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RRT-ACCS study materials
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RRT-ACCS practice questions

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Question 1Patient Assessment and Monitoring

During auscultation of a patient with lobar pneumonia, which breath sound is most expected over the affected area?

  1. Vesicular breath sounds
  2. Coarse crackles that clear with cough
  3. Bronchial breath sounds Correct answer.
  4. Diminished sounds with hyperresonance

Explanation

Consolidated lung tissue transmits higher-frequency sound better than air-filled lung, producing bronchial breath sounds over the affected area. Vesicular sounds are normal over peripheral lung, while hyperresonance with diminished sounds suggests hyperinflation or pneumothorax.

Question 2Patient Assessment and Monitoring

Which site provides a temperature measurement closest to core body temperature in an adult patient?

  1. Axillary
  2. Oral
  3. Temporal artery
  4. Rectal Correct answer.

Explanation

Rectal temperature is measured in a body cavity insulated from the environment and is commonly used as a core-temperature estimate. Oral and axillary sites are more affected by ambient conditions and local blood flow.

Question 3Patient Assessment and Monitoring

A patient with cold extremities, weak pulses, and a pulse oximeter reading of 86% has an arterial SaO2 of 97% on co-oximetry. Which factor best explains the discrepancy?

  1. Methemoglobin excess
  2. Carboxyhemoglobin excess
  3. Poor skin perfusion Correct answer.
  4. Elevated serum bilirubin

Explanation

Pulse oximetry depends on a pulsatile arterial signal, so poor peripheral perfusion can make the reading unreliable and falsely low. Co-oximetry directly measures hemoglobin saturation and is not dependent on pulsatile flow.

Question 4Patient Assessment and Monitoring

Which capnogram finding is most consistent with esophageal intubation?

  1. A curare cleft
  2. A shark-fin waveform
  3. A gradual rise in the ETCO2 baseline
  4. No sustained ETCO2 waveform Correct answer.

Explanation

The esophagus has no significant CO2 source, so an esophageal tube typically produces no sustained end-tidal CO2 waveform. Brief small amounts may appear from gastric gas, but they do not persist.

Question 5Patient Assessment and Monitoring

An ABG shows pH 7.28, PaCO2 60 mm Hg, and HCO3 26 mEq/L. Which interpretation is correct?

  1. Compensated metabolic alkalosis
  2. Acute respiratory acidosis Correct answer.
  3. Uncompensated metabolic acidosis
  4. Chronic respiratory acidosis

Explanation

The low pH with elevated PaCO2 indicates respiratory acidosis. A normal bicarbonate level shows that renal compensation has not yet developed, so the disorder is acute.

Question 6Patient Assessment and Monitoring

Inspiratory stridor in an adult most strongly suggests which problem?

  1. Pleural effusion
  2. Alveolar consolidation
  3. Small airway bronchospasm
  4. Upper airway obstruction Correct answer.

Explanation

Stridor is a high-pitched inspiratory sound generated by turbulent flow through a narrowed extrathoracic or large airway. It points to upper airway obstruction rather than distal lung disease.

Question 7Patient Assessment and Monitoring

Central venous pressure most directly reflects which variable?

  1. Systemic vascular resistance
  2. Pulmonary capillary wedge pressure
  3. Right ventricular preload Correct answer.
  4. Left ventricular afterload

Explanation

CVP measures pressure in the vena cava or right atrium and is used as an estimate of right ventricular preload. It does not directly measure left heart pressures or systemic vascular resistance.

Question 8Patient Assessment and Monitoring

A chest radiograph shows a large hyperlucent hemithorax with mediastinal shift away from it. Which condition is most likely?

  1. Lobar atelectasis
  2. Large pleural effusion
  3. Pulmonary fibrosis
  4. Tension pneumothorax Correct answer.

Explanation

A tension pneumothorax produces a hyperlucent hemithorax with mass effect that pushes the mediastinum away from the affected side. This is a clinical emergency requiring immediate decompression.

Question 9Patient Assessment and Monitoring

A ventilated patient with severe asthma has an end-expiratory hold showing total PEEP 12 cm H2O and set PEEP 5 cm H2O. What is the auto-PEEP?

