كتاب ال CBET

Certified
Biomedical
Equipment
Technician
(CBET)
Certified Biomedical Equipment Technician (CBET)
Healthcare technology management professionals that desire a CBET certification

are expected to have experience in a wide-range of electromechanical devices,
computers, networks and software used in the delivery of healthcare. Generally,
candidates 4 desiring for this certification may work for medical device
manufacturers, hospitals, clinics, home healthcare providers, medical device repair
companies, regulatory bodies/agencies, and software manufacturers – such as EMR
or device integration providers.
CBET candidates typically perform some of the following duties on a daily basis:
 Test and calibrate medical devices (preventive maintenance)

 Troubleshoot medical devices in a clinical setting and/or bench/depot setting
(corrective maintenance)
 Manufacture software, parts or devices for use in patient care
 Ensure compliance with all regulatory processes necessary (i.e. CMS, FDA
GMP, etc.
 Manage medical software/hardware systems (i.e. PACS Administrator,
Integration Specialist, Alarm Management, RTLS Systems, etc.)
 Perform corrective and preventive maintenance on steam systems
 Educate the proper use, care and maintenance of medical devices
 Review technical manuals
 Document any and all maintenance and repairs and maintain records of
maintenance activities
 Troubleshoot medical device networks
- The CBET exam is a three-hour closed book exam

