), wheezing, pressure (MEP), forced vital capacity, stridor, friction rub] x timed forced expiratory volumes [e.g., b. heart sounds, dysrhythmias, murmurs, FEV1], lung compliance, lung mechanics x bruits e. apnea monitoring, sleep studies, c. blood pressure x respiratory impedance plethysmography x 5. Interview patient to determine: f. tracheal tube cuff pressure, volume x a. level of consciousness, orientation to 10. Interpret results of bedside procedures time, place, and person, emotional state, to determine: ability to cooperate x a. ECG, pulse oximetry, transcutaneous b. presence of dyspnea and/or orthopnea, O2 /CO2 monitoring, capnography, mass work of breathing, sputum production, spectrometry x exercise tolerance, and activities of b. tidal volume, minute volume, I:E x daily living x c. blood gas analysis, P(A-a)O2, alveolar c. physical environment, social support ventilation, VD /VT, Q̇s/Q̇t, mixed venous systems, nutritional status x sampling x 6. Assess patient’s learning needs [e.g., age d. peak flow, maximum inspiratory and language appropriateness, education pressure (MIP), maximum expiratory level, prior disease and medication pressure (MEP), forced vital capacity, knowledge] x timed forced expiratory volumes [e.g., 7. Review chest X-ray to determine: FEV1], lung compliance, lung mechanics x a. position of endotracheal or tracheostomy e. apnea monitoring, sleep studies, tube, evidence of endotracheal or respiratory impedance plethysmography x tracheostomy tube cuff hyperinflation x f. tracheal tube cuff pressure, volume x Introduction 5  APP APP ANA ANA LIC LIC REC REC ATI ATI LYS LYS ALL ALL ON ON IS IS N N N N C. Perform procedures and interpret results. 2 3 0 2. Participate in development of respiratory 1. Perform and/or measure the following: care plan [e.g., case management, develop a. ECG, pulse oximetry, transcutaneous and apply protocols, disease management O2 /CO2 monitoring x education] x x b. spirometry before and/or after bronchodilator, maximum voluntary ventilation, diffusing capacity, functional residual capacity, flow-volume loops, II. Select, Assemble, and body plethysmography, nitrogen washout Check Equipment for Proper distribution test, total lung capacity, Function, Operation and CO2 response curve, closing volume, Cleanliness airway resistance x c. arterial sampling and blood gas SETTING: In any patient care analysis, co-oximetry, P(A-a)O2 x setting, the respiratory therapist d. ventilator flow, volume, and pressure selects, assembles, and assures waveforms, lung compliance x cleanliness of all equipment used 2. Interpret results of the following: in providing respiratory care. The a. spirometry before and/or after therapist checks all equipment bronchodilator, maximum voluntary and corrects malfunctions. ventilation, diffusing capacity, functional 14 22 0 residual capacity, flow-volume loops, body plethysmography, nitrogen washout A. Select, obtain, and assure equipment distribution test, total lung capacity, CO2 cleanliness. 5 8 0 response curve, closing volume, airway 1. Select and obtain equipment appropriate resistance, bronchoprovocation x to the respiratory care plan: b. ECG, pulse oximetry, transcutaneous a. oxygen administration devices O2 /CO2 monitoring x (1) nasal cannula, mask, reservoir mask c. arterial sampling and blood gas (partial rebreathing, non-rebreathing), analysis, co-oximetry, P(A-a)O2 x face tents, transtracheal oxygen d. ventilator flow, volume, and pressure catheter, oxygen conserving cannulas x waveforms, lung compliance x (2) air-entrainment devices, tracheostomy collar and T-piece, D. Determine the appropriateness and oxygen hoods and tents x participate in the development of the (3) CPAP devices x respiratory care plan, and recommend b. humidifiers [e.g., bubble, passover, modifications. 