  1. 17 cm H2O
  2. 5 cm H2O
  3. 7 cm H2O Correct answer.
  4. 12 cm H2O

Explanation

Auto-PEEP is the difference between total PEEP measured during an end-expiratory hold and the applied extrinsic PEEP. Subtracting 5 from 12 gives 7 cm H2O.

Question 10Patient Assessment and Monitoring

During volume-controlled ventilation, peak airway pressure is 45 cm H2O and plateau pressure is 30 cm H2O. Which conclusion is best supported?

  1. Airway resistance is normal
  2. Auto-PEEP is the only problem
  3. Alveolar pressure is elevated Correct answer.
  4. The endotracheal tube is obstructed

Explanation

Plateau pressure reflects alveolar distending pressure, and a value of 30 cm H2O is elevated, raising concern for barotrauma. The peak-to-plateau gradient of 15 cm H2O also suggests increased airway resistance.

Question 11Patient Assessment and Monitoring

A patient on volume-controlled ventilation has a tidal volume of 500 mL, plateau pressure 25 cm H2O, and total PEEP 10 cm H2O. What is the static compliance?

  1. 33 mL/cm H2O Correct answer.
  2. 20 mL/cm H2O
  3. 14 mL/cm H2O
  4. 50 mL/cm H2O

Explanation

Static compliance equals tidal volume divided by the difference between plateau pressure and total PEEP. Using 500 mL divided by 15 cm H2O gives about 33 mL/cm H2O.

Question 12Patient Assessment and Monitoring

During pulmonary artery catheter monitoring, a wedge pressure tracing is obtained. What does the pulmonary artery occlusion pressure primarily estimate?

  1. Right atrial pressure
  2. Cardiac output
  3. Left atrial pressure Correct answer.
  4. Pulmonary artery systolic pressure

Explanation

When the balloon is inflated, the catheter senses pressure transmitted retrograde through the pulmonary venous system, which estimates left atrial pressure. It is used as an index of left ventricular filling pressure.

Question 13Patient Assessment and Monitoring

A patient has a mixed venous oxygen saturation of 50% with normal arterial oxygen saturation. Which change is most likely present?

  1. Arterial hypoxemia
  2. Decreased oxygen consumption
  3. Higher tissue O2 extraction Correct answer.
  4. Increased cardiac output

Explanation

Mixed venous oxygen saturation falls when tissues extract a larger fraction of delivered oxygen or when oxygen delivery is inadequate. Normal arterial saturation makes arterial hypoxemia an unlikely primary cause.

Question 14Patient Assessment and Monitoring

A patient has an SpO2 of 85% that does not improve with supplemental oxygen. The blood appears chocolate-colored. Which abnormality is most likely?

  1. Carboxyhemoglobinemia
  2. Hypovolemia
  3. Methemoglobinemia Correct answer.
  4. Severe anemia

Explanation

Methemoglobinemia produces a saturation gap, chocolate-colored blood, and poor response to supplemental oxygen. Co-oximetry is needed to confirm the diagnosis.

Question 15Patient Assessment and Monitoring

An ABG shows pH 7.32, PaCO2 30 mm Hg, and HCO3 15 mEq/L. Which acid-base disorder is present?

  1. Metabolic acidosis with respiratory compensation Correct answer.
  2. Respiratory alkalosis with metabolic compensation
  3. Acute respiratory acidosis
  4. Metabolic alkalosis with respiratory compensation

Explanation

The low pH and low bicarbonate indicate metabolic acidosis. The low PaCO2 shows hyperventilation is providing respiratory compensation.

Question 16Patient Assessment and Monitoring

Which condition is suggested by a shark-fin appearance of the capnogram?

  1. Curare cleft
  2. Esophageal intubation
  3. Cardiac arrest
  4. Airflow obstruction Correct answer.

Explanation

A shark-fin slope occurs when expiratory flow is prolonged, as in obstructive airway disease. It reflects slow emptying of alveoli rather than a circuit or perfusion problem.

Question 17Patient Assessment and Monitoring

A ventilated patient with sinus rhythm has a pulse pressure variation of 18% during controlled ventilation. What does this most likely indicate?

  1. Right heart failure
  2. Volume responsiveness Correct answer.
  3. Severe bronchospasm
  4. Elevated intracranial pressure

Explanation

A pulse pressure variation above about 13% in a fully ventilated patient suggests that cardiac output is responsive to fluid loading. It reflects respiratory variation in left ventricular stroke volume.