consisting of 165 multiple choice questions.
Score required to pass: The minimum score required to
pass the CBET examination is 116/165.
Anatomy & physiology
Q001EXPL
The Trendelenburg position involves positioning a patient so that the head is lower than the feet and hips. The body is
placed flat, in a single plane.
In the Fowler position, the patient's trunk would be elevated at an angle to the legs. The legs and thighs would be kept
parallel to the floor. In effect, this is the position of a patient sitting up in bed.
A prone patient is one lying on his/her abdomen.
Reference: Stedman's Medical Dictionary, Illustrated, 23rd edition, Williams and Wilkins, 1976, pages 1126 – 1127.
Q002EXPL
All of the terms in this question are commonly used in discussions of heart abnormalities, although they are general
anatomic words, and will appear in other contexts as well.
Ischemia refers to a condition where tissue is denied sufficient oxygen to work properly, generally because the blood flow
is less than is needed due to metabolic conditions. Ischemia of heart muscle may lead to myocardial infarction, the death
of heart muscle.
Stenosis refers to a narrowing. This condition may be the cause of ischemia when it occurs in a blood vessel. A heart
valve with stenosis will not open fully, and so blood flow past it is compromised.
Regurgitation refers to something moving in a direction opposite to its normal path. For example, vomit is the
regurgitation of food from the stomach.
Regurgitation may also occur in conjunction with the mitral valve, causing blood to move from the left ventricle to the left
atrium during systole, or in conjunction with the aortic valve, causing blood to move from the aorta into the left ventricle
during systole.
Prolapse refers to something that has slipped out of its normal place. Prolapse of the aortic valve, for example, could be a
cause for aortic regurgitation.
Incompetence is a term to describe a deficiency in the way something operates. An incompetent aortic valve, for example,
would allow blood to flow in either direction, rather than shutting off completely when the pressure in the aorta is higher
than the pressure in the left ventricle.
Reference: Stedman's Medical Dictionary, Illustrated, 23rd edition, Williams and Wilkins, 1976, page 1332.
Q003EXPL
A coronal plane, also referred to as a frontal plane, divides the front of the body (the anterior or ventral side) from the
back of the body (the posterior or dorsal side).
A sagittal plane divides the body into left and right sides. The sagittal plane running down the middle of the body,
dividing it into equal halves, is referred to as a midsagittal plane.
A transverse plane runs horizontally and divides the body into upper and lower portions.
A horizontal plane is not an anatomic expression.
Reference: Thibodeau, Gary A., Structure and Function of the Body, 9th edition, Mosby Year Book, 1992, pages 6 – 9.
Q004EXPL
A clot that develops in a blood vessel is called a thrombus. After development, a clot may break away from its attachment
and become free flowing within the bloodstream. This free flowing clot is called an embolus.
Reference: Guyton, Arthur C., M.D., Human Physiology and Mechanisms of Disease, 5th edition, W. B. Saunders
Company, 1992, page 278.
Q005EXPL
Arterioles are a part of the circulatory system that connects the arteries to capillaries. Arterioles have internal diameters
from 20 micrometers down to about 9 micrometers.
Venules connect capillaries to the veins.
Arteries have a much larger internal diameter than arterioles.
The precapillary sphincters found at the end of the arterioles are used to allow or shut off blood flow from the arteriole
into the capillaries. This is referred to as contraction and dilation. By acting as a valve, the blood flow to the tissues
throughout the body can be varied in response to metabolic needs.
The arterioles do contain smooth muscle fiber where the arterioles attach to the capillaries. This point is known as the
precapillary sphincter.
Reference:
[1] Guyton, Arthur C., M.D., Human Physiology and Mechanisms of Disease, 5th edition, W. B. Saunders Company,
1992, page 110.
Q006EXPL
Before any muscle can contract, depolarization of the muscle must occur. In the heart, the first event in the cardiac cycle is
the depolarization of the atria. This happens just prior to the contraction of the atria, which drives blood into the
ventricles.
The "P" wave is the first electrical event in the cardiac cycle, and it corresponds to the depolarization of the atria.
Similarly, the "QRS" wave corresponds to the depolarization of the ventricles. The "T" wave corresponds to the
repolarization of the ventricles, in preparation for the next contraction. Atrial repolarization occurs at about the time of the
"QRS" wave, and is generally totally obscured by that prominent feature of the electrocardiogram.
Reference:
[1] Guyton, Arthur C., M.D., Human Physiology and Mechanisms of Disease, 5th edition, W. B. Saunders Company,
1992, page 95.
Q007EXPL
In order to perform cardiac catheterization, a small catheter is threaded into the coronary arteries and veins so that a radio-
opaque dye can be injected into the coronary system to observe blood flow in that system, using a fluoroscope.
Generally, the most convenient sites for the insertion of the cardiac catheter are the arteries and veins in the legs and arms,
which are the femoral arteries and veins (in the legs) and the brachial arteries and veins (in the arms). These points are
used because of their relatively large size and their proximity to the surface of the skin.
Reference: Kern, Morton J., The Cardiac Catheterization Handbook, Mosby-Year Book Inc., 1991, pages 37 – 58.
Q008EXPL
A myocardial infarction is the death of cardiac muscle cells resulting from inadequate blood supply. This is often caused
by a coronary thrombosis, i.e., a blood clot in the coronary arteries that supply the heart with the blood it needs to sustain
its own muscle cells.
Myocardial infarction can result in serious cardiac arrhythmias, because it often leads to a change in the electrical
conduction system in the heart.
An interruption in the blood supply to the heart, as might be caused by a coronary thrombosis, may lead to a myocardial
infarction.
Ischemia of the cardiac tissues refers to the loss of sufficient oxygen by the tissues (usually when the blood supply is
compromised). Continued ischemia may cause a myocardial infarction, the actual death of tissue, but, if it does not
continue, is reversible. Ischemia is the cause of angina pectoris, a sharp pain in the chest associated with inadequate
oxygenation of cardiac tissue.
Reference: Thibodeau, Gary A., Structure and Function of the Body, 9th edition, Mosby Year Book, 1992, page 459.
Q009EXPL
Whole blood consists of plasma, red blood cells (or erythrocytes), white blood cells (or leukocytes), and platelets (or
thrombocytes). Plasma is the liquid (extracellular) part of the blood.
Serum consists of plasma plus platelets.
Lymph is the fluid flowing through the lymphatic system. It consists of lymphocytes, proteins, fatty molecules and
plasma.
Transudate is a protein-poor solution that passes through a cell wall. For example, perspiration is a transudate.
Q011EXPL
The root "neph" refers to kidneys. For instance, a nephrologist is a physician who specializes in the treatment of kidneys,
and nephritis is an inflammation of the kidneys.
A nephrogram is an x-ray (or roentgenogram) of the kidneys.
An electroneurogram is a recording of peripheral nerve electrical activity.
Units of weight might be a gram, milligram, or kilogram. (Note: These are actually metric units of mass; however, for
practical purposes, they are referred to as units of weight.)
A urimeter is used to record urine output.
An electroencephalogram is a recording of brain electrical activity.
Reference: Dorland's Illustrated Medical Dictionary, 27th edition, W.B. Saunders Company, 1988, page 1107.
Q012EXPL
Eupnea is normal respiration.
Orthopnea refers to difficulty breathing when not standing or sitting upright. (It is generally used to refer to difficulty
breathing when lying down.)
Hyperpnea is rapid respiration.
Dyspnea is difficult or labored breathing.
Q013EXPL
Anorexia is a loss of appetite.
Acidosis is a more acidic than normal level of blood pH. pH is measured on a scale of 0 to 14, with lower numbers
indicating an acidic condition, and higher numbers indicating an alkaline condition. A pH of 7 is a characteristic of a
neutral solution. Normal blood has an alkaline pH of about 7.4. Blood acidosis would be characterized by a blood pH
below 7.35. Blood rarely has a pH below 7.0, so even when acidosis occurs, the blood is still slightly alkaline.
Alkalosis is a more alkaline than normal level of blood pH.
Auscultation is the monitoring of sounds made by internal organs. A stethoscope is typically used by a physician or nurse
to listen to body sounds, such as those made by the heart.
Q014EXPL
An otoscope is used to examine the ears. The prefix "oto" refers to the ears.
An ophthalmoscope is used to examine the eyes.
Dental instruments are used to examine the teeth.
An oscilloscope is used to observe oscillatory traces, typically in an electrical circuit.
Orthopedic defects would generally be seen in a traditional x-ray.
Reference: Carr, Joseph J., and Brown, John M., Introduction to Biomedical Equipment Technology, 2nd edition, Prentice
Hall Career and Technology, 1993, page 580.
Q015EXPL
Intercalated disks are dark bands found between muscle fibers in the heart. Only cardiac muscle contains intercalated
disks.
Skeletal muscle (also referred to as striated muscle or voluntary muscle) is controlled through conscious action. This is the
kind of muscle used to control activities of the skeleton, such as walking or lifting.
Smooth muscle (also referred as visceral muscle or involuntary muscle) is not controlled through conscious action. It is
typically found in the internal organs of the body, such as in the digestive tract.
Q016EXPL
The hypothalamus regulates body temperature. The hypothalamus is found roughly in the middle of the skull and contains
a large number of temperature-sensitive neurons. It helps control the heartbeat, constriction and dilation of blood vessels,
and contractions of the stomach and intestines.
The medulla oblongata, an enlarged, upward extension of the spinal cord, is found where the brain connects to the spinal
cord. It controls the autonomic, life-sustaining functions, such as the cardiac, respiratory, and vasomotor functions.
The pituitary gland is part of the endocrine system. It releases hormones that control such functions as growth, retention of
water, development of sperm and egg cells, and uterine contractions.
The reticular formation is a large, but vaguely delimited, region of the brain stem and spinal cord, where the gray and
white matter in the neural system are closely mixed. This area of the nervous system does play a role in the central control
of the autonomic and endocrine functions, as well as body posture.
Q017EXPL
Gas exchange, i.e., the introduction of oxygen from the air into the blood, and the removal of carbon dioxide from the
blood, takes place within the lungs. Air that does not reach the lungs cannot participate in gas exchange. Examples of this
are the air in the nasal cavity and the trachea.
Air that is not in the lungs, but that is used to fill the respiratory passages, is contained in the dead space. This volume is
about 150 milliliters for an average adult male.
The residual volume is the volume of air in the lungs after the most forceful expiration. This is about 1200 milliliters for
an average adult male.
The tidal volume is the amount of air inspired or expired with each normal breath. This is about 500 milliliters for an
average adult male.
The expiratory reserve volume is the extra amount of air that can be expired by forceful expiration after the end of a
normal tidal expiration. This is about 1100 milliliters for an average adult male.
Q018EXPL
Veins are blood vessels that carry blood back to the heart.
Veins are less elastic (more distensible) than arteries. While both contain smooth muscle, the muscle is far thicker in the
arteries than the veins.
The internal diameter (lumen) of veins is generally larger than those of arteries.
A unique feature found only in veins are valves. These valves prevent the backflow of blood, such as might happen when
a person stands up, if these valves were not present.
While most veins do carry deoxygenated blood, the pulmonary veins, i.e., the veins leading from the lungs back to the
heart, carry oxygenated blood.
Reference: Thibodeau, Gary A., Structure and Function of the Body, 9th edition, Mosby Year Book, 1992, page 234-236,
239.
Q019EXPL
In order for blood to be pumped out of the heart during systole, the pressures reached inside the heart must be greater than
the pressure in the aorta. The valve between the left ventricle and the aorta is the aortic valve.
This valve will open during systole to allow blood to leave the heart. Once the pressure inside the heart starts dropping
during diastole, the aortic valve closes to allow the heart to fill with fresh oxygenated blood from the lungs.
The dichrotic notch is a feature seen on the descending portion of an arterial waveform. It corresponds to the closing of
the aortic valve.
Reference: Cromwell, Leslie, Weibell, Fred J., and Pfeiffer, Erich A., Biomedical Instrumentation and Measurements, 2nd
edition, Prentice Hall, 1980, page 94.
Q020EXPL
Korotkoff sounds are the sounds heard in a stethoscope placed on an arm when a cuff is occluding the arm. These sounds
are used to detect blood pressure.
The cuff around the arm occludes the brachial artery in the upper arm. When the cuff pressure exceeds the systolic
pressure, no blood flows past the cuff. As the pressure on the cuff is released, blood starts flowing past the cuff once its
pressure is lower than the systolic pressure. This blood jetting through the partially occluded vessel, resulting in turbulent
blood flow, as opposed to the laminar flow normally found in the artery, is believed to cause the Korotkoff sounds. Once
the pressure in the cuff is lower than the diastolic pressure, blood flow is no longer interrupted, and no more sounds are
heard. Thus, the Korotkoff sounds are directly caused by arterial obstruction.
Company, 1992, pages 118 - 119
Q021EXPL
The prefix "ortho" refers to straight things; for example, orthodontics refers to the straightening of teeth and orthopedics
refers to disorders of the skeletal system, which is used to keep the body straight.
The prefix "oto" refers to ears; for example, an otoscope is used to examine the ears.
The prefix "onc" refers to masses, or tumors. Oncology is the study of cancer.
The prefix "osteo" refers to bones, and osteology is the study of the bone structure.
Q022EXPL
The vagus nerve is the tenth of the twelve cranial nerves. It travels from the brain into the thoracic and abdominal cavities.
It is used to conduct nerve impulses for the parasympathetic nervous system. The parasympathetic system generally
involves control of autonomic nervous system functions, while the sympathetic nervous system generally functions to
prepare the body for emergency conditions, such as the "fight or flight" response.
For example, parasympathetic activation of the heart will slow the heart rate, while sympathetic nerve activity will speed
up the heart rate.
Both the sympathetic and parasympathetic nervous systems generally control unconscious functions, i.e., activities that do
not require active thought, as distinguished from voluntary nerve activity, such as the purposeful movement of an arm or
leg.
The vagus nerve is active in the control of abdominal and digestive organs, such as the esophagus, stomach, pancreas, and
the first half of the large intestine.
Q023EXPL
Phlebitis is an inflammation of a vein.
Anemia is a deficiency of red blood cells, which lowers the ability of the blood to carry oxygen.
Edema occurs when there is excess fluid in the tissues. Edema can be a cause of swelling, for instance, in the skin or the
brain.
Hypertension is higher than normal blood pressure.
Q024EXPL
Motor neurons (also referred to as efferent neurons), conduct impulses from the brain and spinal cord to muscle and
glandular epithelial tissue. By conducting nerve impulses, they can initiate the contraction of muscle fibers, which results
in movement. This movement may be the result of conscious action, or an involuntary reflex.
Other types of neurons are sensory neurons (or afferent neurons), which conduct impulses from sensors located
throughout the body to the spinal cord and brain, and interneurons, which conduct impulses from sensory neurons to
motor neurons.
Q025EXPL
The bone that is found in the upper arm is the humerus. Two bones make up the forearm: the radius and the ulna. The
bone in the thigh is the femur, and the bones found between the knee and the foot are the tibia and the fibula. (The tibia is
the larger bone.)
The pelvis is an anatomic region, rather than a bone. The pelvis is the region below the abdomen formed by the hip bones.
Reference: Thibodeau, Gary A., Structure and Function of the Body, 9th edition, Mosby Year Book, 1992, page 86
Q026EXPL
The cranium is the skull, which consists of the eight bones that encase the brain.
The pharynx is the throat.
The optic nerve is a nerve that conducts information between the eyes and the brain.
The ventricles are spaces within the brain that are filled with cerebrospinal fluid. Two lateral ventricles are found inside
the brain, the third ventricle is found in the middle of the brain, underneath the lateral ventricles. The fourth ventricle is
below the third ventricle, and is located in the area where the brain and spinal cord connect. (The word ventricle also
refers to a portion of the heart.)
The cerebellum is a part of the brain located at the back of the head, above the spinal cord.
The pons is another part of the brain, located in front of the cerebellum. It is part of the brain stem.
The cerebrum is the largest and uppermost part of the brain.
The medulla oblongata is the portion of the brain that provides the connection between the brain and the spinal cord.
A nephron is found in the kidney, and is the functional unit of the kidney.
The maxilla is the upper jawbone.
The thalamus is a part of the brain located above the hypothalamus.
The hippocampus is a ridge in the brain located along each lateral ventricle.
Reference: Thibodeau, Gary A., Structure and Function of the Body, 9th edition, Mosby Year Book, 1992, pages 142-145,
149-150.
Q027EXPL
The ileum is the distal portion of the small intestine. It is the final part of the small intestine and is found just before the
large intestine. The other parts of the small intestine are the duodenum and the jejunum.
Q028EXPL
Skeletal muscle (also referred to as striated muscle or voluntary muscle) is controlled through conscious action. This is the
kind of muscle used to control activities of the skeleton, such as walking, or lifting.
Smooth muscle (also referred as visceral muscle or involuntary muscle) is not controlled through conscious action. It is
typically found in the internal organs of the body, such as in the digestive tract.
Cardiac muscle is only found in the heart. It is a specialized type of involuntary muscle that produces the regular
contractions associated with the heartbeat.
Q029EXPL
The environment inside a nerve cell is relatively low in sodium ions and high in potassium ions, compared to the
environment outside the cell. The difference in ionic concentrations between the inside and outside of the cell, and the
relative permeability of the cell membrane to those ions, leads to a difference of electrical potential between the inside and
outside of the cell.
While at rest, the normal membrane polarization is about -90 millivolts inside the cell, relative to the environment outside
the cell. While at rest, the conductance for potassium ions is substantially greater than the conductance for sodium ions.
When activated, the sodium conductance increases dramatically, causing a change in the membrane potential.
When a nerve fires, the transmembrane potential changes from -90 millivolts to +35 millivolts. After a brief period, about
0.1 milliseconds, the membrane conductance to sodium reverses again, causing the membrane potential to fall back to its
resting value.
Company, 1992, pages 46 – 47.
Q030EXPL
Nephritis is an inflammation of the kidneys.
Cholecystitis is an inflammation of the gall bladder and/or gall bladder duct, usually caused by a gallstone that cannot
pass through the cystic duct.
Hepatitis is an inflammation of the liver.
Q031EXPL
Systole is the period when the heart contracts. Generally, systole refers to ventricular systole, which is the period when the
ventricles contract, as opposed to atrial systole, when the atria contract.
During systole, the heart muscle contraction forces blood out of the heart.
The opposite of systole is diastole, which is the period of time when the heart muscle is resting, so that blood is flowing
into the heart.
Fibrillation is the disorganized contraction of the heart. This leads to inefficient emptying of the heart, and is generally a
very serious medical condition.
Q033EXPL
Korotkoff sounds are the sounds heard in a stethoscope placed on an arm when a cuff is placed around the arm to occlude
the brachial artery. These sounds are used to detect blood pressure.
The cuff around the arm occludes the brachial artery in the upper arm. When the cuff pressure exceeds the systolic
pressure, no blood flows past the cuff. As the pressure on the cuff is released, blood starts flowing past the cuff once its
pressure is lower than the systolic pressure. This blood jetting through the partially occluded vessel is believed to cause
turbulent flow, as opposed to the normal laminar flow found in the artery, resulting in the Korotkoff sounds. Once the
pressure in the cuff is lower than the diastolic pressure, blood flow is no longer interrupted, and no more sounds are heard.
Thus, the Korotkoff sounds are directly caused by arterial obstruction.
Company, 1992, pages 118 – 119.
Q034EXPL
For an electrocardiogram, lead wires are normally placed on the right arm, left arm, and left leg.
The voltage difference recorded between the right arm (-) and left arm (+) is called Lead I.
The voltage difference recorded between the right arm (-) and left leg (+) is called Lead II.
The voltage difference recorded between the left arm (-) and left leg (+) is Lead III.
Taken together, Leads I, II and III are called the limb leads, and form what is known as the Einthoven triangle.
Graphically, it can be shown that Lead I + Lead III = Lead II.
Additional leads are also often recorded. These are referred to as the augmented unipolar limb leads. aVL is recorded by
finding the voltage between the left arm lead (+) and an average of the right arm and left leg leads (-). aVR is recorded by
finding the voltage between the right arm lead (+) and an average of the left arm and left leg leads (-). The final
augmented lead, aVF, is recorded by finding the voltage between the left leg lead (+) (the F stands for foot) and an
average of the right arm and left arm leads (-).
Graphically, it can be shown that the sum of the three augmented leads is zero.
edition, Prentice Hall, 1980, pages 113 – 115.
Q036EXPL
Apnea is the temporary cessation of breathing.
Eupnea is normal respiration.
Hyperventilation is rapid and deep respiration.
Dyspnea is difficult or labored breathing.
Hypoventilation is slow and shallow respiration.
Q037EXPL
A barometer is used to measure atmospheric pressure.
A spirometer is used to measure various lung volumes by having a subject exhale in different ways, and measuring the
volume of air associated with that exhalation.
A tachometer is used to measure the speed of revolution.
A cardiometer is used to measure heart rate.
Q038EXPL
The term pulmonary is used to refer to the lungs. Measurements that are typically made of pulmonary function include the
following:
Vital capacity (VC) - the maximum volume of gas that can be expelled from the lungs by forceful effort after a maximal
inspiration.
Total lung capacity (TLC) - the volume of gas contained in the lungs at the end of a maximal inspiration.
Inspiratory capacity (IC) - the maximum amount of gas that can be inspired after reaching the end expiratory level.
Functional residual capacity (FRC) - the volume of gas remaining in the lungs at the end expiratory level.
Q040EXPL
For an adult male, the normal tidal volume is about 500 milliliters.
Other important pulmonary volumes and capacities for a normal adult male include:
Q041EXPL
Blood is normally a slightly alkaline fluid. Arterial blood has a pH range of 7.38 to 7.44. Venous blood is slightly more
acid, with a pH of about 7.35.
pH is a measurement of acidity or alkalinity. Something that is neutral (neither acid nor alkaline), has a pH of 7.0. An acid
has a pH lower than 7, and a base (alkaline substance) has a pH higher than 7.
Reference: Webster, John G., Medical Instrumentation: Application and Design, Houghton-Mifflin Company, 1978, page
536.
Q042EXPL
Tidal volume is the volume of air inspired or expired during a normal, quiet, respiration cycle.
Q043EXPL
Cardiac output is the volume of blood pumped by the heart in a one-minute period. It is normally in the range of 3 to 5
liters per minute.
The ejection fraction is the fraction of the blood in the left ventricle at the end of diastole that is ejected during systole.
This is usually about 60 percent.
The minute volume, or minute respiratory volume, is the total amount of new air moved into the respiratory passages each
minute. For a normal adult male, the tidal volume is about 500 milliliters, and the normal respiratory rate is about 12
breaths per minute, yielding a minute respiratory volume of 6 liters per minute.
Q044EXPL
Peristalsis refers to the wavelike, rhythmic contractions of the stomach and intestines that move food material along the
digestive tract.
Q045EXPL
A nephron is the anatomical and functional unit of the kidney. It consists of the renal corpuscle and the renal tubule. The
renal corpuscle consists of the glomerulus, a formation of capillary loops, and a capsule surrounding the glomerulus.
The frontal lobe is a portion of the brain.
An auricle is the external part of the ear. It is also another term for the atria of the heart.
A neuron is a nerve fiber.
Q046EXPL
For a human, the term anterior (or ventral) refers to the front of the body. It is divided from the back (posterior or dorsal)
side of the body by a coronal plane.
The left and right sides of the body are divided by a sagittal plane. The sagittal plane running down the middle of the
body, dividing it into equal halves, is referred to as a midsagittal plane.
The upper and lower parts of the body are divided by a transverse plane.
The skull is also referred to as the cranium.
Reference: Thibodeau, Gary A., Structure and Function of the Body, 9th edition, Mosby Year Book, 1992, pages 6 – 9.
Q047EXPL
Pericardium is the membrane that surrounds the heart.
Systole is the period when the heart contracts. Generally, systole refers to ventricular systole, which is the period when the
ventricles contract, as opposed to atrial systole, when the atria contract. During systole, the heart muscle contraction
forces blood out of the heart.
Myocardium is the muscle of the heart.
Diastole is the period of time when the heart muscle is not contracting, so that blood is flowing into the heart.
Q048EXPL
Hemolysis is the process by which red blood cells break down and hemoglobin is released. This occurs normally at the
end of the life span of a red blood cell. It may also occur abnormally with certain diseases or conditions, such as
hemolytic anemia.
Q049EXPL
A dendrite is a branch-like projection from the cell body of a neuron.
An axon is the elongated projection of a cell body used to transmit impulses away from the neuron cell bodies.
A soma is the main cell body of a neuron.
Myelin is the segmented wrapping material that covers most axons.
Reference: Thibodeau, Gary A., Structure and Function of the Body, 9th edition, Mosby Year Book, 1992, pages 132-134.
Q050EXPL
The sinoatrial node is the heart's own pacemaker. It is where a normal heartbeat starts.
The atrioventricular node is the portion of the heart's electrical conduction system that transmits the cardiac impulse from
the atria to the ventricles. It acts as an electrical delay line, allowing the electrical excitation of the ventricles to take place
after atrial contraction and after the ventricles have filled with blood.
The Purkinje network consists of fibers that very rapidly conduct the cardiac impulse throughout the ventricles, so that the
entire ventricles can contract simultaneously, efficiently emptying the ventricles.
The Bundle of His are fibers that connect the atrioventricular node to the Purkinje fibers. They are also known as the
atrioventricular bundle, or the AV bundle.
Q051EXPL
Whole blood consists of red blood cells (erythrocytes), white blood cells (leukocytes), platelets (thrombocytes) and
plasma.
If a test tube of whole blood is placed in a centrifuge, the blood will separate into components.
The bottom layer will consist of red blood cells, which are the highest density component of whole blood. The percentage
of these blood cells, compared to the entire volume of blood, is known as the hematocrit. Normal hematocrit values are 42
to 54% for an adult man, and 38 to 46% for an adult woman.
Above the red blood cells, in the spun test tube, will be a much smaller layer of white blood cells and platelets, known as
the buffy coat or buffy layer.
The rest of the test tube will consist of plasma, which is the extracellular fluid in the blood.
A differential count is the examination of white blood cells to determine which types are present, and the proportion
between them. Five types of white blood cells are counted: neutrophils, lymphocytes, monocytes, eosinophils, and
basophils.
Q052EXPL
A neoplasm is an abnormal growth of new tissue, and may be either benign or malignant.
Necrosis is the localized death of tissue that occurs in response to disease or injury.
Toxicosis is any disease condition due to poisoning.
Endometriosis is a disorder in women in which tissue resembling the inner lining of the uterus (endometrium) is found at
unusual places in the pelvis or lower abdomen. Tissue may be found on the outside of the ovaries, behind the uterus, low
in the pelvic cavity, on the intestinal wall, and rarely, at other sites far away.
Q053EXPL
Stasis is the stagnation of a bodily fluid, especially blood.
Hemostasis is the stopping of the flow or circulation of blood.
Homeostasis is a term used by physiologists to mean the maintenance of static, or constant, conditions in the internal
environment of the body.
Myostasis is not a word. (Myotasis refers to the stretching of a muscle.)
Q054EXPL
Cells use oxygen and release carbon dioxide in order to provide the energy needed to sustain them. Cellular respiration
results in an accumulation of carbon dioxide in the cell, and a deficit of oxygen. This provides a concentration gradient
which results in the movement of oxygen into the cells and carbon dioxide out of the cells into the blood stream.
Pulmonary respiration complements cellular respiration by continuing the gas exchange process in the lungs. Oxygen is
removed from the inspired air, and carbon dioxide is removed from the blood and brought to the expired air.
Therefore, the level of oxygen is lower in the expired air than the inspired air, and the level of carbon dioxide is higher in
the expired air than the inspired air.
Inspired air contains about 21% oxygen and 0.04% carbon dioxide. Expired air contains about 17% oxygen and 4%
carbon dioxide.
Nitrogen and argon do not participate in the respiration process, and so their concentrations are virtually identical in both
inspired and expired air. (In fact, the concentrations of these gases may change slightly, because the water vapor content
of inspired and expired air is different, and, one mole of oxygen in inspired air produces less than one mole of carbon
dioxide in the expired air, as the oxygen is used in a chemical reaction that produces both carbon dioxide and water.)
Q055EXPL
Colloid osmotic pressure is the pressure differential between the inside of the capillaries, and the interstitial space, caused
by the difference in concentration of proteins across the capillary membrane. Proteins are present in the blood plasma, but
do not diffuse readily through the capillary membrane. If a plasma protein does diffuse through the capillary membrane
into the interstitial spaces, it is quickly removed by the lymph system. As a result, the concentration of proteins is much
higher in the capillaries than in the interstitial space.
This difference in concentration leads to a pressure gradient known as the colloid osmotic pressure.
Company, 1992, page 129
Q056EXPL
Subconcious control of vital body functions is provided by the "primitive" structures within the brain, such as the brain
stem. This region of the brain is common to all mammals. The ability to perform higher functions, such as thinking
ability, is what differentiates the human brain from that of other animals, and is the responsibility of the other portions of
the brain.
The cerebrum is primarily responsible for sensory perception, emotions, willed movements, consciousness, and memory.
The motor cortex is responsible for the control of voluntary muscles, such as those in the hands, arms, legs, and mouth.
The cerebellum is responsible for muscle coordination, and the maintenance of equilibrium and posture.
The pons and medulla are responsible for the control of cardiac function, respiration, vasomotor control, and providing a
two-way conduction pathway between the spinal cord and the higher brain centers. The pons and medulla are part of the
brain stem.
Q058EXPL
The sinoatrial node is the heart's own pacemaker. It is where a normal heartbeat starts.
The atrioventricular node is the portion of the heart's electrical conduction system that transmits the cardiac impulse from
the atria to the ventricles. It acts as an electrical delay line, allowing the electrical excitation of the ventricles to take place
after the ventricles have filled with blood. The atrioventricular node also only allows one-way conduction of the cardiac
impulse, and so prevents unintended excitation of the atria after the ventricles have been excited.
The Purkinje network consists of fibers that very rapidly conduct the cardiac impulse throughout the ventricles, so that the
ventricles can contract simultaneously, efficiently emptying the ventricles.
These are fibers that connect the atrioventricular node to the Purkinje fibers. They are also known as the atrioventricular
bundle, or the AV bundle.
Q059EXPL
Hypoxia is a lower than normal level of oxygen in the blood. A common cause of this in a normal person is ascending to a
high altitude, where the density of the air is lower. The low oxygen content under these conditions can lead to
hyperventilation, and the hyperventilation could be a cause of the excessive removal of carbon dioxide. However, this is a
side effect, not a primary effect.
Apnea is the temporary cessation of breathing.
Hyperventilation is the occurrence of excessive ventilation, caused by very rapid, or deep respirations, or both.
Hyperventilation can lead to the expiration of excessive amounts of carbon dioxide, lowering the amount of carbon
dioxide in the blood. If this continues for a prolonged period, it can lead to respiratory alkalosis, i.e., the raising of blood
pH levels caused by the excessive removal of carbon dioxide. In the bloodstream, carbon dioxide forms carbonic acid and
hydrogen ions, increasing the acidity of the blood.
Acidosis can be caused by excessive amounts of carbon dioxide in the blood. This might be the result of hypoventilation.
Q060EXPL
Histology is the science dealing with the microscopic identification of cells and tissue. This laboratory would need to
prepare specimens appropriately to allow microscopic examination. To be properly observed under a microscope, a
specimen needs to be cut into very thin slices so that it fits onto a microscope slide and light can penetrate, so that
individual cells can be readily seen. Phlebotomy deals with the processing of blood samples. A phlebotomist is a person
who specializes in taking blood samples from a patient.
Serology pertains to the examination of blood serum.
Laryngology is the branch of medicine that deals with diseases of the larynx.
Q061EXPL
An electroencephalogram (EEG) is a recording of brain electrical activity as measured by electrodes placed on the surface
of the scalp.
The peak-to-peak signal amplitudes typically are in the range of 1 microvolt up to 100 microvolts.
The amplitude of these signals is far smaller than that of the electrocardiogram (ECG), which may be as high as several
millivolts, as measured by chest electrodes. In addition, while a normal ECG exhibits very regular patterns as the different
areas of the heart are activated in succession, the EEG is much more disorganized in appearance, generally featuring
irregular undulations of the signal without any organization apparent to the untrained observer.
Reference: Webster, John G., Medical Instrumentation: Application and Design, 2nd edition, Houghton Mifflin Company,
1992, pages 10 - 11.
Q062EXPL
Diffusion is the movement of a substance from an area of high concentration to an area of low concentration. For
example, in the lungs, oxygen diffuses into the bloodstream because the oxygen levels in the inspired air are higher than
the oxygen levels in the blood.
Blood gas analysis is the determination of the levels of the respiratory gases dissolved in the blood, i.e., determining the
partial pressure of oxygen and carbon dioxide in the blood.
Ventilation is the physical movement of air into and out of the lungs during respiration.
Respiration is the entire process involved in the interchange of gases between an organism and the medium in which it
lives. Respiration includes both external respiration and internal respiration.
External respiration includes ventilation (the physical process of the inspiration and expiration of air), and the exchange of
oxygen and carbon dioxide in the lungs. Internal respiration includes the exchange of gases between the bloodstream and
nearby cells, i.e., the delivery of oxygen to and the removal of carbon dioxide from the cells.
Hall Career and Technology, 1993, pages 155 - 156
Q063EXPL
edition, Prentice Hall, 1980, page 113
Q064EXPL
Afferent nerves (also referred to as sensory neurons) conduct impulses from sensors located throughout the body to the
spinal cord and brain.
Efferent nerves (or motor neurons), conduct impulses from the brain and spinal cord to muscle and glandular epithelial
tissue. By conducting nerve impulses, efferent nerves can initiate the contraction of muscle fibers, which results in
movement. This movement may be the result of conscious action or an involuntary reflex.
Interneurons constitute the third type of nerve. Their function is to conduct impulses directly from sensory neurons to
motor neurons, such as might be involved in a reflex action.
Reference: Thibodeau, Gary A., Structure and Function of the Body, 9th edition, Mosby Year Book, 1992, page 132
Q065EXPL
Before a muscle can contract, the muscle fiber must be electrically triggered. This triggering produces depolarization, and
results in the contraction of the muscle fiber.
This activity can be measured using surface electrodes. The electrocardiogram (ECG) is the result of the electrical activity
associated with the contraction of the muscles in the different parts of the hear. When the muscle activity of other muscles
is measured, the result is the electromyogram (EMG).
Q066EXPL
Cells use oxygen and release carbon dioxide in order to provide the energy needed to sustain them. Cellular respiration is
the process of moving oxygen into the cells and carbon dioxide out of the cells into the bloodstream.
Pulmonary respiration complements cellular respiration by continuing the gas exchange process in the lungs. Oxygen is
removed from the inspired air, and carbon dioxide is removed from the blood and brought to the expired air.
Therefore, the level of oxygen is lower in the expired air than the inspired air, and the level of carbon dioxide is higher in
the expired air than the inspired air.
Inspired air contains about 21% oxygen and 0.04% carbon dioxide. Expired air contains about 17% oxygen and 4%
carbon dioxide.
Hall Career and Technology, 1993, page 236
Q067EXPL
The heart contains four valves. These valves are used to allow blood flow to proceed in only one direction.
The aortic valve is located at the exit of the left ventricle, where blood enters the aorta, the body's main artery.
The mitral valve divides the left atrium from the left ventricle. The mitral valve is also known as the bicuspid valve.
The pulmonary valve is located at the entrance to the pulmonary artery, and prevents the flow of blood back into the right
ventricle.
The tricuspid valve is found at the exit of the right atrium, and allows blood to flow into the right ventricle, but not back
again.
Reference: Thibodeau, Gary A., Structure and Function of the Body, 9th edition, Mosby Year Book, 1992, pages 226
Q068EXPL
Ectopic refer to something occuring in other than the normal position.
A normal heartbeat starts at the sinoatrial (SA) node.
A heart beat that starts at any other place in the heart is an ectopic beat. For example, an ectopic beat might start in the
atrioventricular node.
Q069EXPL
Severe diarrhea can lead to the loss of a substantial amount of sodium bicarbonate. Large amounts of this alkaline
substance are found in normal gastrointestinal secretions. When this is removed from the body through the action of the
diarrhea, the blood becomes more acidic than usual, leading to metabolic acidosis.
Diabetes is caused by a deficiency of insulin. Insulin in manufactured in the pancreas.
Edema results from leakage of fluid into body compartments that normally contain relatively low volumes of fluid. If the
body is unable to properly remove fluid, edema could be the result. During an episode of diarrhea, excessive amounts of
water are usually lost from the body, so edema is not likely to result.
Q070EXPL
The normal cardiac output for an adult male is about 3 to 5 liters per minute.
A lower value indicates an abnormality.
An extraordinarily healthy individual would have a normal cardiac output, or perhaps a higher than normal cardiac output,
rather than a significantly lower than normal cardiac output.
An individual in shock would have a lower than normal cardiac output.
To compensate, the body would automatically restrict blood flow to only those organs requiring full blood flow, such as
the brain, heart, and kidneys, while reducing blood flow to less than essential organs and body systems, such as the limbs
and digestive system.
A patient with tachycardia would have a higher than normal heart rate. Tachycardia, by itself, would not result in a lower
than normal cardiac output.
Q072EXPL
The pulmonary artery receives its blood from the right ventricle. The right ventricle is far smaller and exerts less pressure
on the blood than the left ventricle.
Blood pressure is normally recorded as a systolic over diastolic value. The systolic value (the higher reading) is the
pressure attained immediately after the contraction of the ventricles is completed. The diastolic reading is the pressure at
the completion of the cardiac cycle, after the heart has completed its resting state. It is the lower reading.
Blood pressure in an artery in an extremity, such as the arm, would normally be about 120/80.
Blood pressure in the pulmonary artery is normally about 25/8.
Blood pressure in the right atrium is normally about 3/0.
Q073EXPL
Blood flow in the gastrointestinal (GI) tract is directly related to the level of activity in the GI system. After a large meal,
the stomach and intestines would become active to promote the proper digestion of the food that was eaten. Additional
blood would be needed to supply the muscles of the stomach and intestines with the nutrients and oxygen they need to
function. In addition, the blood is needed to remove the digested nutrients from the small intestines.
When a blood vessel dilates, it becomes larger, allowing more blood to flow through it.
Company, 1992, pages 485 - 486
Q074EXPL
The aortic valve is located at the exit of the left ventricle and prevents the backflow of blood from the aorta into the
ventricle.
This valve, like all others in the heart, closes when there is back pressure on the valve.
Q075EXPL
Carbon dioxide is the most abundant (in terms of volume) of all the end products of metabolism.
Cellular metabolism also produces water and urea. While these are important end products of metabolism, their volume is
substantially smaller than the volume of carbon dioxide produced.
In order to function properly, cells must have a constant supply of oxygen and a method for continuously removing
carbon dioxide. For this reason, respiration is a continuous process, which, if interrupted for only a few minutes, will lead
to death.
Q076EXPL
Under normal conditions, after the heart contracts, it fully repolarizes before the next heartbeat occurs. The period of
repolarization is seen on the electrocardiogram as the T-wave.
If a defibrillator pulse were to occur during the T-wave, it could lead to fibrillation, because some of the heart tissue is
refractory (i.e., not capable of being excited) and other heart tissue has already repolarized (i.e., is ready to be excited). As
a result, if a defibrillation pulse were to occur at this point, some, but not all, of the heart muscle would fire. If this were to
continue, fibrillation, the uncoordinated contraction of the heart, would result.
Cardioversion is generally used to counteract the effects of atrial fibrillation, when the heart's atria are contracting in an
uncoordinated manner, but the ventricles still contract normally.
By defibrillating the heart with a cardioverter, it is hoped that the heart will be restored to its normal rhythm, with the atria
contracting as a single unit. For this reason, cardioverters are designed to prevent firing during the T-wave.
Instead, they generally fire shortly after the R-wave peak (about 30 milliseconds), when the heart's ventricles are still in
their refractory period.
The T-wave generally starts about 150 milliseconds after the R-wave, and continues for about 150 milliseconds. Thus, the
vulnerable period for the heart is the period from about 150 to 300 milliseconds after the R-wave occurs.
By 500 milliseconds after the R-wave peak, the T-wave has been completed, and so the heart is not likely to go into
fibrillation if a shock was delivered at that time.
Thus, of the choices offered in this question, the heart is most likely to go into fibrillation if a shock were delivered about
200 milliseconds after the R-wave peak.
Reference: Webster, John G., Medical Instrumentation: Application and Design, 2nd edition, Houghton Mifflin Company,
1992, pages 718-719
Q077EXPL
Immunopathology is the study of diseases or conditions resulting from immune reactions (antigen-antibody reactions).
Microbiology is the branch of biology that deals with microbes (microscopic and ultramicroscopic organisms). Generally,
this is associated with the study of infectious diseases.
Hematology is the medical specialty that deals with the blood and blood-forming tissues.
Histology is the science dealing with the microscopic identification of cells and tissue.
Reference: Stedman's Medical Dictionary, Illustrated, 23rd edition, Williams and Wilkins, 1976, page 624
Q078EXPL
Blood is normally a slightly alkaline fluid. Arterial blood has a pH range of 7.38 to 7.44. Venous blood is slightly more
acid, with a pH of about 7.35.
pH is a measurement of acidity or alkalinity. Something that is neutral (neither acid nor alkaline), has a pH of 7.0. An acid
has a pH lower than 7, and a base (alkaline substance) has a pH greater than 7.
536
Q307EXPL
High levels of bilirubin can occur in neonates if the liver has not yet fully developed. The liver helps in the breakdown of
red blood cells that are no longer needed. The step in the chemical breakdown of these red blood cells that is lacking in
these infants can be augmented by the use of phototherapy (light at a wavelength of 425 nanometers). The light changes
the molecular structure of the bilirubin so that the immature liver can process it.
Reference: http://www.nlm.nih.gov/medlineplus/ency/article/003479.htm
Q382EXPL
One kilogram is equal to 2.2 pounds. In this case, the patient's weight in pounds is:
Weight = 77 kg X 2.2 lb/kg