0 1 4 cascade, wick, heat moisture exchanger] x 1. Determine the appropriateness of the c. aerosol generators [e.g., pneumatic prescribed respiratory care plan and nebulizer, ultrasonic nebulizer] x recommend modifications where indicated: d. resuscitation devices [e.g., manual a. analyze available data to determine resuscitator (bag-valve), pneumatic pathophysiological state x (demand-valve), mouth-to-valve mask b. review planned therapy to establish resuscitator] x therapeutic plan x e. ventilators c. determine appropriateness of prescribed (1) pneumatic, electric, microprocessor, therapy and goals for identified fluidic x pathophysiological state x (2) non-invasive positive pressure x d. recommend changes in therapeutic f. artificial airways plan if indicated (based on data) x (1) oro- and nasopharyngeal airways x e. perform respiratory care quality (2) oral, nasal and double-lumen assurance x x endotracheal tubes x f. implement quality improvement (3) tracheostomy tubes and buttons x program x x (4) intubation equipment [e.g., g. review interdisciplinary patient and laryngoscope and blades, exhaled family care plan x x CO2 detection devices] x 6 Introduction  APP APP ANA ANA LIC LIC REC REC ATI ATI LYS LYS ALL ALL ON ON IS IS N N N N g. suctioning devices [e.g., suction B. Assemble and check for proper equipment catheters, specimen collectors, function, identify and take action to oropharyngeal suction devices] x correct equipment malfunctions, and h. gas delivery, metering and clinical perform quality control. 9 14 0 analyzing devices x 1. Assemble, check for proper function, and (1) regulators, reducing valves, identify malfunctions of equipment: connectors and flow meters, air/ a. oxygen administration devices oxygen blenders, pulse-dose (1) nasal cannula, mask, reservoir systems x mask (partial rebreathing, non- (2) oxygen concentrators, air rebreathing), face tents, compressors, liquid-oxygen systems x transtracheal oxygen catheter, (3) gas cylinders, bulk systems and oxygen conserving cannulas x manifolds x (2) air-entrainment devices, (4) capnograph, blood gas analyzer tracheostomy collar and T-piece, and sampling devices, co-oximeter, oxygen hoods and tents x transcutaneous O2/CO2 monitor, (3) CPAP devices x pulse oximeter x b. humidifiers [e.g., bubble, passover, (5) CO, He, O2 and specialty gas cascade, wick, heat moisture exchanger] x analyzers x c. aerosol generators [e.g., pneumatic i. patient breathing circuits nebulizer, ultrasonic nebulizer] x (1) IPPB, continuous mechanical d. resuscitation devices [e.g., manual ventilation x resuscitator (bag-valve), pneumatic (2) CPAP, PEEP valve assembly x (demand-valve), mouth-to-valve mask j. aerosol (mist) tents x resuscitator] x k. incentive breathing devices x e. ventilators x l. percussors and vibrators x (1) pneumatic, electric, microprocessor, m. manometers and gauges fluidic x (1) manometers—water, mercury and (2) non-invasive positive pressure x aneroid, inspiratory/expiratory f. artificial airways x pressure meters, cuff pressure (1) oro- and nasopharyngeal airways x manometers x (2) oral, nasal and double-lumen (2) pressure transducers x endotracheal tubes x n. respirometers [e.g., flow-sensing (3) tracheostomy tubes and buttons x devices (pneumotachometer), volume (4) intubation equipment [e.g., displacement] x laryngoscope and blades, exhaled o. electrocardiography devices [e.g., ECG CO2 detection devices] x oscilloscope monitors, ECG machines g. suctioning devices [e.g., suction (12-lead), Holter monitors] x catheters, specimen collectors, p. vacuum systems [e.g., pumps, oropharyngeal suction devices] x regulators, collection bottles, pleural h. gas delivery, metering and clinical drainage devices] x analyzing devices x q. metered dose inhalers (MDIs), MDI (1) regulators, reducing valves, spacers x connectors and flow meters, air/ r. Small Particle Aerosol Generators oxygen blenders, pulse-dose systems x (SPAGs) x (2) oxygen concentrators, air s. bronchoscopes x compressors, liquid-oxygen systems x 2. Assure selected equipment cleanliness (3) gas cylinders, bulk systems and [e.g., select or determine appropriate manifolds x agent and technique for disinfection and/or (4) capnograph, blood gas analyzer sterilization, perform procedures for and sampling devices, co-oximeter, disinfection and/or sterilization, monitor transcutaneous O2/CO2 monitor, effectiveness of sterilization procedures] x pulse oximeter x Introduction 7  APP APP ANA ANA LIC LIC REC REC ATI ATI LYS LYS ALL ALL ON ON IS IS N N N N (5) CO, HE, O2, and specialty gas (4) intubation equipment [e.g., analyzers x laryngoscope and blades, exhaled i. patient breathing circuits CO2 detection devices] x (1) IPPB, continuous mechanical g. suctioning devices [e.g., suction ventilation x catheters, specimen collectors, (2) CPAP, PEEP valve assembly x oropharyngeal suction devices] x j. aerosol (mist) tents x h. gas delivery, metering and clinical k. incentive breathing devices x analyzing devices x l. percussors and vibrators x (1) regulators, reducing valves, m. manometers—water, mercury and connectors and flow meters, air/ aneroid, inspiratory/expiratory pressure oxygen blenders, pulse-dose meters, cuff pressure manometers x systems x n. respirometers [e.g., flow-sensing (2) oxygen concentrators, air devices (pneumotachometer), volume compressors, liquid-oxygen systems x displacement] x (3) gas cylinders, bulk systems and o. electrocardiography devices [e.g., ECG manifolds x oscilloscope monitors, ECG machines (4) capnograph, blood gas analyzer (12-lead), Holter monitors] x and sampling devices, co-oximeter, p. vacuum systems [e.g., pumps, transcutaneous O2 /CO2 monitor, regulators, collection bottles, pleural pulse oximeter x drainage devices] x i. patient breathing circuits x q. metered dose inhalers (MDIs), (1) IPPB, continuous mechanical MDI spacers x ventilation x r. Small Particle Aerosol Generators (2) CPAP, PEEP valve assembly x (SPAGs) x j. aerosol (mist) tents x 2. Take action to correct malfunctions of k. incentive breathing devices x equipment: l. percussors and vibrators x a. oxygen administration devices m. manometers—water, mercury and (1) nasal cannula, mask, reservoir mask aneroid, inspiratory/expiratory pressure (partial rebreathing, non-rebreathing), meters, cuff pressure manometers x face tents, transtracheal oxygen n. respirometers [e.g., flow-sensing catheter, oxygen conserving cannulas x devices (pneumotachometer), volume (2) air-entrainment devices, displacement] x tracheostomy collar and T-piece, o. vacuum systems [e.g., pumps, oxygen hoods and tents x regulators, collection bottles, pleural (3) CPAP devices x drainage devices] x b. humidifiers [e.g., bubble, passover, p. metered dose inhalers (MDIs), cascade, wick, heat moisture exchanger] x MDI spacers x c. aerosol generators [e.g., pneumatic 3. Perform quality control procedures for: x nebulizer, ultrasonic nebulizer] x a. blood gas analyzers and sampling d. resuscitation devices [e.g., manual devices, co-oximeters x resuscitator (bag-valve), pneumatic b. pulmonary function equipment, ventilator (demand-valve), mouth-to-valve mask volume/flow/pressure calibration x resuscitator] x c. gas metering devices x e. ventilators x (1) pneumatic, electric, microprocessor, fluidic x (2) non-invasive positive pressure x f. artificial airways (1) oro- and nasopharyngeal airways x (2) oral, nasal and double-lumen endotracheal tubes x (3) tracheostomy tubes and buttons x 8 Introduction  APP APP ANA ANA LIC LIC REC REC ATI ATI LYS LYS ALL ALL ON ON IS IS N N N N d. communicate information relevant to III. Initiate, Conduct, and coordinating patient care and discharge planning [e.g., scheduling, avoiding Modify Prescribed conflicts, sequencing of therapies] x Therapeutic Procedures e. apply computer technology to patient SETTING: In any patient care management [e.g., ventilator waveform setting, the respiratory therapist analysis, electronic charting, patient communicates relevant informa- care algorithms] x tion to members of the health- f. communicate results of therapy and care team, maintains patient alter therapy per protocol(s) x records, initiates, conducts, and 3. Protect patient from noscomial infection modifies prescribed therapeutic by adherence to infection control policies procedures to achieve the de- and procedures [e.g., universal/standard sired objectives and assists the precautions, blood and body fluid physician with rehabilitation and precautions] x home care. B. Conduct therapeutic procedures to 15 36 28 maintain a patent airway and remove bronchopulmonary secretions. 2 3 0 1. Maintain a patent airway, including the A. Explain planned therapy and goals care of artificial airways: to patient, maintain records and a. insert oro- and nasopharyngeal airway, communication, and protect patient from select endotracheal or tracheostomy nosocomial infection. 