Question 18Patient Assessment and Monitoring

On room air, a patient has PaO2 60 mm Hg and PaCO2 40 mm Hg. What is the alveolar-arterial oxygen gradient approximately?

  1. 60 mm Hg
  2. 40 mm Hg Correct answer.
  3. 10 mm Hg
  4. 100 mm Hg

Explanation

The alveolar oxygen tension is about 100 mm Hg on room air with a PaCO2 of 40 mm Hg. Subtracting the arterial PaO2 of 60 mm Hg gives an A-a gradient of about 40 mm Hg.

Question 19Patient Assessment and Monitoring

Which scale is commonly used to assess the depth of sedation in mechanically ventilated adults?

  1. Glasgow Coma Scale score
  2. Braden pressure ulcer risk assessment
  3. Richmond Agitation-Sedation Correct answer.
  4. APACHE II severity score

Explanation

The Richmond Agitation-Sedation Scale describes arousal and agitation from unarousable to combative. It is widely used to titrate sedation in critically ill ventilated patients.

Question 20Patient Assessment and Monitoring

A patient receiving a neuromuscular blocker has a train-of-four count of 1. What does this indicate?

  1. Overdose requiring reversal
  2. Adequate block for extubation
  3. Deep neuromuscular block Correct answer.
  4. Full recovery from blockade

Explanation

A train-of-four count of 1 means only one twitch is present out of four, indicating deep neuromuscular blockade. Full recovery would show four twitches with a train-of-four ratio near 1.0.

Question 21Patient Assessment and Monitoring

During constant-flow volume-controlled ventilation, the pressure-time curve shows an upward concavity with a stress index greater than 1. Which finding is most likely?

  1. Falling compliance during inspiration Correct answer.
  2. Rising compliance during inspiration
  3. Constant airway resistance
  4. Ventilator circuit leak

Explanation

A stress index above 1 indicates that airway pressure rises progressively as the breath is delivered, consistent with decreasing compliance and alveolar overdistension. A stress index below 1 suggests increasing compliance or recruitment.

Question 22Patient Assessment and Monitoring

A patient has PaCO2 40 mm Hg and mixed expired CO2 20 mm Hg. Using the Bohr equation, what is the approximate dead-space fraction?

  1. 1.00
  2. 0.20
  3. 0.80
  4. 0.50 Correct answer.

Explanation

The Bohr equation gives dead-space fraction as (PaCO2 minus mixed expired CO2) divided by PaCO2. Using (40 minus 20) divided by 40 equals 0.50.

Question 23Patient Assessment and Monitoring

Which change will increase arterial oxygen content the most in a patient with severe anemia and normal oxygenation?

  1. Transfusing packed RBCs Correct answer.
  2. Increasing cardiac output
  3. Increasing FiO2 from 0.21 to 1.0
  4. Administering a bronchodilator

Explanation

Arterial oxygen content is determined mainly by hemoglobin concentration and saturation. In severe anemia, increasing hemoglobin with packed red blood cells raises oxygen content more than maximizing dissolved oxygen.

Question 24Patient Assessment and Monitoring

A patient being evaluated for weaning has a maximum inspiratory pressure of -15 cm H2O. How should this be interpreted?

  1. Normal respiratory muscle strength
  2. Increased inspiratory reserve
  3. Excellent cough strength
  4. Respiratory muscle weakness Correct answer.

Explanation

A maximum inspiratory pressure less negative than about -20 to -25 cm H2O suggests reduced inspiratory muscle strength. More negative values indicate stronger inspiratory effort.

Question 25Patient Assessment and Monitoring

A patient has a respiratory rate of 30 breaths/min and tidal volume of 250 mL. What is the rapid shallow breathing index?

  1. 83 breaths/min/L
  2. 30 breaths/min/L
  3. 120 breaths/min/L Correct answer.
  4. 250 breaths/min/L

Explanation

The rapid shallow breathing index is respiratory rate divided by tidal volume in liters. Dividing 30 by 0.25 L gives 120 breaths/min/L.

Question 26Patient Assessment and Monitoring

After placement of a subclavian central line, a patient develops crepitus over the chest and neck. This finding most directly indicates which complication?