Weight = 169.4 lb
So the patient's weight in pounds, if his weight is 77 kilograms, is 169.4 pounds, which is about 170 pounds.
Reference: None
Q643EXPL
The hypothalmus regulates body temperature. The hypothalmus is found roughly in
the middle of the skull and contains a large number of temperature-sensitive
neurons. It also helps control the heartbeat, constriction and dilation of blood
vessels, and contractions of the stomach and intestines.
The medulla oblongata, an enlarged, upward extension of the spinal cord, is found
where the brain connects to the spinal cord. It controls the autonomic, life-
sustaining functions, such as the cardiac, respiratory, and vasomotor functions.
Wernicke’s area is in the temporal lobe of the brain and controls understanding
of speech. Broca’s area is located in the frontal lobe of the brain and controls
the delivery of speech.
The amygdala in the limbic system of the brain controls emotion. The amygdala is
an almond shaped structure which has extensive connections to other parts of the
brain. Stimulating the amygdala causes feelings of fear and aggression.
References:
[1] Silverthorn, Dee Unglaub, Human Physiology, Pearson-Benjamin Cummings, 2006,
pages 315-316
[2] Thibodeau, Gary A., Structure and Function of the Body, Ninth Edition, Mosby
Year Book, 1992, page 144
[3] Get Body Smart, Nervous System, Brain,
http://www.getbodysmart.com/ap/nervoussystem/cns/brain/menu/menu.html, retrieved
9/10/2014
Q669EXPL
Cerebrospinal fluid is produced by the choroid plexus which is located in the
cerebral ventricles of the brain. The choroid plexus consists of arterial tufts
which produce the fluid primarily from arterial blood. The cerebellum is the
lower part of the brain where physiological functions are controlled, e.g.
respiration, heart rate, etc. No fluids are produced in the cerebellum because of
the blood brain barrier.
The cerebrum is the front of the brain and controls higher functions, e.g.
thought, creativity, etc. No spinal fluid is produced in the cerebrum because of
the blood brain barrier.
The brain stem connects the brain to the spinal cord. No fluids are produced in
the brain stem.
Reference:
[1] Agamanolis, Dimitri P., MD, Neuropathology, Chapter 14,
http://neuropathology-web.org/chapter14/chapter14CSF.html, retrieved September
23, 2014
[2] Cerebrospinal Fluid, Wikipedia,
http://en.wikipedia.org/wiki/Cerebral_spinal_fluid, retrieved September 23, 2014
Q670EXPL
All of the items described in this question are glands. A gland is an organ that
produces a hormone. Hormones are chemical substances excreted by glands that then
control various body activities, such as metabolic rate or maturation.
The thyroid gland is located in the anterior part of the chest at the base of the
throat. The thyroid produces hormones that primarily regulate metabolism. The
thyroid is made up of two lobes, each of which has dimensions of approximately 5
cm long, 3 cm wide, and 2 cm thick.
The hypothalmus is located in the brain, just above the brainstem. The
hypothalamus produces hormones that are responsible for controlling body
temperature, hunger, sexual function, thirst, fatigue, sleep and circadian
rhythms.
The pituitary gland is located in the brain, just under the hypothalamus. It is a
small gland, about the size of a pea. The hormones that it releases regulate
stress, growth, some sexual functions, and lactation.
The adrenal glands are located just above (superior to) each kidney. The hormones
that these glands produce regulate the body’s reaction to stress.
References:
[1] Thyroid, Wikipedia, http://en.wikipedia.org/wiki/Thyroid, retrieved September
25, 2014
[2] Thyroid hormone, Wikipedia, http://en.wikipedia.org/wiki/Thyroid_hormone,
retrieved September 25, 2014
[3] Hypothalmus, Wikipedia, http://en.wikipedia.org/wiki/Hypothalamus, retrieved
September 25, 2014
[4] Pituitary Gland, Wikipedia, http://en.wikipedia.org/wiki/Pituitary_gland,
[5] Adrenal Gland, Wikipedia, http://en.wikipedia.org/wiki/Adrenal_gland,
[6] Kidney Disease, WebMD, http://www.webmd.com/urinary-incontinence-oab/picture-
of-the-kidneys, retrieved September 25, 2014
Q671EXPL
The Circle of Willis is a series of arteries that form a structure that is the
main arterial blood supply to the brain. This structure is separated into an
anterior and posterior system to supply different parts of the brain. The
structure of these arteries provides redundancies and opportunities for
collateral circulation, so that if one part of the circle becomes blocked, there
are additional paths for blood flow to be maintained throughout the brain.
The mesenteric arteries are located in the abdomen. They supply blood flow to the
gastrointestinal system.
The brachiocephalic artery is the first branch of the aortic arch, and then
branches into the subclavian and the common carotid arteries. It supplies blood
to the right arm, head and neck. It is not within the brain.
The splenic artery is in the abdomen. It runs along the bottom of the pancreas
and supplies the spleen.
The subclavian arteries branch off of the aorta. The left subclavian artery
branches directly off of the aorta and supplies blood to the left arm. The right
subclavian is a branch of the brachiocephalic artery, and it supplies blood to
the right arm. Branches of the right subclavian artery also supply blood to the
head and thorax.
References:
[1] Circle of Willis, Wikipedia, http://en.wikipedia.org/wiki/Circle_of_Willis,
[2] Mesentery, Wikipedia, http://en.wikipedia.org/wiki/Mesentery, retrieved
September 25, 2014
[3] Brachiocephalic artery, Wikipedia,
http://en.wikipedia.org/wiki/Brachiocephalic_artery, retrieved September 25, 2014
[4] Splenic artery, Wikipedia, http://en.wikipedia.org/wiki/Splenic_artery,
[5] Subclavian artery, Wikipedia, http://en.wikipedia.org/wiki/Subclavian_artery,
Q672EXPL
The cerebrum is the largest part of the brain in humans and acts as a nerve
impulse processor as well as memory bank and controller of voluntary muscles.
The cerebellum is second largest portion of the human brain and is the lower part
of the the brain. It is associated with smooth body muscle movements,
physiological functions, balance and equilibrium.
The frontal lobe is part of the cerebrum and within this lobe there are motor
neurons that control certain body muscles.
The brainstem is made up of the medulla, pons, midbrain, and diencephalon. The
brainstem structures are associated with the control of heart rate and
respiration rate, as well as other autonomic functions, such as maintaining
consciousness, sleeping and eating. The brainstem connects the brain and spinal
cord.
Reference:
[1] Carr, Joseph J. and Brown, John M., Introduction to Biomedical Equipment
Technology, 4th Edition, Prentice Hall, 2001, pages 355-365
Q674EXPL
The cranial nerves arise directly from the brain or brainstem. They supply the
head, neck and most of the viscera.
There are 12 cranial nerve pairs, traditionally numbered I through XII. Each
nerve pair consists of a left and right nerve. The numbering of the nerves is as
follows:
I – Olfactory nerves
II – Optic nerves
III – Oculomotor nerves
IV – Troclear nerves
V – Trigeminal nerves
VI – Abducens nerves
VII – Facial nerves
VIII – Vestibulocochlear nerves
IX – Glossopharyngeal nerves
X – Vagus nerves
XI – Accessory nerves
XII – Hypoglossal nerves
References:
[2] Cranial Nerves, Wikipedia, http://en.wikipedia.org/wiki/Cranial_nerves,
Q676EXPL
Hepatitis is an inflammation or infection of the liver, usually due to a virus.
Meningitis is the inflammation of the meninges, a brain membrane.
Sepsis is a widespread infection of bacteria in the body, not specific to the

membranes.
Multiple sclerosis (MS) is a disease that damages the insulating sheath (myelin)
of the nerve cells in the brain and spinal cord. While this disease does affect
the brain, it does not damage the meninges. It does result in demyelination of
axons.
Sinusitis is the inflammation and congestion of the sinuses due to an infection.

