MCAT questions 47-50

I cannot reveal my source, but I once again am privy to esoteric wisdom. The following is a question I have obtained from the Medical College Admission Exam (MCAT):

What would you do in response to the following situation and laboratory results:

The patient has end stage COPD and is laboring to breathe.  His lungsounds are diminished.  He notes taking breathing treatments every hour to two hours at home with Albuterol and normal saline.  He says he didn't come to the emergency room earlier because every time he comes in his doctor won't let him have breathing treatments when he needs them, and if he's at home he can do what he wants.  The following ABGs are obtained:  pH 7.21, CO2 78, PO@ 59; HCO3 34 on 3lpm.  

The patient is given a breathing treatment at 1700, and he feels much better.  He is vary happy.  He ordered to have lasix, systemic corticosteroids, and the following: 

•   a.  Albuterol nebulizer Q4 hours, call for sats less than 88 percent
•   b.  Duoneb nebulizer every four hours with peak flows
•   c.  Lebalbuterol nebulizers Q4 hours with Albuterol prn
•   d.  Levalbuterol Q4 hours, call for sats less than 90 percent

MCAT question #48:  Based on the scenerio for question #47

The hospital respiratory therapist calls you at 1819 and says that patient is short of breath and really responded well the the earlier treatment.  His hospital does not have a breathing treatment protocol. The RT says, "His biggest fear about being admitted is he's afraid he won't get treatments when he needs them, and they really help.  He's asking for one now.  Can we have a PRN order?"

What is the best response:

• a.  Do an ABG STAT, give a breathing treatment now, but no PRN order at the present time.  
• b.  Give an Albuterol treatment STAT and then do them Q4 as needed
• c.  If it will make the patient happy, and if you think they're needed, you can have a PRN order.  Thanks for calling.  If you need anything else let me know. 
• d.  "I will be right in to see the patient." In the meantime, you may give a breathing treatment.  

MCAT question #49:  Based on the scenereo presented in question 47 and 48 above, the following ABG results were obtained by the repeat ABG:  pH 7.32; CO2 70; PO2 82; HCO3 34 on 3lpm

At about 1840 the respiratory therapist calls you at home while you are eating dinner and says over the phone that the patient feels and looks much better after the breathing treatment.  He wonders if he can have a prn breathing treatment order now, that the patient is asking for treatments every 1-2 hours, and usually can't make it that long on a good day.  What is the best response to him?

• a.  Xopenex PRN
• b.  Albuterol PRN
• c.  Xopenex Q3 hours and put the patient on BIPAP at 10/4 for bothering me during dinner hours
• d.  Say to the RT: "Leave the patient alone and he'll be fine."

MCAT question #50: Based on the scenereo presented in questions 47-49, you are told that the above ABGs were done on 3lpm, and your order was for 2lpm.  What is the best response to that:

• Say in a grumpy tone: "I ordered 2lpm.  Why is the patient on 3lpm?  Don't you know the patient is a CO2 retainer?  Why are you oxygenating him?" Give an order for an Fio2 on BiPAP of 28%
• Order for oxygen to maintain an Spo2 over 88 percent
• Write up the nurse and respiratory therapist for mass incompetence
• No change at this time