  1. Hemothorax
  2. Pulmonary thromboembolism
  3. Tension pneumothorax with shock
  4. Subcutaneous emphysema Correct answer.

Explanation

Crepitus results from air trapped in subcutaneous tissue after pleural injury or catheter tract tracking. It is the hallmark of subcutaneous emphysema, though a larger air leak still warrants evaluation for pneumothorax.

Question 27Patient Assessment and Monitoring

A patient with smoke inhalation has an SpO2 of 99% on room air but is confused, and the carboxyhemoglobin level is 30%. Why is the pulse oximeter reading misleading?

  1. It reflects tissue oxygen use
  2. COHb reads as oxyhemoglobin Correct answer.
  3. It measures only dissolved oxygen
  4. It is invalid only above PaO2 100

Explanation

Pulse oximetry uses two wavelengths and cannot reliably separate carboxyhemoglobin from oxyhemoglobin. Carboxyhemoglobin is read as if it were oxyhemoglobin, so saturation can appear normal despite severe carbon monoxide poisoning.

Question 28Patient Assessment and Monitoring

An arterial blood gas shows pH 7.52, PaCO2 28 mm Hg, and HCO3 22 mEq/L. Which acid-base disorder is present?

  1. Acute respiratory acidosis
  2. Metabolic acidosis
  3. Compensated metabolic alkalosis
  4. Acute respiratory alkalosis Correct answer.

Explanation

The pH is alkalemic and the PaCO2 is low, indicating a respiratory cause. The near-normal bicarbonate does not suggest a primary metabolic alkalosis, so this is an acute respiratory alkalosis.

Question 29Patient Assessment and Monitoring

A ventilated patient's capnogram suddenly falls to zero and no waveform is visible. What is the most likely cause?

  1. Circuit disconnection Correct answer.
  2. Bronchospasm
  3. Mucus plugging
  4. Malignant hyperthermia

Explanation

A sudden loss of exhaled CO2 to zero suggests that exhaled gas is no longer reaching the sensor or that ventilation has stopped. Circuit disconnection or extubation is the immediate concern and requires rapid assessment.

Question 30Patient Assessment and Monitoring

A patient has a blood pressure of 120/80 mm Hg. What is the mean arterial pressure?

  1. 87 mm Hg
  2. 80 mm Hg
  3. 100 mm Hg
  4. 93 mm Hg Correct answer.

Explanation

Mean arterial pressure is estimated as (systolic pressure + 2 × diastolic pressure) ÷ 3. For 120/80 mm Hg, this is (120 + 160) ÷ 3 = 93 mm Hg.

Question 31Patient Assessment and Monitoring

During inspiration, a patient's systolic blood pressure falls 15 mm Hg and returns to baseline during expiration. What is this finding called?

  1. Pulsus bisferiens
  2. Pulsus paradoxus Correct answer.
  3. Pulsus tardus et parvus
  4. Pulsus alternans

Explanation

An inspiratory systolic pressure drop greater than about 10 mm Hg is pulsus paradoxus. It is associated with conditions such as cardiac tamponade and severe obstructive lung disease.

Question 32Patient Assessment and Monitoring

During volume-controlled ventilation, both peak airway pressure and plateau pressure fall abruptly, and exhaled tidal volume is lower than set. What is the most likely cause?

  1. Auto-PEEP
  2. Circuit leak Correct answer.
  3. Decreased lung compliance
  4. Increased airway resistance

Explanation

A simultaneous fall in peak and plateau pressures with low exhaled volume points to volume loss from the circuit or airway. A leak reduces both pressures because less gas is delivered to the lung.

Question 33Patient Assessment and Monitoring

An ECG shows ST-segment elevation in leads II, III, and aVF. Which myocardial wall is most likely injured?

  1. Inferior Correct answer.
  2. Anterior
  3. Septal
  4. Lateral

Explanation

Leads II, III, and aVF look at the inferior wall of the left ventricle. ST elevation in these contiguous leads suggests an acute inferior injury pattern.

Question 34Patient Assessment and Monitoring

A patient has MAP 65 mm Hg, CVP 5 mm Hg, and cardiac output 5 L/min. What is the systemic vascular resistance?