It does not affect the brain membranes.
Reference:
[1] Martini, Frederic H., PhD, Fundamentals of Anatomy and Physiology, 4th
Edition, Prentice Hall, 1998, pages 168, 214, 410, 420, and 912
Q677EXPL
The gallbladder is located below the right lobe of the liver. It is a hollow,
pear-shaped muscular organ. Bile is manufactured by the liver and is used during
digestion to help break down fats. The gallbladder stores the bile, and then
releases it into the small intestine in response to the presence of fats in the
digestive system.
The pancreas produces several hormones. The best known pancreatic hormone is
insulin, which helps control the level of glucose in the blood. Insulin is
produced in the Islets of Langerhans in the pancreas. The pancreas also produces
digestive enzymes that are used as part of the digestive process in the small
intestine.
The thalamus gland is located in the middle of the brain. Its functions include
the relaying of sensory and motor signals to the cerebral cortex, and the
regulation of consciousness, sleep, and alertness.
The pituitary gland is pea-sized gland located in the middle of the brain, just
under the hypothalamus. It produces several hormones, including hormones that
control stress, growth, sexual function, and lactation.
The pancreas, thyroid, thalamus and pituitary gland are all glands. They are all
part of the endocrine system.
References:
Edition, Prentice Hall, 1998, pages 895-896
[2] Gallbladder, Wikipedia, http://en.wikipedia.org/wiki/Gallbladder, retrieved
September 25, 2014
[3] Pancreas, Wikipedia, http://en.wikipedia.org/wiki/Pancreas, retrieved
September 25, 2014
25, 2014
[5] Thalamus, Wikipedia, http://en.wikipedia.org/wiki/Thalamus, retrieved
September 25, 2014
[6] Pituitary gland, Wikipedia, http://en.wikipedia.org/wiki/Pituitary_gland,
Q678EXPL
A gland is a specialized organ that produces substances such as hormones or
enzymes. Hormones are chemicals that regulate various body functions. For
example, insulin is a hormone that regulates glucose levels in the blood.
The pineal gland is located in the brain and produces melatonin, which is a
hormone associated with the circadian rhythm and the wake/sleep cycle.
The pancreas produces several hormones. The best known pancreatic hormone is
insulin, which helps control the level of glucose in the blood. Insulin is
produced in the Islets of Langerhans in the pancreas. The pancreas also produces
digestive enzymes that are used as part of the digestive process in the small
intestine.
The adrenal glands are located just above (superior to) each kidney. The hormones
that these glands produce regulate the body’s reaction to stress, i.e, control
the “fight or flight” response to allow rapid reactions to life-endangering
situations.
Reference:
Technology, 4th Edition, Prentice Hall, 2001, page 364
[2] Anthony, Catherine Parker and Kolthoff, N.J., Textbook of Anatomy and
Physiology, Mosby, 1975, pages 277-278
Edition, Prentice Hall, 1998, pages 625-628 and 889-890
[4] Pancreas, Wikipedia, http://en.wikipedia.org/wiki/Pancreas, retrieved
September 25, 2014
25, 2014
[6] Adrenal Gland, Wikipedia, http://en.wikipedia.org/wiki/Adrenal_gland,
[7] Pineal gland, Wikipedia, http://en.wikipedia.org/wiki/Pineal_gland, retrieved
September 25, 2014
Q680EXPL
The lymphatic system is a network of vessels that carry lymph fluid towards the
heart. Lymph fluid is a clear liquid derived from the blood that carries protein
and excess interstitial fluid. Lymph can also carry bacteria to the lymph nodes,
which are able to destroy the bacteria.
The exocrine system consists of glands that have ducts (ducted glands). The
products secreted by the exocrine glands are generally not released directly into
blood. For example, the bile produced by the liver goes into the digestive tract,
while sweat glands produce perspiration on the skin. Examples of glands that are
part of the exocrine system include the the sweat glands, salivary glands,
mammary glands and liver.
The glands of the endocrine system release their hormones into the blood. These
glands do not have ducts. These glands produce a variety of hormones that control
many of the critical functions of the body, including growth and metabolism.
Examples of glands that are part of the endocrine system include the pituitary
gland, pancreas, thyroid and hypothalamus.
Although the gastric system derives nutrients used for growth or in the metabolic
process, it is not considered a control system for these functions.
Reference:
[1] Anthony, Catherine Parker and Kolthoff, N.J., Textbook of Anatomy and
Physiology, Mosby, 1975, pages 277-278
[2] Lymphatic system, Wikipedia, http://en.wikipedia.org/wiki/Lymphatic_system,
[3] Exocrine glands, Wikipedia, http://en.wikipedia.org/wiki/Exocrine_gland,
[4] Endocrine gland, Wikipedia, http://en.wikipedia.org/wiki/Endocrine_gland,
[5] Human gastrointestinal tract, Wikipedia,
http://en.wikipedia.org/wiki/Human_gastrointestinal_tract, retrieved September
27, 2014
Q681EXPL
The kidneys are responsible for the removal of metabolic waste products. This is
done by filtering the blood to remove water soluble waste products to produce
urine. As part of the filtering process, the kidneys first remove both waste
products and essential nutrients, such as sodium, magnesium and glucose, and then
later reabsorb water and essential nutrients in a controlled manner to maintain
the desired levels in the body. Urine contains urea and ammonium. The kidneys
also act to regulate blood pH by controlling the acid/base balance of the blood
within a small range. This is accomplished by reabsorbing bicarbonate from the
urine, and by excreting excess hydrogen ions into the urine. While the kidneys do
not directly sense blood pressure, they do regulate blood pressure by reacting to
hormones that cause the kidneys to increase or decrease their reabsorption of
sodium chloride, regulating the sodium levels in the body. By changing the sodium
balance, fluid volumes are changed, which causes blood pressure to increase or
decrease over the long term.
The renal system does not produce or secrete bile. Bile is produced by the liver
and stored in the gall bladder. It is released into the small intestine to aid in
the digestion of fats.
Body temperature is primarily regulated by hormones that are secreted by the

hypothalamus.
References:
Edition, Prentice Hall, 1998, pages 872 and 891-895
Q682EXPL
There are two adrenal glands. These cone-shaped glands sit atop each kidney. They
produce hormones that regulate the body’s reaction to stress.
Reference:
Edition, Prentice Hall, 1998, pages 614
Q687EXPL
The blood–brain barrier (BBB) is a highly selective permeability barrier that
separates the circulating blood from the brain extracellular fluid (BECF) in the
central nervous system (CNS). The blood–brain barrier is formed by capillary
endothelial cells, which are connected by tight junctions with an extremely high
electrical resistance. This type of tight junction is exclusive to the brain, and
is not found in the normal circulatory system.
The blood–brain barrier allows the passage of water, some gases, and lipid
soluble molecules by passive diffusion. A selective, active transport mechanism
allows molecules such as glucose and amino acids, which are crucial to neural
function, to cross the BBB. Endothelial cells restrict the diffusion of
microscopic objects (e.g., bacteria) and large or hydrophilic molecules into the
cerebrospinal fluid (CSF), while allowing the diffusion of small hydrophobic
molecules (such as oxygen, carbon dioxide and hormones).
The blood-brain barrier is not reliant on either a thick physical membrane, or

the existence of small bores in the capillary walls.
To allow the exchange of gases, metabolites and nutrients between brain cells and
the blood flowing in capillaries, those capillaries must be embedded within the
brain's extracellular space. The result is that having a physical separation or
gap between brain cells and the blood is not possible.
Reference:
[1] Blood-Brain Barrier, Wikipedia,
http://en.wikipedia.org/wiki/Blood%E2%80%93brain_barrier, retrieved September 25,
2014
Q688EXPL
The central area of gray matter in the brain and spinal cord is composed of the
cell bodies and dendrites of efferent neurons (neurons that send signals to
muscles or glands), the entering fibers of afferent neurons (neurons that receive
information from body sensors, such as the eyes or ears), and glial cells. It is
called gray matter because there are more cell bodies (which appear gray) than
myelinated fibers (which appear white).
The gray matter is surrounded by white matter, which consists of groups of

myelinated axons of interneurons. These groups of axons, called fiber tracts or
pathways, run longitudinally through the spinal cord, some descending to relay
information from the brain to the spinal cord, others ascending to transmit
information to the brain. It appears white because it is dominated by myelinated
axons that look white.
The cerebrospinal fluid, on the other hand, fills the spaces within and around
the brain and spinal cord. Thus, the central nervous system literally floats in a
cushion of cerebrospinal fluid (CSF). Since the brain and spinal cord are soft,
delicate tissues with a consistency similar to gelatin, they are somewhat
protected by this shock-absorbing fluid from sudden and jarring movements.
Reference:
[1] Vander, Arthur J., Sherman, James H., and Luciano, Dorothy S., Human
Physiology: The Mechanisms of Body Function, 8th edition, McGraw Hill, 2001
Q689EXPL
The liver is a vital organ of the digestive system present in vertebrates and
some other animals. The functions of the liver include the secretion of bile.
Bile acts in the small intestines to emulsify large masses of fat, and turn them
into smaller pieces that have more surface area and are therefore easier for the
body to digest. The liver also plays a key role in the metabolism of
carbohydrates, lipids, and proteins.
It also serves as a primary storage location for essential nutrients, vitamins,

and minerals, including glycogen (a derivative of glucose that serves as an
energy source) and iron. Another function performed by the liver is the
detoxification of blood. The liver metabolizes toxins, such as alcohol and many
drugs. It also removes excess hormones produced by the body’s own glands.
Blood glucose regulation is primarily the function of the pancreas. Glucose

levels in the blood are monitored by the cells in the pancreas's Islets of
Langerhans. The pancreas releases the hormones glucagon or insulin to control the
conversion of glycogen into glucose, or glucose into glycogen, as needed, by the
liver. Therefore, it is the pancreas that handles this physiological function,
not the liver.
References:
[1] Liver, Wikipedia, http://en.wikipedia.org/wiki/liver, retrieved September 30,
2014
[2] Liver, InnerBody website, http://www.innerbody.com/image_digeov/card10-
new2.html, retrieved September 30, 2014
[3] Blood Sugar Regulation, Wikipedia,
http://en.wikipedia.org/wiki/Blood_sugar_regulation, retrieved September 30, 2014
Q703EXPL
The kidneys form urine out of the plasma component of the blood. Plasma is the
extra-cellular fluid that makes up around 55% of the blood. Plasma transports
nutrients, enzymes and hormones to the organs and removes their waste products.
The kidneys then remove the waste from the plasma.
Erythrocytes (red blood cells) are a component of blood that carry the oxygen in
the blood. Erythrocytes supply oxygen to the kidneys but urine is not formed from
the erythrocytes.
Thrombocytes (platelets) are a blood component that are used for clotting or
coagulating blood. The coagulation function is necessary to stop bleeding.
Leukocytes (white blood cells) are a blood component that are a part of the
immune system. Leukocytes play a defensive role in the blood by defending the
body from disease. Leukocytes increase or decrease in response to disease.
Lymph is not a component of blood, but is part of the lymphatic system, which is
a part of the immune system. The lymph system drains interstitial fluid and
provides a mechanism to transport bacteria to the lymph nodes, where the bacteria
can be destroyed.
References:
[1] Khandpur, R.S., Biomedical Instrumentation: Technology and Applications,
McGraw Hill, 2005, pages 444, 785, 815
[2] Tortora, Gerard J., and Derrickson, Bryan, Principles of Anatomy and
Physiology, John Wiley & Sons, 2009, pages 689–692, 831
Q704EXPL
The root word "nephr" means "kidneys" and the suffix "ology" means the "study
of." Therefore, nephrology is the study of the kidneys.
Urology is the branch of science that deals with the male and female urinary
systems.
Neurology is the study of the nervous system.
Gastroenterology is the study of the gastric system, which includes the stomach,
intestines, gallbladder and bile duct.
Pulmonology is a study of the respiratory system and especially the lungs.

Reference:
Physiology, John Wiley & Sons, 2009, pages G11-G12, G18, G22, 689-692, 831, 1018
Q705EXPL
The pancreas is a glandular organ that is a component of both the digestive
system and the endocrine system. The pancreas is both an exocrine gland (one that
secretes enzymes into ducts) and an endocrine gland (one that secretes hormones
into circulatory system). The pancreas produces and secretes pancreatic juice.
This juice contains digestive enzymes that flow through ducts into the small
intestine to break down chyme and assist with digestion. The pancreas also
produces the hormones insulin, glucagon, somatostatin and pancreatic polypeptides
that are secreted into the blood stream.
The liver's role in the digestive system is the production of bile. Bile aids in
the digestion of lipids (fats).
The kidneys are bean-shaped and are located retroperitoneal, that is, outside the
peritoneum, which is the membrane that lines the abdominal cavity. The kidneys
are responsible for removing metabolic waste products from the bloodstream. These
waste products are removed from the body in the urine. The kidneys also release
hormones to maintain blood glucose levels.
The gallbladder stores the bile produced by the liver, and then releases that
bile in response to the presence of fats in the digestive system.
The large intestine completes the digestion process with the absorption of
certain vitamins and the formation and expulsion of feces.
Reference:
Physiology, John Wiley & Sons, 2009, pages G19, 944-964, 1020
Q706EXPL
The pancreas is both an exocrine gland (one that secretes enzymes into ducts) and
an endocrine gland (one that secretes hormones into the circulatory system). The
pancreas produces several hormones including insulin, glucagon, somatostatin and
pancreatic polypeptide, all of which are secreted directly into the blood stream.
Insulin and glucagon control the glucose levels in the blood. The pancreas is
also a part of the digestive system. It produces and secretes pancreatic juice
that contains digestive enzymes. This juice travels to the small intestine via
ducts leading from the pancreas into the small intestine.
The kidney also produces several hormones, which are released into the
bloodstream. The kidneys produce the hormone erythropoietin in response to low
oxygen levels in the blood. Erythropoietin stimulates the production of red blood
cells, which are the blood cells that carry oxygen in the blood. The kidneys also
produce the hormone calcitriol, which helps to regulate the calcium balance in
the body. Another hormone produced by the kidneys is renin which is part of a
system that raises blood pressure.
The heart produces hormones that help regulate blood volume and blood pressure.
The heart muscle cells produce atrial natriuretic peptide (ANP), which helps to
regulate fluid balance, and leads to a reduction of blood volume and blood
pressure.
The testes are classified as an endocrine gland and as a male reproductive organ.
The testes produce the male sex hormones testosterone and inhibin. The testes are
part of the male reproductive system.
The ovary is classified as an endocrine gland and as a female reproductive organ.