2 3 0 tube, perform endotracheal intubation, 1. Explain planned therapy and goals to change tracheostomy tube, maintain patient in understandable terms to achieve proper cuff inflation, position of optimal therapeutic outcome, counsel endotracheal or tracheostomy tube x patient and family concerning smoking b. maintain adequate humidification x cessation, disease management education x c. extubate the patient x 2. Maintain records and communication: d. properly position patient x a. record therapy and results using e. identify endotracheal tube placement conventional terminology as required by available means x in the health-care setting and/or by 2. Remove bronchopulmonary secretions: regulatory agencies [e.g., date, time, a. perform postural drainage, perform frequency of therapy, medication, and percussion and/or vibration x ventilatory data] x b. suction endotracheal or tracheostomy b. note and interpret patient’s response tube, perform nasotracheal or to therapy orotracheal suctioning, select closed- (1) effects of therapy, adverse reactions, system suction catheter x patient’s subjective and attitudinal c. administer aerosol therapy and response to therapy x prescribed agents [e.g., bronchodilators, (2) verify computations and note corticosteroids, saline, mucolytics] x erroneous data x d. instruct and encourage (3) auscultatory findings, cough and bronchopulmonary hygiene techniques sputum production and characteristics x [e.g., coughing techniques, autogenic (4) vital signs [e.g., heart rate, drainage, positive expiratory pressure respiratory rate, blood pressure, (PEP) device, intrapulmonary percussive body temperature] x ventilation (IPV), Flutter®, High (5) pulse oximetry, heart rhythm, Frequency Chest Wall Oscillation capnography x (HFCWO)] x c. communicate information regarding patient’s clinical status to appropriate C. Conduct therapeutic procedures to achieve members of the health-care team x adequate ventilation and oxygenation. 2 5 9 Introduction 9  APP APP ANA ANA LIC LIC REC REC ATI ATI LYS LYS ALL ALL ON ON IS IS N N N N 1. Achieve adequate spontaneous and 6. Perform spirometry/determine vital artificial ventilation: capacity, measure lung compliance and a. instruct in proper breathing techniques, airway resistance, interpret ventilator flow, instruct in inspiratory muscle training volume and pressure waveforms, techniques, encourage deep breathing, measure peak flow x instruct and monitor techniques of 7. Monitor mean airway pressure, adjust incentive spirometry x and check alarm systems, measure tidal b. initiate and adjust IPPB therapy x volume, respiratory rate, airway pressures, c. select appropriate ventilator I:E, and maximum inspiratory pressure d. initiate and adjust continuous (MIP) x mechanical ventilation when no settings 8. Measure FiO2 and/or liter flow x are specified and when settings are 9. Monitor cuff pressures x specified [e.g., select appropriate tidal 10. Auscultate chest and interpret changes volume, rate, and/or minute ventilation] in breath sounds x e. initiate nasal/mask ventilation, initiate E. Modify and recommend modifications and adjust external negative pressure in therapeutics and recommend ventilation [e.g., culrass] pharmacologic agents. 3 12 17 f. initiate and adjust ventilator modes [e.g., 1. Make necessary modifications in therapeutic A/C, SIMV, pressure-support ventilation procedures based on patient response: (PSV), pressure-control ventilation (PCV)] x a. terminate treatment based on patient’s g. administer prescribed bronchoactive response to therapy being administered agents [e.g., bronchodilators, b. modify IPPB: corticosteroids, mucolytics] x (1) adjust sensitivity, flow, volume, h. institute and modify weaning procedures x pressure, FiO2 x 2. Achieve adequate arterial and tissue (2) adjust expiratory retard x oxygenation: (3) change patient—machine interface a. initiate and adjust CPAP, PEEP, and [e.g., mouthpiece, mask] x non-invasive positive pressure x c. modify incentive breathing devices [e.g., b. initiate and adjust combinations of increase or decrease incentive goals] x ventilatory techniques [e.g., SIMV, d. modify aerosol therapy: PEEP, PS, PCV] x (1) modify patient breathing pattern x c. position patient to minimize hypoxemia, (2) change type of equipment, change administer oxygen (on or off ventilator), aerosol output x prevent procedure-associated (3) change dilution of medication, hypoxemia [e.g., oxygenate before and adjust temperature of the aerosol x after suctioning and equipment changes] x e. modify oxygen therapy: D. Evaluate and monitor patient’s response (1) change mode of administration, to respiratory care. 2 6 2 adjust flow, and FiO2 x 1. Recommend and review chest X-ray x (2) set up or change an O2 blender x 2. Interpret results of arterial, capillary, and (3) set up an O2 concentrator or liquid mixed venous blood gas analysis O2 system x 3. Perform arterial puncture, capillary blood f. modify bronchial hygiene therapy [e.