  1. 960 dyn·s·cm−5 Correct answer.
  2. 1,200 dyn·s·cm−5
  3. 800 dyn·s·cm−5
  4. 1,040 dyn·s·cm−5

Explanation

Systemic vascular resistance is calculated as (MAP − CVP) × 80 ÷ cardiac output. Using (65 − 5) × 80 ÷ 5 gives 960 dyn·s·cm−5.

Question 35Patient Assessment and Monitoring

A patient has an oxygen consumption of 250 mL/min, arterial oxygen content of 20 mL/dL, and mixed venous oxygen content of 15 mL/dL. What is the cardiac output by the Fick principle?

  1. 3 L/min
  2. 10 L/min
  3. 5 L/min Correct answer.
  4. 7 L/min

Explanation

The Fick equation is cardiac output = oxygen consumption ÷ (arterial O2 content − mixed venous O2 content). The content difference is 5 mL/dL, or 50 mL/L, so 250 ÷ 50 = 5 L/min.

Question 36Patient Assessment and Monitoring

A patient has a PaO2 of 80 mm Hg on an FiO2 of 0.40. What is the PaO2/FiO2 ratio?

  1. 320
  2. 120
  3. 200 Correct answer.
  4. 160

Explanation

The PaO2/FiO2 ratio is calculated by dividing PaO2 by the fraction of inspired oxygen. 80 ÷ 0.40 = 200.

Question 37Patient Assessment and Monitoring

A patient with bilateral infiltrates has a PaO2 of 55 mm Hg on FiO2 0.60. How should the oxygenation be classified by the Berlin ARDS criteria?

  1. 120, moderate
  2. 150, moderate
  3. 92, severe Correct answer.
  4. 100, moderate

Explanation

The PaO2/FiO2 ratio is 55 ÷ 0.60, or about 92. In the Berlin definition, a ratio below 100 with bilateral infiltrates identifies severe ARDS.

Question 38Patient Assessment and Monitoring

A patient has a plateau pressure of 30 cm H2O and an esophageal pressure of 15 cm H2O. What is the transpulmonary pressure?

  1. 30 cm H2O
  2. 5 cm H2O
  3. 45 cm H2O
  4. 15 cm H2O Correct answer.

Explanation

Transpulmonary pressure is airway pressure minus pleural pressure, estimated here by esophageal pressure. 30 − 15 = 15 cm H2O.

Question 39Patient Assessment and Monitoring

Which ventilator finding best detects auto-PEEP during volume-controlled ventilation?

  1. Plateau pressure falls below set PEEP
  2. Peak pressure exceeds 40 cm H2O
  3. Expiratory flow does not reach zero Correct answer.
  4. Inspiratory flow rises sharply

Explanation

Auto-PEEP occurs when expiration is incomplete and end-expiratory alveolar pressure remains above set PEEP. On the flow-time curve, expiratory flow fails to return to zero before the next breath.

Question 40Patient Assessment and Monitoring

A patient develops sudden hypercapnia, masseter rigidity, fever, and tachycardia after receiving succinylcholine. What is the most likely cause?

  1. Anaphylactic transfusion reaction
  2. Malignant hyperthermia Correct answer.
  3. Severe bronchospasm
  4. Pulmonary thromboembolism

Explanation

Malignant hyperthermia is a hypermetabolic reaction triggered by volatile anesthetics or depolarizing neuromuscular blockers. It causes rising end-tidal CO2, rigidity, fever, and tachycardia.

Question 41Patient Assessment and Monitoring

A patient has cold, mottled fingers and a weak pulse, and the pulse oximeter shows a poor waveform. What is the best action to obtain a reliable SpO2?

  1. Increase FiO2 to 1.0
  2. Trust the displayed SpO2
  3. Use a better-perfused site Correct answer.
  4. Repeat reading on same finger

Explanation

Poor peripheral perfusion reduces pulse oximeter signal quality and can make the reading unreliable. Moving the probe to a better-perfused site and correlating with arterial blood gas improves accuracy.

Question 42Patient Assessment and Monitoring

During volume-controlled ventilation, the pressure-time waveform shows a small negative deflection before each breath. What does this finding indicate?