The ovary is a female sex organ that produces estrogen, progesterone, relaxin,
and inhibin. The ovary is part of the female reproductive system.
Reference:
Physiology, John Wiley & Sons, 2009, pages G19, 642-667, 673-674, 944-964, 1020
Q707EXPL
The endocrine system is made up of glands and organs that produce hormones. These
hormones are secreted by the glands in this system and are then transported by
the blood stream to appropriate targets throughout the body. The hormones have a
wide variety of effects, including the regulation of cell activity and growth,
the body’s metabolism, various reproductive processes, and the circadian rhythm
which helps control the daily activity level and wake/sleep cycle.
The digestive system breaks down food into molecules and absorbs nutrients into
the bloodstream for distribution to the cells requiring those nutrients. The
digestive system also eliminates some waste products.
The lymphatic system provides a part of the body’s defense mechanisms against
disease.
The urinary system, also known as the renal system, consists of the kidneys,
ureters, bladder and urethra. The kidneys produce several hormones that are
responsible for controlling blood volume, red blood cell volume and blood
pressure, among other functions. The kidneys do not produce hormones that
directly influence cell activity and growth, the body’s metabolism, or influence
the reproductive processes or circadian rhythm.
The nervous system regulates body activity through nerve impulses and not through
hormonal secretions.
Reference:
Physiology, John Wiley & Sons, 2009, pages 415, 642, 831, 921
Q708EXPL
The endocrine system is made up of glands and organs that produce hormones. The
thyroid gland, adrenal gland, hypothalamus, ovaries and testes all produce
hormones and all are part of the endocrine system. These hormones are then
secreted into the bloodstream where they circulate, initiating appropriate
actions in the target organs.
None of the glands indicated in this question are part of either the urinary
system, digestive system, or lymphatic system.
The urinary system includes the kidneys, ureters, bladder and urethra. The major
components of the digestive system include the mouth, esophagus, stomach, small
intestine, large intestine, liver, pancreas, and gallbladder. The lymphatic
system includes the bone marrow (which produces lymphocytes), lymph, lymph nodes,
thymus and spleen.
The reproductive system is affected by some of the hormones produced by some of

the glands listed in this question, and in particular the hormones produced by
the hypothalamus, ovaries and testes. However, the reproductive system does not
include the thyroid or adrenal glands.
Reference:
Physiology, John Wiley & Sons, 2009, pages 658, 684-685, 869, 1019, 1116
Q709EXPL
An endocrinologist is a physician who specializes in issues with the endocrine
system and the hormones produced by the glands that are part of this sytem.
Insulin, a hormone produced by the pancreas, is responsible for managing sugar
levels in the blood.
A urologist specializes in treating disorders of the male and female urinary

systems.
A neurologist specializes in disorders of with the nerves, spinal cord and brain.
A pulmonologist specializes in disorders associated with the pulmonary system and

would treat problems with breathing.
A cardiologist treats conditions associated with the heart.
Reference:
Physiology, John Wiley & Sons, 2009, pages G5, G7, G18, G22, 689-692, 831, 1018
Q710EXPL
The gallbladder is pear-shaped and is part of the digestive system. It stores
bile and releases it into the intestines.
The liver produces the bile that is stored in the gallbladder. Bile is used to
emulsify dietary fats to aid in their absorption.
The pancreas is a fish-shaped, digestive system organ that secretes pancreatic

fluid (also known as pancreatic juice) into ducts connected to the small
intestines.
The stomach is J-shaped and empties partially digested food into the small
intestines.
The kidneys are bean-shaped and are not part of the digestive system but are part
of the urinary system.
Reference:
Physiology, John Wiley & Sons, 2009, pages 937, 945, 948, 949, 1020
Q711EXPL
The pancreas is both part of the digestive system and the endocrine system. As
part of the digestive system, it produces pancreatic fluid (also known as
pancreatic juice), which aids in the digestion of food. This fluid travels from
the pancreas to the small intestine via ducts. The role of the pancreas in the
endocrine system is to produce a variety of hormones, including insulin,
glucagon, somatostatin, and pancreatic polypeptide. In terms of structure, the
pancreas has a head, body and tail.
The kidneys are bean-shaped and produce hormones, but they do not secrete
digestive fluids.
The esophagus is a long tube and secretes mucus, but it does not secrete
digestive fluids or hormones.
The gallbladder is shaped like a pear, stores and releases bile into the
intestines and does not secrete hormones.
The J-shaped stomach does secrete digestive fluids and hormones, but it does not
have the head, body and tail structure described in this question. The top of the
stomach is referred to as the fundus, while the main portion is called the body.
Reference:
Physiology, John Wiley & Sons, 2009, pages 643, 934, 942–944, 1020
Q712EXPL
Bile emulsifies dietary lipids (fats). The large intestine converts proteins into
peptides and eliminates feces from the rectum. Pancreatic juices digest starch.
Reference:
Physiology, John Wiley & Sons, 2009, pages 972-974
Q713EXPL
The brain has three principal components: the cerebrum, the brain stem, and the
cerebellum. The cerebrum is the largest component and consists of the right and
left hemispheres with a thin outer layer of gray matter and the thicker inner
core of white matter. Conscious activity is controlled by the outermost gray
matter, which is referred to as the cerebral cortex. The inner white matter acts
as a transmission conduit of neurons that carry impulses to and from the cerebral
cortex.
The brain stem is involved in motor control of the visceral organs. These organs
include the larger internal organs in the chest and abdomen, such as the heart,
lungs, liver, pancreas and intestines. The brain stem also plays a role in the
control of consciousness and the wake/sleep cycle. Damage to the brain stem can
result in permanent unconsciousness (i.e., coma).
Included in the brain stem is the diencephalon, or interbrain, that is enclosed
by the cerebral hemispheres. The diencephalon is located above the brain stem.
Within the diencephalon is the hypothalamus, an endocrine gland that controls
various body activities such as growth, endocrine functions, and body
temperature.
The cerebellum is located at the lower back of the brain. It controls motor
activities and muscle contractions, and by doing so makes the movement of
skeletal muscles smooth and coordinated. In appearance, the cerebellum resembles
cauliflower.
References:
[1] Baura, Gail D., Medical Device Technologies: A System Based Overview Using
Engineering Standards, Elseiver Inc., New York, 2012, pages 276-277
[2] Askew, Jim, The Central Nervous System, Crescent Public Schools,
http://crescentok.com/staff/jaskew/isr/anatomy/anatomy1/unit10.htm, retrieved
August 19, 2014
[3] Definition of Visceral, MedicineNet.com website,
http://www.medicinenet.com/script/main/art.asp?articlekey=18275, retrieved August
19, 2014
[4] Definition of Endocrine, MedicineNet.com website,
http://www.medicinenet.com/script/main/art.asp?articlekey=25210, retrieved August
19, 2014
Q717EXPL
The tympanic membrane is the eardrum. The tympanic membrane separates the outer
ear and the middle ear. The outer ear is where sound enters the ear through the
auditory canal (auditory os), while the the middle ear is where sound starts
being processed. Sound waves cause the tympanic membrane to vibrate, stimulating
mechanical movement of the auditory bones (auditory ossicles) of the middle ear,
which then transmit that motion into the cochlea.
The auditory bones are the malleus (hammer), incus (anvil), and stapes (stirrup).
The malleus touches the tympanic membrane to receive its vibrations, and the
stapes touches the round window of the cochlea to transmit vibrations into the
cochlea. The cochlea contains an incompressible fluid that efficiently transfers
sound vibrations to nerve cells that detect those vibrations.
The cochlea is found in the inner ear and is the structure within the ear that
reacts to sound waves. The scala tympani, or tympanic duct, is a fluid-filled
duct located in the cochlea of the ear. Fluid in the scala tympani moves when
stimulated by sound. This mechanical movement stimulates hair cells lining the
Organ of Corti, that then trigger nerve impulses that the brain uses to perceive
sound.
The basilar membrane is a stiff membrane that separates the scala tympani duct
from the scala media duct, which is the actual structure that contains the Organ
of Corti. The basilar membrane acts as a resonator, with different portions of it
most sensitive to different frequencies. Its structure then allows it to
stimulate the hair cells in a particular region when a specific audio frequency
is received.
References:
[2] Diagram of Ear Anatomy, BioGraphix website,
http://www.biographixmedia.com/human/ear-anatomy.html, retrieved August 19, 2014
Q720EXPL
The pancreas is a long, slender organ located behind the bottom half of the
stomach.
Glucose, which serves as an energy source for the body, circulates in the
bloodstream. Glucose levels are regulated by the hormones insulin and glucagon,
both of which are secreted by the pancreas within the cells of the Islets of
Langerhans.
The acini tissues of the pancreas secrete enzyme-containing digestive juices into
the small intestine. These enzymes help in the digestion of carbohydrates,
proteins and lipids. The Islets of Langerhans (pancreatic islets) secrete the
hormones glucagon, insulin, somatostatin, and pancreatic polypeptide.
Somatostatin has a role in the regulation of growth. Pancreatic polypeptide is
used as part of the pancreas’s self-regulation, and helps control the release of
the pancreatic juices and hormones.
References:
[2] Pancreas, Wikipedia, http://en.wikipedia.org/wiki/pancreas, retrieved October
22, 2014
Q722EXPL
The pancreas contains about 1-2 million islets of Langerhans (also known as the
pancreatic islets). Each islet contains alpha, beta, delta and gamma cells.
The alpha cells secrete glucagon, a hormone that is released when blood glucose
levels drop too low. Glucagon causes the liver to convert stored glycogen into
glucose.
Beta cells secrete insulin and amylin. Insulin has the opposite effect of
glucagon. Elevated blood glucose levels stimulate the release of insulin, which
then acts on the liver to cause the conversion of glucose in the blood into
glycogen, which the liver stores. Amylin is released by the pancreas along with
insulin. Amylin acts to slow the speed at which food is digested, which then
slows the release of glucose into the bloodstream.
The delta cells secrete somatostatin. Somatostatin inhibits the release of both
glucagon and insulin. Somatostatin also has a role in the control of growth.
Gamma cells secrete pancreatic polypeptide, which helps the pancreas regulate
itself. Pancreatic polypeptide also appears to play a role in satiety, the
feeling of fullness that acts to suppress appetite.
Omega cells do not exist.

References:
[2] Pancreas, Wikipedia, http://en.wikipedia.org/wiki/pancreas, retrieved October
22, 2014
[3] The Endocrine Pancreas, Openstax website,
http://cnx.org/content/m46685/latest/?collection=col11496/latest, retrieved
August 19, 2014
[4] What is Amylin?, WiseGeek website, http://www.wisegeek.com/what-is-
amylin.htm, retrieved August 19, 2014
Q724EXPL
The primary role of the kidneys is to remove metabolic waste products from the
blood. In addition, the kidneys regulate the levels of electrolytes and the acid-
base balance of the blood. Blood enters the kidneys and then goes into the
nephrons. Each nephron initially filters the blood to remove water, glucose,
amino acids, sodium chloride, and urea. In later sections of the nephron, those
chemicals are selectively reabsorbed in order to maintain the appropriate balance
in the bloodstream, while poorly reabsorbing waste products so they can be
excreted from the body.
The nephrons produce urine to remove those waste products. The urine produced by
the nephrons travels through ducts, and eventually these ducts all connect to the
ureter. The ureter empties the collected urine into the bladder. The urine then
leaves the bladder through the urethra to complete the excretion of urine from
the body.
Reference:
Engineering Standards, Elseiver Inc., New York, 2012, page 197
Q726EXPL
The primary role of the kidneys is to remove metabolic waste products from the
blood. In addition, the kidneys regulate the levels of electrolytes and the acid-
base balance of the blood. Blood enters the kidneys and then goes into the
nephrons.
Each nephron contains a structure known as a Bowman’s capsule. Inside that

capsule, there is a dense capillary network called the glomerulus. It is in the
glomerulus where small molecules such as water, glucose, amino acids, sodium
chloride, and urea are filtered from the blood due to hydrostatic pressure. This
fluid is known as the glomerular filtrate.
In later sections of the nephron (the peritubular capillaries), those chemicals

are selectively reabsorbed in order to maintain the appropriate balance in the
bloodstream, while waste products are poorly reabsorbed so that they can be
The nephrons produce urine to remove those waste products. The urine produced by
the nephrons travels through ducts, and eventually these ducts all connect to the
ureter. The ureter empties the collected urine into the bladder. The urine then
leaves the bladder through the urethra to complete the excretion of urine from
the body.
(Source: http://commons.wikimedia.org/wiki/File:Physiology_of_Nephron.svg, use of
image licensed under Creative Commons Attribution-Share Alike 3.0 Unported
license via Wikimedia Commons, image author: Madhero88)
Reference:
Engineering Standards, Elseiver Inc., New York, 2012, page 197
Q727EXPL
The gallbladder is a flask-shaped organ that stores about 50 ml (in adults) of
bile. It lies below the right lobe of the liver and is attached to the liver by
connective tissue. Bile, produced in the liver, emulsifies (breaks down) fats and
neutralizes acids in partly digested food. The gallbladder receives and
concentrates bile from the liver, and releases bile into duodenum (the part of
the small intestine immediately after the stomach) to further digest food there,
especially food containing fat. The concentrated bile is released when food
containing fat enters the digestive tract. The presence of fats in the duodenum
stimulates the duodenum wall to secrete the hormone cholecystokinin (CCK). CCK
then stimulates gallbladder to contract, releasing bile.
The pancreas is also an organ in the digestive system, as well as being an

endocrine system organ. As part of the digestive system, it produces pancreatic
juice, which contains enzymes that help digest carbohydrates, proteins and
lipids.
The kidneys are responsible for filtering blood to remove waste products, such as
urea. The kidneys produce urine, which is then stored in the bladder and later
The spleen is part of the circulatory system. It acts to remove old red blood
cells from the bloodstream and stores those old cells as a reserve if needed,
such as in the case of hemorrhagic shock. The spleen also plays a role in the
immune system. It produces antibodies, which attach to bacteria. The antibody-
coated bacteria are trapped in the spleen, where they are destroyed.
References:
[1] Standring, Susan, et al., Gray's Anatomy, Fortieth Edition, Churchill
Livingstone/Elsevier, Edinburgh, 2008, pages 1177-1178, 1183-1184, 1191-1192,
1225-1230
[2] Gallbladder, http://en.wikipedia.org/wiki/Gallbladder, retrieved May 2, 2015
Q729EXPL
Bile is a chemical produced by the liver. Bile aids in the digestion of fats by
emulsifying fats in the small intestine and neutralizing acids in partially
digested food. After the liver manufactures bile, it travels via the hepatic duct
to the gallbladder, which stores bile. When fats are present in the small
intestines, the gallbladder contracts and forces bile into the small intestine.
The stomach is also part of the digestive system. After food is swallowed, it
travels down the esophagus into the stomach, where the food is mixed with stomach
acid to continue the digestive process started in the mouth. The stomach releases
partially digested food into the small intestine, where most of digestion takes
place, and where the nutrients released by the digested food are released into
the bloodstream.
References:
[1] Standring, Susan, et al., Gray's Anatomy, Fortieth Edition, Churchill
Livingstone/Elsevier, Edinburgh, 2008, pages 1177-1178
[2] Human Digestive System, Wikipedia,
http://en.wikipedia.org/wiki/Digestive_system, retrieved October 24, 2014
Q2024EXPL
The surface area of the skin of an adult human is approximately 20 square feet
(approximately 1.9 m2), which makes the skin one of the largest human organ
systems.
The human skin is the outer covering of the body. In humans, it is the largest
organ of the integumentary system. The integumentary system includes skin, hair,
and nails. Among other functions, the skin and other parts of the integumentary
system serve to protect the body from infections as well as to waterproof,
cushion, and protect the deeper tissues. It participates in excreting wastes and
regulating temperature. It also serves as the attachment site for sensory
receptors used to detect pain, sensation, pressure, and temperature.
References:
[1] Picture of the Skin, https://www.webmd.com/skin-problems-and-
treatments/picture-of-the-skin#1, retrieved September 3, 2018.
[2] Human Skin, https://en.wikipedia.org/wiki/Human_skin, retrieved September 3,

2018.
[3] Integumentary System, https://en.wikipedia.org/wiki/Integumentary_system,

retrieved September 3, 2018.
Q2025EXPL
Human skin has three layers:
- Epidermis: the outermost layer of skin, which provides a waterproof barrier and
creates our skin tone.
- Dermis: beneath the epidermis, it contains tough connective tissue, hair
follicles, and sweat glands.
- Hypodermis: the deeper subcutaneous tissue, which consists of fat and
connective tissue.
Hypodermic is an adjective that means below (hypo) the skin (dermis). A

hypodermic needle is used to inject medication beneath the skin.
Dermatitis is a noun that means inflammation (itis) of the skin (dermis).