  1. Low lung compliance from edema
  2. Auto-PEEP from incomplete exhalation
  3. Patient inspiratory effort Correct answer.
  4. Circuit leak at the expiratory valve

Explanation

A negative pressure deflection before a delivered breath reflects the patient's inspiratory effort against the ventilator. It can indicate patient triggering or dyssynchrony depending on timing and settings.

Question 43Patient Assessment and Monitoring

Which tool is designed to screen for delirium in mechanically ventilated ICU patients?

  1. SAS
  2. RASS
  3. CAM-ICU Correct answer.
  4. BIS

Explanation

The CAM-ICU is a validated delirium screening tool adapted for nonverbal and ventilated ICU patients. It assesses acute change, inattention, altered consciousness, and disorganized thinking.

Question 44Patient Assessment and Monitoring

A patient receiving a neuromuscular blocker has a train-of-four ratio of 0.90. How should this be interpreted?

  1. Deep blockade
  2. Moderate neuromuscular blockade
  3. Need for redosing
  4. Adequate recovery Correct answer.

Explanation

A train-of-four ratio of at least 0.90 indicates adequate recovery from neuromuscular blockade. Ratios below this suggest residual blockade and increased risk of weakness.

Question 45Patient Assessment and Monitoring

Before extubation, a patient has no audible cuff leak after the endotracheal cuff is deflated. What does this most suggest?

  1. High risk of laryngeal edema Correct answer.
  2. Adequate airway protection
  3. Need for immediate extubation
  4. Normal expected finding

Explanation

An absent cuff leak suggests airflow obstruction around the tube, often from laryngeal edema. Such patients are at increased risk of post-extubation stridor and should be evaluated further before extubation.

Question 46Patient Assessment and Monitoring

Pulmonary capillary oxygen content is 20 mL/dL, arterial oxygen content is 18 mL/dL, and mixed venous oxygen content is 14 mL/dL. What is the shunt fraction?

  1. 33% Correct answer.
  2. 10%
  3. 50%
  4. 20%

Explanation

The shunt fraction is (pulmonary capillary O2 content − arterial O2 content) ÷ (pulmonary capillary O2 content − mixed venous O2 content). Using (20 − 18) ÷ (20 − 14) gives 2 ÷ 6, or about 33%.

Question 47Patient Assessment and Monitoring

A patient has a cardiac output of 5 L/min and an arterial oxygen content of 18 mL/dL. What is the oxygen delivery?

  1. 90 mL/min
  2. 900 mL/min Correct answer.
  3. 450 mL/min
  4. 1,800 mL/min

Explanation

Oxygen delivery is cardiac output × arterial oxygen content × 10 to convert dL to L. 5 × 18 × 10 = 900 mL/min.

Question 48Patient Assessment and Monitoring

Peak airway pressure is 35 cm H2O, plateau pressure is 20 cm H2O, and inspiratory flow is 60 L/min (1 L/s). What is the airway resistance?

  1. 10 cm H2O/L/s
  2. 20 cm H2O/L/s
  3. 5 cm H2O/L/s
  4. 15 cm H2O/L/s Correct answer.

Explanation

Airway resistance is the peak-to-plateau pressure difference divided by inspiratory flow. (35 − 20) ÷ 1 L/s = 15 cm H2O/L/s.

Question 49Patient Assessment and Monitoring

A patient with chronic hypercapnia has a PaCO2 of 60 mm Hg. Which bicarbonate level is most consistent with chronic respiratory acidosis?

  1. 26 mEq/L
  2. 28 mEq/L
  3. 24 mEq/L
  4. 30 mEq/L Correct answer.

Explanation

In chronic respiratory acidosis, bicarbonate rises by about 3 to 4 mEq/L for every 10 mm Hg increase in PaCO2. A rise from 40 to 60 mm Hg would predict a bicarbonate of roughly 30 to 32 mEq/L, so 30 mEq/L is most consistent.

Question 50Patient Assessment and Monitoring

Arterial oxygen content is 18 mL/dL and mixed venous oxygen content is 12 mL/dL. What is the oxygen extraction ratio?

  1. 67%
  2. 33% Correct answer.
  3. 6%
  4. 50%

Explanation

The oxygen extraction ratio is (arterial O2 content − mixed venous O2 content) ÷ arterial O2 content. (18 − 12) ÷ 18 = 0.33, or 33%.