Dermatitis is a general term for skin inflammation.
Dermatology is a noun that refers to the study (ology) of the skin (dermis). A
dermatologist is a medical doctor who uses scientific knowledge to treat skin
problems.
Subcutaneous refers to something happening under the skin. A subcutaneous

injection would be an injection given under the skin. It is a synonym for
hypodermic.
Reference:
[1] Picture of the Skin, https://www.webmd.com/skin-problems-and-
treatments/picture-of-the-skin#1, retrieved September 3, 2018.
Q2039EXPL
The pupil is a hole through which the eye's interior can be viewed.
During an eye examination (funduscopy), the ophthalmoscope is the instrument used

to inspect the interior of the eye. The ophthalmoscope directs a bright light
through the pupil of the eye by bouncing light from a light bulb against a mirror
or prism so it is directed into the interior of the eye.
For a more comprehensive eye exam, a patient's pupil will be dilated (opened
wider) using a medicated eye drop to allow better visualization of the structures
at the back of the eye, including the retina, optic disk, retinal blood vesses,
macula, and choroid. The light shined into the eye reflects off of these
structures and can then be viewed by a clinician through the optics of the
ophthalmoscope. The ophthalmoscope is particularly useful as a screening tool for
various ocular diseases and irregularities.
The iris is the colored portion of the eye. Muscles in the iris can contract or
relax to allow less or more light into the eye.
The cornea of the eye is the front of the eye. It covers the iris, pupil, and
anterior chamber of the eye. It, along with the lens, serves as an optical system
that focuses light coming into the eye on the retina.
The lens is a structure behind the cornea that helps to focus light coming into
the eye on the retina. Muscles in the eye are used to change the shape of the
lens to help focus light coming from objects at different distances.
The retina is the light-sensitive layer of cells found at the back of the eye.
When light is focused on the retina, the many cells in the retina are activated
to allow the individual to see what is in front of the eye. The retina contains
specialized cells that allow vision under dim lighting conditions (rods, used
mainly for black-and-white images), as well as other cells that allow color
vision under brighter lighting conditions (cones).
References:
[1] Ophthalmoscopy, https://en.wikipedia.org/wiki/Ophthalmoscopy, retrieved
September 10, 2018.
[2] Ophthalmoscope, https://www.britannica.com/technology/ophthalmoscope,

[3] Iris (anatomy), https://en.wikipedia.org/wiki/Iris_(anatomy), retrieved

September 10, 2018.
{4} Cornea, https://en.wikipedia.org/wiki/Cornea, retrieved September 10, 2018.
[5] Lens (anatomy), https://en.wikipedia.org/wiki/Lens_(anatomy), retrieved

September 10, 2018.
[6] Retina, https://en.wikipedia.org/wiki/Retina, retrieved September 10, 2018.
Q2075EXPL
Cystometric studies measure the pressure inside of the bladder to see how well
the bladder is working. During cystometry, the bladder is filled with water to
measure its ability to hold in and push out the water. A small tube (catheter)
may be placed in the patient's rectum to measure pressure as the bladder fills. A
small pad or needle may be placed near the patient's anus to measure muscle
function in this area. Pressures, flow rate, total bladder volume, residual
volume and other measurements are made in order to determine if the bladder and
bladder sphincter are functioning normally.
Cystometric studies are also called cystometrograms or CMGs.
Cystometry is one of the tests that might be done at the request of a urologist
to determine the performance of the bladder. Cystometric studies determine the
volume of the fluid the bladder can hold, and how the bladder responds to
pressure buildup. A related test is uroflowmetry, which measures the speed and
volume of the urine flow as the bladder expels the urine it has been holding.
Cystometric testing does not determine the quantity of cysts on a person's skin.
These tests also do not determine the chemical composition of the urine that is
produced by the kidneys and held by the bladder.
Cystometric testing also does not involve any part of the gastrointestinal tract.
Therefore, it does not involve eiter the swallowing pressure or any component of
the ability of the stomach to do its job.
References:
[1] Cystometry: Test Overview,
https://myhealth.alberta.ca/Health/Pages/conditions.aspx?hwid=hw210024, retrieved
December 16, 2018.
[2] Cystometric Study, https://www.healthline.com/health/cystometric-study,

retrieved December 16, 2018.
[3]Why Would I Need a Urodynamic Test?,

https://www.scinternalmedicine.com/2018/10/26/why-would-i-need-a-urodynamic-test,
Electronic & electricity
Q079EXPL
For a capacitor, the voltage across it cannot change instantaneously; however, the current flowing through the capacitor
can. (This is the complement to an inductor, which can have the voltage across it change instantaneously, but not the
current.)
For this reason, changes in current must occur before any change in voltage can take place for a capacitor.
The current through a capacitor is found by differentiating the voltage across it. If a sine wave voltage is used as the
voltage driving the circuit, then the current flow will be represented by a cosine wave. (The derivative of a sine is a
cosine.)
At 0o, the value of a sine is 0, which then rises to 1 at 90o. The value of the sine drops to 0 at 180o, reaches -1 at 270o,
and returns to 0 at 360o. At 0o, a cosine has a value of 1. This drops to 0 at 90o, then -1 at 180o. Since the cosine for a
given angle reaches the value that the sine will reach 90o later, the cosine is leading the sine by 90o. Therefore, the current
through a capacitor leads the voltage across a capacitor by 90o.
Reference: Principles of Electric Circuits, 9th edition, Thomas L. Floyd, Prentice Hall, 2010, Chapter 12
Q080EXPL
For two inductors in parallel, the equation used to find the total inductance is:
L = (L1 X L2) / (L1 + L2)
In this case,
L = (2 X 3) / (2 + 3)
L=6 /5
L = 1.2 henrys
Q081EXPL
CMRR refers to common-mode rejection ratio. It describes the relative amplification of a differential voltage across the
terminals of an amplifier, compared to a common-mode voltage applied simultaneously to both terminals of an amplifier.
CMRR can be expressed as either a ratio or in decibels (dB).
The equation for the calculation of voltage gain in decibels is:
dB = 20 log (V2 / V1)
By setting V2 equal to the differential voltage, and V1 equal to the common mode voltage, we can convert the dB value to
a ratio by keeping in mind the meaning of logarithms.
logab = c
is equivalent to saying: ac = b
That is, the logarithm function gives us the exponent, in this case c. When we raise the base (a) to the power of c, we get
b. For dB calculations, the base 10 is used. Applying this to the formula above gives us:
dB = 20 log (Vdiff / Vcm)
(dB / 20) = log (Vdiff / Vcm)
This can be transformed to:
10(dB/20) = (Vdiff / Vcm)
In this case:
V2 / V1 = 10(86 / 20)
V2 / V1 = 10(4.3)
V2 / V1 = 20,000
Therefore, the ratio of the differential voltage to the common mode voltage is 20,000:1.
A simple way to analyze decibels is to remember that 20 dB is equivalent to multiplying by 10, and 6 dB is equivalent to
multiplying by 2.
Therefore, 86 dB is equivalent to multiplying by 10 X 10 X 10 X 10 X 2, which is equal to 20,000.
References:
[1] http://www.allaboutcircuits.com/vol_5/chpt_4/6.html (accessed 12/29/11)
[2] Electronic Devices, Conventional Current Version, 9th edition, Thomas L. Floyd, Prentice Hall, 2012, Chapter 12
Q082EXPL
Resolution is the smallest voltage increment that can be represented with the number of bits being used. Note that it is not
the number of levels that can be represented, but the step size, or change in output, when we increment by one bit. A
digital-to-analog converter has a resolution of [1 /(2n - 1)] where n is the number of bits. This formula is often
approximated as (1 / 2n). This approximation will give an error of less than 1% for 7 or more bits, but for a small number
of bits, the error can be quite significant.
Consider a two-bit D/A converter. A voltage of 0 would be represented by the bits 00. If a 1volt level were represented by
the bits 11, then a voltage of 0.33 volts would be represented by 01, and 0.67 volts would be represented by 10. Each
increment represents a step of 0.33 volts. We can express the resolution in terms of the step size itself or in terms of
percent resolution. Percent resolution is the step size divided by the full scale voltage, in this case, 0.33 V / 1.00 V, or
33%. Similarly, a three-bit converter would have 8 levels, giving 7 transitions, and a resolution of 1/7 or 0.143 or 14.3%.
That is, it can measure increments as small as 14.3% of the full range being measured.
A seven-bit convertor would have 128 levels. The resolution is 1/127, or 0.0079 or 0.79%.
Reference: http://www.allaboutcircuits.com/vol_4/chpt_13/10.html (accessed January 4, 2012)
Q083EXPL
At resonance, the inductive reactance in a circuit cancels the capacitive reactance, leading to a very low impedance for
the circuit.
In a series-tuned LC circuit, at resonance, the current is limited only by the resistance in the circuit. Because of this, the
current flow may be very large. This current flowing through the inductor and capacitor will cause large changes in the
voltage across these circuit elements. However, because the voltages across these elements will be opposite in polarity,
the total voltage across the circuit (the applied voltage) can be less than the voltage across either the capacitor or the
inductor.
Q084EXPL
The resonant frequency of an LC circuit is the frequency at which the impedance of the inductor is equal to the
impedance of the capacitor. At this frequency, the circuit impedance is purely resistive.
The equations for inductive impedance and capacitive impedance are:
XL = 2 X Π X f X L
XC = 1 / (2 X Π X f X C)
If these are equated, solving for the frequency yields the result:
f = 1 / (2 X Π X square root(L X C))
In this case:
f = 1 / (2 X 3.14 X square root(600 X 10-6 X 200 X 10-12))
f = 1 / (6.28 X square root(1.2 X 10E-13))
f = 1 / (6.28 X 3.46 X 10-7)
f = 1 / 2.18 X 10-6
f = 460,000 hertz
f = 460 kilohertz
Reference: Principles of Electric Circuits, 9th edition, Thomas L. Floyd, Prentice Hall, 2010
Q085EXPL
Impedance matching requires a turns ratio that is equal to the square root of the impedance ratio. That is:
Turns ratio = square root(Zp / Zs)
where Zp is the impedance on the primary side of the transformer, and Zs is the impedance connected to the secondary
side of the transformer.
In this case:
Turns ratio = square root(8100 / 900)
Turns ratio = square root(9)
Turns ratio = 3
Therefore, the turns ratio of the transformer must be 3 to 1 to properly match the impedances given.
Reference: Principles of Electric Circuits, 9th edition, Thomas L. Floyd, Prentice Hall, 2010
Q086EXPL
A silicon-controlled rectifier (SCR) is a 4-layer PNPN device used as a diode (rectifier) which can be turned on by a
positive voltage applied to its gate. The terminology used to describe the SCR's terminals is similar to that for a diode,
with an anode and cathode, along with an additional terminal known as the gate.
Like a normal diode, in order for the SCR to conduct, the anode must be more positive than the cathode. However, SCRs
are typically selected so that the breakover voltage (the voltage at which the SCR will begin to conduct without triggering)
is well above the voltages normally seen in the circuit. Conduction is triggered when a positive voltage pulse is applied to
the gate, resulting in a gate current which turns the SCR on.
The connection between the gate and cathode is equivalent to that between the base and emitter of an NPN transistor. In
order to start conduction of that type of transistor, the bias applied to the base must be positive (with respect to the
emitter). For the SCR to start conducting, similar conditions apply, with the gate positive with respect to the cathode.
Because the SCR will continue conducting once triggered, only a pulse is needed to activate the device. Conduction will
stop once the anode becomes negative with respect to the cathode. At that time, to restart conduction, a new trigger pulse
must be applied to the gate.
References:
[1] Electronic Devices, Conventional Current Version, 9th edition, Thomas L. Floyd, Prentice Hall, 2012, Chapter 11
[2] http://www.allaboutcircuits.com/vol_3/chpt_7/5.html (accessed 12/29/11)
Q087EXPL
Assuming the transistor is properly biased, the base-emitter junction must be forward biased.
For an NPN transistor, this means the base voltage will be more positive than the emitter voltage.
The base current will continue to increase as the base voltage becomes more positive.
If the base voltage goes too far in the positive direction, the transistor will saturate.
At that point, the collector current will have reached its maximum value, and further increases in base current will not
result in an increase in collector current.
However, as the base voltage drops there is a corresponding drop in base current, which causes the collector current to
drop as well. If the base voltage drops too low, the base-emitter junction will no longer be forward biased, and the
transistor will go into cutoff.
Reference: Electronic Devices, Conventional Current Version, 9th edition, Thomas L. Floyd, Prentice Hall, 2012, Chapter
4
Q088EXPL
The amplifier circuit is shown below:
The left side shows the internal block diagram for the amplifier, with a gain of A, and an output impedance of R0. The
right side shows the external connections to the amplifier, with a load resistance is R1, and an output voltage of VO across
it.
For the problem given, the voltage gain, A, is 60, and Vin = 100 millivolts. This means that:
V' = A X Vin
V' = 60 X 100 mV
V' = 6000 mV
V' = 6 volts
The output voltage, VO, is now determined by the voltage divider produced by RO (4.0 kilohms) and R1 (8.0 kilohms).
VO = V' X R1 / (RO + R1)
VO = 6 X 8 / (4 + 8)
VO = 48 / 12
VO = 4 volts
6
Q089EXPL
A diode will conduct when the anode is positive, with respect to the cathode. This is the forward biased condition. The
diode will have a very high resistance when the anode is negative with respect to the cathode. This is the reverse biased
condition.
The peak inverse voltage (also sometimes called the peak reverse voltage) rating tells the maximum voltage that can
safely be placed across the diode when it is reverse biased.
There are two reverse ratings. VRRM refers to repetitive application of a voltage, such as would occur in a power supply
circuit where the diode is subject to both the positive and negative cycles of an AC input. VR is the relevant rating for a
continuous (DC) reverse voltage.
References:
http://www.allaboutcircuits.com/vol_3/chpt_3/3.html (accessed 12/28/11)
Electronic Devices, Conventional Current Version, 9th edition, Thomas L. Floyd, Prentice Hall, 2012, Chapter 2
Q090EXPL
Electric current is a measure of the number of charged particles flowing past a particular point over a period of time.
Electric current can flow whenever freely moving charged particles are available in a medium.
In solids, such as conductors and semiconductors, the atoms remain in fixed positions, and only electrons can move freely.
Thus, in solids, electric current flow consists of the flow of electrons. Solids made of atoms with loosely bound electrons,
such as copper and silver, are good conductors of electricity.
In liquids and gases, the atoms can move about easily. An atom with a charge is an ion. So in liquids and gases, electric
current consists of the flow of ions.
Liquids with a high concentration of ions are good conductors. Strong acids and bases have many free ions, and are good
conductors.
Liquids with salts dissolved in them can also conduct current. Conductivity of the dialysate is used to monitor salt
concentration in dialysis machines.
Gases which easily ionize are also good conductors. Air, when subject to high voltages, breaks down (forms ions), and
conducts electricity.
For example, this is what happens in a spark plug. Argon beam coagulators also use the relatively low ionization potential
of argon gas as a way of delivering current to a surgical site to stop bleeding.
References:
[1] http://www.mdsr.ecri.org/summary/detail.aspx?doc_id=8172 (accessed January 3, 2012)
[2] http://www.uptodate.com/contents/argon-plasma-coagulation-in-the-management-of-gastrointestinal-hemorrhage
(accessed January 3, 2012).
Q091EXPL
Thermionic emission is the release of electrons by a hot metal. This is what happens in the heated cathode of a vacuum
tube. In an x-ray tube, for example, the mA control determines the amount of current, and therefore the amount of heating,
at the cathode, which in turn determines the number of electrons released by the cathode.
Photometry is the measurement of light intensity.
Conductivity is a measure of how easy it is for electric current to pass through a substance.
Photoelectricity is the release of electrons when an appropriate substance is illuminated by light. This is what happens in a
photoelectric (or solar-powered) cell.
1
Q092EXPL
For resistors in parallel, the total resistance is determined by the equation:
RT = 1 / [ (1/R1) + (1/R2) + (1/R3) ]
In this case:
RT = 1 / [ (1/8) + (1/12) + (1/24) ]
RT = 1 / [ (3/24) + (2/24) + (1/24) ]
RT = 1 / (6/24)
RT = 1 / 0.25
RT = 4 ohms
Q093EXPL
In digital logic, a low output is equivalent to a 0, and a high output is equivalent to a 1.
The truth table for a NAND gate is:
where A and B are the inputs to the gate.

The output of this gate will only be 0 when both inputs are 1 simultaneously. If either input is a 0, the output will be a 1.
Reference: Digital Electronics: A Practical Approach, 8th edition, William Kleitz, Pearson Prentice Hall, 2008, Chapter 3
Q094EXPL
For the symbols shown, the + sign represents a logical OR function, and the multiplication represents a logical AND
function.
To determine this equivalence, the equation in this problem can be rewritten as shown below:
A + B + AB = A + B(1 + A)
A + B + AB = A + B(1)
A + B + AB = A + B
An alternate approach to solving this problem would involve the construction of truth tables.
Comparing the third column and fifth column, it is seen that these are equivalent, again demonstrating that A + B + AB =
A+B
Q095EXPL
To analyze this summing amplifier circuit, the current through each of the input resistors is found separately.
For an operational amplifier (op amp) circuit with negative feedback, the voltage at the inverting input will be the same as
the voltage at the non-inverting input. Because there is no power source at the non-inverting input, the non-inverting input
will be at ground. By the virtual ground principle for an op amp, the inverting input will also be at ground.
The current through the 1 megohm resistor will be:
I1 = (V1 - 0) / 1 MΩ
I1 = (5 V - 0) / 1 MΩ
I1 = 5 / 1 X 106 A
I1 = 5 X 10-6 amperes
The current through the 500 kilohm resistor will be:
I5 = (V2 - 0) / 500 KΩ
I5 = (2 V - 0) / 500 KΩ
I5 = 4 X 10-6 amperes
The current through the 200 kilohm resistor will be:
I2 = (V3 - 0) / 200 KΩ
I2 = (-3 V - 0) / 200 KΩ
I2 = -15 X 10-6 amperes
The total current at the non-inverting input will be:
I = I1 + I5 + I2
I = (5 + 4 - 15) X 10-6
I = -6 X 10-6 amperes
The negative sign for I2 and for the total current indicates that current is flowing from the summing node back through the
resistor network. For an ideal op amp, no current will go into the input terminals, so all this current must go through the 1
MΩ feedback resistor. Because the total current is negative, it means that the current is flowing from the output to the
summing junction.
The voltage at the output can be calculated as the voltage at the summing junction minus the voltage drop across the
feedback resistor. The voltage at the summing junction is zero, so we have:
Vout = 0 - (I X 1 MΩ)
Vout = -(-6) X 10-6 X 1,000,000
Note: The extra negative sign is to account for the direction of the current.
Vout = +6 X 10-6 X 1 X 106
Vout = +6 volts
13
Q096EXPL
For an ideal operational amplifier (op amp) with negative feedback, the voltage at the non-inverting terminal will be
equal to the voltage at the inverting terminal.
In this case, the voltage at the non-inverting terminal is Vin. Therefore, the voltage at the inverting terminal will also be
Vin. The current through the 100 KΩ resistor will be:
I100K = Vin / 100 KΩ
The input impedance of an ideal op amp is infinite, therefore, all the current going through the 100 KΩ resistor must also
go through the 500 KΩ resistor. Therefore,
Vout = [(I100K) X 500 KΩ)] + [(I100K) X 100 KΩ)]
Vout = I100K X 600 KΩ
Substituting for I100K:
Vout = (Vin / 100 KΩ) X 600 KΩ
Vout = Vin X 6
Solving for the circuit gain, Vout/Vin:
Vout/Vin = 6
12.
Q097EXPL
The two's complement of a binary number is found by performing two steps. First, the one's complement is calculated by
changing each 0 to a 1, and each 1 to a 0. The second step involves adding 1 to the resulting number.
In this case, the one's complement of 101101 is 010010.
Adding 1 to this result gives 010011. Taking the two’s complement of a number is the same as changing the sign.
Reference: Digital Electronics: A Practical Approach, 8th edition, William Kleitz, Pearson Prentice Hall, 2008, Chapter 7.
Q098EXPL
***
Q099EXPL
The voltage across the load (VL) can be found using Ohm's law.
VL = I X R
VL = (4 X 10-3 amperes) X (2000 ohms)
VL = 8 volts
The ripple is 5% of the load voltage:
Vr = 0.05 X VL
Vr = 0.05 X 8
Vr = 0.4 volts
Therefore, the value of the ripple voltage in this problem is 0.4 volts.
2
Q100EXPL
For an RC circuit, the value of the voltage across the capacitor can be found using the equation:
Vc = Vin X (1 - exp(-t/RC))
where Vc is the voltage across the capacitor, Vin is the input voltage to the circuit, and t is the time elapsed since the
voltage was applied to the circuit.
For this equation, at t = 0, the exponential terms is 1, making Vc = 0. At t = infinity, the exponential term approaches zero,
so that Vc = Vin.
RC (the resistance value multiplied by the capacitance value) is known as the time constant. During a time equivalent to
one time constant, the capacitor will charge to 63% of the final value. If time equal to a second time constant passes, the
capacitor will charge to 87% of its final value, and so on, as shown in the chart below. By the time five time constants
have passed, we assume that the capacitor is fully charged.
Reference: Principles of Electric Circuits, 9th edition, Thomas L. Floyd, Prentice Hall, 2010, Chapter 12.
Q101EXPL
For a common base circuit, the output current is in phase with the input current.
For a common emitter circuit, the output current is out of phase with the input current.
For the common collector circuit, the output current is in phase with the input current.
The emitter follower circuit is another name for the common collector circuit.
6
Q102EXPL
The color code for resistors is shown below:
The first three bands are described by the color scheme below:
The fourth band, if there is one, describes the tolerance, as shown below:
The first two bands are used to determine the significant figures. In this case, blue = 6 and white = 9. The third band
determines the multiplier. Green represents five zeros that should be added to the ends of the first two figures, so the
resistance is 6,900,000 ohms.
The fourth band describes the tolerance. In this case, silver, representing a tolerance of +/- 10%.
Reference: Principles of Electric Circuits 9th edition, Thomas L. Floyd, Prentice Hall, 2010, Chapter 2.
Q103EXPL
Power in a resistive circuit can be determined by the equation:
P = V2 / R
The resistance can be found by rearranging the equation to yield:
R = V2 / P
In this case:
R = (12)2 / 1.2
R = 144 / 1.2
R = 120 ohms
Q104EXPL
The equations for power are:
P = I2 X R
and
P = V2 / R
First, solving for the current flow:
I = square root(P / R)
I = square root(16 / 4)
I = square root(4)
I = 2 amperes
Next, solving for the voltage:
V = square root(P X R)
V = square root(16 X 4)
V = square root(64)
V = 8 volts
Q105EXPL
The circuit under consideration is shown below:
The output voltage can be found from the equation:
Vo = Vin (R2 / (R1 + R2))
If R2 increases, Vo will also increase.
Q106EXPL
The resistors are arranged in such a way as to reduce the supply voltage to the levels needed in the circuit. The voltage
drop across each resistor is determined by the current through that resistor. Thus, the circuit is dividing the input voltage
on the left side of the circuit to produce multiple output voltages (on the right side of the circuit). In general, the load
impedance must be significantly higher than the voltage divider's resistance values to prevent drawing off enough current
to affect the delivered voltages.
Because of the current limitations of a voltage divider, it is not a useful replacement for a power supply in most circuits.
Q107EXPL
Kirchoff's Current Law addresses the current in a circuit. It states that the current flowing into a node or branching point
is equal to the sum of the individual currents leaving the node or branching point.
Kirchoff's Voltage Law describes the voltage in a circuit. It states that the sum of the voltages in a closed current loop is
equal to zero.
Reference: Principles of Electric Circuits, 9th edition, Thomas L. Floyd, Prentice Hall, 2010, Chapters 5 and 6
Q108EXPL
The time constant (Τ) for an RC circuit (one consisting of a resistor and a capacitor) is equal to RC.
The voltage across the capacitor for an RC circuit where the capacitor starts from zero volts and charges up to the input
voltage can be described by:
Vc = Vin X (1 - e(-t/Τ))
If the capacitor discharges to zero, the capacitor voltage can be described in terms of its starting voltage V0 by:
Vc = V0 X e(-t/Τ)
The time constant for an RL circuit (one consisting of a resistor and an inductor) is equal to L/R.
In an inductive circuit, the current changes exponentially, just as the voltage across a resistor does in an RC circuit. The
voltage across the resistor of an RL circuit (which is proportional to the current by Ohm's Law) can be described by
formulas like the ones used for RC circuits. If the initial voltage across the resistor is zero at the instant a voltage is
applied, the resistor voltage can be described by:
Vr = Vin X (1 - e(-t/Τ))
If the input voltage is removed, the current through the circuit, and therefore the voltage across the resistor, will decay
exponentially and can be described by:
Vr = V0 X e(-t/Τ)
Reference: Principles of Electric Circuits, 9th edition, Thomas L. Floyd, Prentice Hall, 2010, Chapters 12 and 13.
Q109EXPL
For an RL circuit, if we start with a steady state current, we can determine the current at time t using the equation:
Where It is the current at time t, and Ii is the initial (or steady state) current. When t = zero, the exponential term reduces
to 1, and the current is equal to the initial current. As t increases, the exponential gets smaller. As t approaches infinity, the
current approaches zero.
L/R is the time constant. For any circuit like this, the following relations apply:
Thus, by the time we reach 5 time constants, the current is at 99% of its final value. In this case, the final value would be
zero.
Q110EXPL
For an LC circuit, the resonant frequency is given by:
f = 1 / (2Π X square root(LC))
Rearranging terms, it can be shown that the inductance can be found to be:
L = 1 / (4Π2 X f2 X C)
In this case, the inductance is:
L = 1 / (4 X (3.14)2 X (100 X 103)2 X (25 X 10-12)
L = 1 / (4 X 9.86 X 1 X 10 10 X 25 X 10-12)
L = 1 / (986 X 102)
L = 0.101 henrys
L = 101 millihenrys.
Q111EXPL
The truth table for an AND gate is shown below:
The truth table for an OR gate is:
The truth table for a NAND gate is:
The truth table for an Exclusive-OR gate is:

Q112EXPL
A NOT gate has the truth table shown below:
That is, the output is the inverse of the input. Therefore, a NOT gate is the same as an inverter.
Q113EXPL
In operation, a transistor has its base-emitter junction forward biased, and its base-collector junction reverse biased. For an
NPN transistor (the type of transistor shown in this drawing), current flows into the base and collector leads, and flows out
of the emitter lead.
Thus, the emitter current is equal to the sum of the base and collector currents, and it is the largest current. The base
current is typically much smaller than the emitter current, so it is sometimes convenient to approximate the collector
current as being equal to the emitter current, but in fact it is slightly smaller.
4.
Q115EXPL
RAM is Random Access Memory. This is usually semiconductor memory used to store information in a computer.
However, RAM will only keep information as long as there is power on the device. Once power is turned off, all the
information inside the RAM is lost. RAM allows new information to be written into the memory as that information is
generated by the computer program. Therefore, RAM is only used for temporary storage.
RAM is described as a volatile device, in that the information inside it will only remain while there is power on the
device. However, it is not correct terminology to say that it is used for volatile storage.
Reference: Digital Electronics: A Practical Approach, 8th edition, William Kleitz, Pearson Prentice Hall, 2008, Chapter
16
Q116EXPL
The logic equation for gate 1, a NAND gate, is:

E = NOT(AB)
The logic equation for gate 2, an OR gate is:
F=C+D
The logic equation for gate 3, an OR gate, is:
G=E+F
Substituting:
G = NOT(AB) + (C + D)
G = NOT(AB) + C + D
Q117EXPL
A transistor with an arrow pointing from the emitter into the base is a PNP transistor. As with any transistor, for it to
work correctly, the base-emitter junction must be forward biased, and the base-collector junction must be reverse biased.
The base-emitter junction of a PNP transistor will be forward biased when the emitter is positive with respect to the base.
The base-collector junction will be reverse biased when the collector is negative with respect to the base.
Note that because the supply voltage is negative with respect to ground, these bias conditions are met, so this circuit does
show a correctly biased PNP transistor circuit.
Electronic Devices, Conventional Current Version, 9th edition, Thomas L. Floyd, Prentice Hall, 2012, Chapter 5
Q118EXPL
The symbol shown represents a silicon-controlled rectifier (SCR). It is also known as a thyristor. Like other diodes, it will
conduct in only one direction. Unlike standard diodes, it incorporates a third terminal, the gate, which is used to turn the
SCR on by applying a positive voltage between the gate and cathode. Once triggered, the SCR will continue to conduct,
even with no voltage on the gate, as long as the anode is positive with respect to the cathode. An SCR can be used to
control the high current levels generally found in devices, such as heating elements, light dimmers, and over-voltage
protection circuits.
11
Q119EXPL
Gate A is a NAND gate, gate B is an OR gate, gate C is an AND gate, and gate D is a NOR gate.
The inputs to gate A are a 1 and a 0, so the output will be a 1.
The inputs to gate B are a 1 and a 0, so the output will be a 1.
The inputs to gate C are a 1 (from gate B) and a 1, so the output will be a 1.
The inputs to gate D are a 1 (from gate A) and a 1 (from gate C), so the output will be a 0.
Q120EXPL
A comparator is used to compare two voltages, and provide a logic state output value that indicates the magnitude
relationship between the input voltages.
If the voltage on the non-inverting input is positive with respect to the inverting input, then the output of the comparator
will be at its most positive value. Conversely, if the voltage on the non-inverting input is negative with respect to the
inverting input, then the output of the comparator will be at its most negative value.
The most positive value of the output will be the positive saturation voltage, +Vsat. The most negative value of the output
will be the negative saturation voltage, -Vsat.
13.
Q121EXPL
The input to a voltage follower goes to the non-inverting input. All of the output is fed back to the inverting input,
resulting in a gain of 1. Therefore, the output voltage will be exactly the same as the input voltage. The circuit has very
high input impedance, and very low output impedance. These characteristics make it useful as a buffer amplifier between
sources that have a high impedance with loads that have low impedance.
12.
Q122EXPL
A synchronous logic circuit is one that only changes state at specific times.
In order for this to happen, the logic devices must be driven by a clock circuit. The output logic states will only change
when a clock pulse occurs.
Note that all computers and monitors that are part of an enterprise system must by synchronized together, thus they must
all operate from the same clock.
12.
Q123EXPL
Unused inputs in different logic families may float to different values. In TTL, for example, an unused input will
generally assume a high value. However, noise can "leak" into the input circuitry, and cause it to assume an indefinite
state. For this reason, all unused inputs should be tied to a fixed logic level so that the circuit's proper operation can be
assured.
Where A and B are the inputs to the gate.

The output of this gate will be 0 only when both inputs are 1 simultaneously. If either input is a 0, the output will always
be a 1. Therefore, to assure proper operation of the gate, unused inputs should be tied to 1.
Q124EXPL
A piezoelectric crystal produces a voltage in response to physical force imposed on it, and deforms when a voltage is
placed on it.
A typical application for a piezoelectric crystal is in an ultrasound application. The crystal can be excited with a high
frequency square wave voltage, producing pulses of ultrasonic vibrations directed into a body. Reflections from within the
body can then be detected with the same crystal, which will produce voltages in response to the received ultrasonic wave
energy. Alternately, an ultrasound transducer can have two piezoelectric crystals. One of the crystals has a continuous
voltage applied to produce ultrasonic vibrations, which are directed into the body. The second crystal is then used to
receive the reflected ultrasonic vibrations.
Reference: Carr, Joseph J., and Brown, John M., Introduction to Biomedical Equipment Technology, Prentice Hall, 2001,
Chapter 17.
Q125EXPL
A MOSFET contains a very thin piece of insulating glass between the gate and the source-drain channel. By applying
appropriate voltages to this gate, an electric field is created that can cause the source-drain current to increase or decrease.
Because of the insulator at the gate, the device has an extremely high input impedance, so virtually no gate current is used
to drive the MOSFET.
8.
Q126EXPL
In digital logic, a low input is equivalent to a 0, and a high input is equivalent to a 1.
The truth table for an OR gate is:
The output of this gate will only be 0 when both inputs are 0 simultaneously. If either input is a 1, the output will be a 1.
Q127EXPL
RAM, or Random-Access Memory, comes in two major configurations.
Dynamic RAM stores bits as a charge on a capacitor. Because this charge leaks off over time, the memory must be
refreshed periodically to prevent the loss of information.
Static RAM stores bits in flip-flops. Once a bit is stored in a flip-flop, it will remain there, until the power to the flip-flop
is turned off.
The advantage that dynamic RAMs have over static RAMs is they can be made significantly more densely, and they are
easier to manufacture, making them less expensive. Static RAMs, in addition to not needing to be refreshed, also have
much faster access times than dynamic RAMs.
RAM is also described as being volatile, which means that the information stored in the device is lost once power is
turned off.
ROM is Read-Only Memory, (which is different from RAM), which is used to store information permanently.
16.
Q128EXPL
Load regulation describes the ability of a power supply to maintain a constant output voltage under varying loads.
Under a no-load condition, the load does not require any current. Under full-load condition, the load requires the
maximum amount of current that can be delivered by the power supply.
Source regulation describes the ability of the power supply to maintain a constant output voltage when the input line
voltage changes.
3.
Q129EXPL
In normal operation, a bipolar junction transistor operates with its base-emitter (BE) junction forward biased, and its
collector (BC) junction reverse biased. If the base-emitter junction (BE)is reverse biased the transistor will be in cut-off.
Forward biasing the BE junction will turn the transistor on.
The beta of a transistor is a measure of the ratio of a change in its collector current to a change in base current. Because it
is a ratio, beta is a pure number and does not have units.
A transistor acts as an amplifier, with a relatively small base current controlling much larger collector and emitter
currents.
4.
Q130EXPL
The common-mode rejection ratio of an amplifier is the ratio of its differential voltage gain to its common-mode voltage
gain.
In this case, the differential voltage gain, Ad is:
Ad = 10 volts / 10 millivolts
Ad = 10,000 millivolts / 10 millivolts
Ad = 1,000
Similarly, the common-mode voltage gain, Acm is:
Acm = 1 millivolt / 10 millivolts
Acm = 0.1
The common-mode rejection ratio, CMRR, is:
CMRR = Ad / Acm
CMRR = 1,000 / 0.1
CMRR = 10,000
This can be converted to decibels by the equation:
CMRR' = 20 X log (CMRR)
CMRR' = 20 X log (10,000)
CMRR' = 20 X 4
CMRR' = 80 decibels
CMRR' = 80 dB
6.
Q131EXPL
To find the voltage drop across the load resistor, the collector current must be determined.
The collector current will be approximately equal to the emitter current.
To find the emitter current, the base voltage must first be found. Assuming the circuit is designed properly, so that the
base current is negligible, then the 18 K resistor and the 2.2 K resistor form a voltage divider.
The voltage at the base is:
VB = Vcc X 2.2 / (18 + 2.2)
VB = 12 X 2.2 / 20.2
VB = 1.3 volts
To find the emitter current, the emitter voltage is determined. The base-emitter voltage drop will be about 0.7 volts when
the transistor is active, so:
VE = VB - 0.7
VE = 1.3 - 0.7
VE = 0.6 volts
The emitter current will be:
IE = VE / 100 ohms
IE = 0.6 / 100
IE = 0.006 amperes
IE = 6 milliamperes
Equating the emitter current and the collector current, the voltage drop across the load resistor will be:
VRL = IC X RL
VRL = IE X RL
VRL = 6 X 1
VRL = 6 volts
5.
Q132EXPL
For a common base circuit, the input voltage is applied between the base-emitter circuit, and the output voltage is taken
across the collector-base circuit. Because the base is common to both the input and the output, the circuit is known as a
common base circuit. The common base configuration has a maximum current gain of 1, although it can have a high
voltage gain. It has a low input impedance and can be utilized in high frequency circuits where there is a need for
impedance matching.
For a common emitter circuit, the input voltage is applied across the base-emitter circuit, and the output voltage is taken
across the collector-emitter circuit. Because the emitter is common to both the input and output, the circuit is known as a
common emitter circuit. A common emitter circuit amplifies well, but its output voltage is very dependent upon the β
(shown by the Greek letter beta) of the transistor, and this value can have a very wide range for a given transistor type.
Various biasing methods can be used to minimize the effect of changes in β to stabilize the output. The common emitter
configuration, and variations upon this, are the most common type of amplifier configuration.
For a common collector circuit, the input voltage is applied between the base-collector circuit, and the output voltage is
taken across the collector-emitter circuit. Because the collector is common to both the input and the output, the circuit is
known as a common collector circuit. The common collector circuit is also known as an emitter follower circuit. The
voltage gain of this circuit is usually close to 1, but it is useful because it has a high input impedance and high current
gain.
While the circuit shown in the diagram does use an NPN transistor, this is only a part of the circuit, and this is not the
name given to the overall circuit.
In this case, the input voltage is applied across the base-emitter circuit, while the output is taken at the collector, across the
collector-emitter circuit, making this a common emitter circuit.
6.
Q133EXPL
A representation of this circuit is shown below:
In order for the NAND gate to have a LOW output, both inputs must be HIGH. Because both inputs come from NOR
gates, we need the conditions where the NOR gate outputs will be HIGH. This occurs when both inputs to a NOR gate are
LOW.
A truth table can be constructed for this circuit.
From this, it can be seen that the only time the output will be 0 (low) is when all of the inputs are 0 (low). That is, none of
the inputs to the NOR gates are high.
Reference: Digital Electronics: A Practical Approach, 8th edition, William Kleitz, Pearson Prentice Hall, 2008.
Q134EXPL
Negative feedback for an operational amplifier circuit offers many advantages.
An operational amplifier without feedback has an extremely high voltage gain. By adding negative feedback, the circuit
gain is reduced, but it can be made virtually constant. The circuit gain is dependent upon the circuit components
surrounding the op amp. In this way, the overall circuit gain can be stabilized.
Op amp circuits without negative feedback have a bandwidth that is narrower than those with negative feedback. In other
words, there is a trade-off between gain and bandwidth.
The input impedance of an op amp circuit without negative feedback is high. With negative feedback, the input
impedance is dependent upon the type of feedback used. For a non-inverting circuit with negative feedback, the input
impedance is increased. For an inverting circuit with negative feedback, the input impedance decreases.
Output impedance will decrease with negative feedback for both inverting and non-inverting amplifiers.
12.
Q135EXPL
The + sign indicates an OR function between the terms in this equation. The truth table for this equation is shown below.
Thus, the output is 1 regardless of the value of A.
Q136EXPL
***
Q137EXPL
If it could be built, an ideal op amp would have the following characteristics:
* infinite differential voltage gain under open-loop conditions,
* infinite input impedance
* zero output impedance
* infinite frequency response (an infinite bandwidth)
Most modern op amps come close to meeting these ideal specifications.
The importance of high input impedance and low output impedance is related to the loading effect. In a voltage divider,
the higher voltage will be across the higher value resistance (or impedance). Consider the case of two amplifier stages. We
would like the output of the first stage to be low impedance and the input of the second stage to be high impedance to
avoid degradation of the signal. If the output impedance of the op amp is about the same as the input impedance of the
following circuitry, then the output voltage of the first stage would decrease, because there would be a significant voltage
drop within the op amp itself.
On the other hand, if the output impedance of the first op amp is very low compared to the input impedance of following
circuitry, then the internal voltage drop within the first op amp would be negligibly small, and almost all of the output
voltage would appear across the input terminals of the second op amp because its input impedance is so much higher than
the output impedance of the first op amp.
12.
Q138EXPL
The truth table for an EXCLUSIVE-OR gate is:
The output of this gate will be 0 only when both inputs are 0 or both inputs are 1. If one input is 0 and the other is 1, then
the output will be 1.
Q139EXPL
A pressure transducer with four strain gauges arranged in a bridge will have two of the gauges undergo compression, and
two undergo extension. When properly arranged, this allows the circuit to have four times the sensitivity of a single strain
gauge.
Reference: http://www.medscape.com/viewarticle/563819 (accessed January 4, 2012).
Q140EXPL
Tri-state buffers are used to send information along a bus. Because many devices are connected to a bus simultaneously,
but only one can be actively sending data at any given time, a method must be used to disconnect transmitting devices
from the bus. This is the function of a tri-state buffer.
When the buffer is active, its output can be either high or low and will be the same as its input, just as with a traditional
buffer. However, when the buffer is inactive, its output goes to a high impedance state, so that it is effectively
disconnected from the bus.
Q141EXPL
Tri-state buffers are used to send information along a bus. Because many devices are connected to a bus simultaneously,
but only one can be actively sending data at any given time, a method must be used to disconnect transmitting devices
from the bus. This is the function of a tri-state buffer.
When the buffer is active, its output can be either high or low and will be the same as its input, just as with a traditional
buffer. However, when the buffer is inactive, its output goes to a high impedance state, so that it is effectively
disconnected from the bus.
Q142EXPL
The resonant frequency of a circuit is only dependent upon the inductive and capacitive elements in the circuit. It is
completely independent of the resistance in the circuit.
However, increasing the resistance of the circuit, while it does not change the resonant frequency, will change the Q of the
circuit. This is a measure of the sharpness with which the circuit will resonate. A circuit with a high resistance will have a
low Q and will demonstrate a broad range over which the current will change as the frequency approaches the resonant
frequency. A circuit with a low resistance will have a high Q, and the range over which the current changes will be very
narrow by comparison.
Q143EXPL
In the inverting configuration, the inputs of an op amp are both at ground voltage, because of the virtual ground principle
that an op amp operates under.
In this configuration, the input signal is applied to the inverting input through a resistor. Therefore, the resistance to
ground seen by an input signal is equal to that resistance, because one side of the resistor is at the input signal voltage, and
the other side is at ground.
Reference: Malvino, Albert Paul, Electronic Principles, 4th edition, McGraw-Hill Book Company, 1989, pages 764 – 767.
Q144EXPL
A crowbar circuit is used to protect components from damaging voltages by shorting the output of the power supply,
which then typically blows a fuse.
A discriminator circuit is used by an FM receiver to convert the FM signal to an AM signal, which can then be processed
to detect the information on the signal.
A swamping circuit is a type of amplifier that uses a feedback emitter resistor as part of a common emitter circuit to
provide negative feedback, which makes the voltage gain of the amplifier much more stable than it would otherwise be.
A watchdog circuit waits for a certain event to occur within a given time period, and if it does not, takes actions to disable
or reboot the device. A typical use for a watchdog circuit is in an infusion pump. If the pump motor does not make a step
in a specified time period, the watchdog circuit assumes that a fault condition exists, and shuts down the pump, generating
an alarm. Embedded microprocessor systems use watchdog circuits. If the system fails to restart the watchdog timer, thus
allowing the timer to compete its count-down, the watchdog sends a reset signal to the processor.
References: http://www.allaboutcircuits.com/vol_3/chpt_7/5.html (accessed 11/26/2011)
http://www.eetimes.com/discussion/beginner-s-corner/4023849/Introduction-to-Watchdog-Timers (accessed 11/26/2011).
Q145EXPL
The reactance of an inductor is given by the equation:
XL = 2 Π f L
Solving for the frequency gives:
f = XL / 2 Π L
In this case:
f = 425 / (2 X 3.14 X 10 X 10 -3)
f = 425 / (0.0628)
f = 6,768 hertz
Q146EXPL
The binary number system is based on the number 2, with each place in a number representing a power of 2. For example,
101 represents 1 X 2+2 + 0 X 2+1 + 1 X 20 = 1 X 4 + 0 X 2 + 1 X 1 = 5 (base 10).
In this case:
010110010011 (base 2) = 0 X 2+11 + 1 X 2+10 + 0 X 2+9 + 1 X 2+8 + 1 X 2+7 + 0 X 2+6 + 0 X 2+5 + 1 X 2+4 + 0 X 2+3 + 0 X
2+2 + 1 X 2+1 + 1 X 20
010110010011 (base 2) = 0 X 2048 + 1 X 1024 + 0 X 512 + 1 X 256 + 1 X 128 + 0 X 64 + 0 X 32 + 1 X 16 + 0 X 8 + 0 X
4+1 X2+1X1
010110010011 (base 2) = 1024 + 256 + 128 + 16 + 2 + 1
010110010011 (base 2) = 1427
Q147EXPL
For a balanced bridge, the voltage across the meter shown in the circuit will be zero.
To determine the value of the resistance needed, first the voltage at the junction of the 40 ohm and 10 ohm resistors is
found. This voltage is V1.
V1 = Es X (10 / (40 + 10)
V1 = 0.2 X Es
Now, the voltage at the junction of the 28 ohm and unknown value resistors is found. This voltage is V2.
V2 = Es X (28 / (Rx + 28))
For the bridge to be balanced, V2 = V1, so, substituting, and then solving for Rx.
0.2 X Es = Es X (28 / (Rx + 28))
0.2 = 28 / (Rx + 28)
0.2Rx + (0.2)(28) = 28
Rx + 28 = 5 X 28
Rx = (5 X 28) - 28
Rx = 112 ohms
Q148EXPL
Resolution is the smallest voltage increment that can be represented with the number of bits being used. Note that it is not
the number of levels that can be represented, but the step size, or change in output, when we increment by one bit. A
digital-to-analog converter has a resolution of [1 / (2n - 1)], where n is the number of bits. This formula is often
approximated as (1 / 2n). The approximation will give an error of less than 1% for seven or more bits, but for a small
number of bits, the error can be quite significant.
Consider a 2-bit D/A converter. A voltage of 0 would be represented by the bits 00. If a 1volt level were represented by
the bits 11, then a voltage of 0.33 volts would be represented by 01, and 0.67 volts would be represented by 10. Each
increment of one bit represents a step of 0.33 volts.
We can express the resolution in terms of the step size itself, or in terms of percent resolution. Percent resolution is the
step size divided by the full scale voltage; in this case, 0.33 V/1.00 V, or 33%. Similarly, a 3-bit converter would have 8
levels, giving 7 transitions, and a resolution of 1/7 or 0.143 or 14.3%. That is, it can measure increments as small as
14.3% of the full range being measured.
A 9-bit converter would have 512 levels. The resolution is 1/511, or 0.0020 or 0.2%.
Reference: http://www.allaboutcircuits.com/vol_4/chpt_13/10.html.
Q149EXPL
A switching power supply can operate with a relatively poorly filtered input voltage. A linear power supply needs a better
filtered input voltage to operate properly.
A switching power supply differs from a linear supply in that the series pass transistor in a switching supply operates non-
linearly, turning on and off to supply power to the output filter. A linear supply operates with the series pass transistor
operating in its linear region, making small changes in the series pass current to compensate for output changes.
Generally, the output voltage of a linear supply is better regulated than that of a switching supply. Both types of power
supplies need filter capacitors in order to produce a regulated output. The heat produced by a linear supply is generally
significantly higher than that of a switching supply operating under the same conditions.
A given switching power supply can only produce a single output voltage.
Secondary transformers may or may not be required, depending upon the particular application.
Because switching power supplies can operate with much less well-regulated input voltages than a linear supply, the
bridge rectifier circuit providing the DC to operate the switching supply is frequently connected directly across the AC
line and then filtered. Most linear supplies need to have an input voltage much closer to their output voltage, and so will
not be able to operate directly from the AC line voltage.
17.
Q150EXPL
For an integrator, the output waveform represents the area under the input waveform.
When the square wave is high, the area increases linearly as time goes by. Thus, the output also increases linearly. When
the square wave goes to zero (or goes negative), the area goes down linearly. The output also goes down linearly.
This is the description of a triangular waveform.
Integrators find use in applications where we want the sum of an event over time. For example, the flow rate of exhalation
summed over time gives the exhaled volume. Another example, the summation of the temperature change over time in
blood, is used to calculate cardiac output.
Reference: Malvino, Albert Paul, Electronic Principles, 4th edition, McGraw-Hill Book Company, 1989, pages 828 – 829.
Q151EXPL
To determine the characteristics of this circuit, we need to examine the characteristics of the components in the input
circuit at varying input frequencies.
The resistor's impedance will not change with changes in frequency. However, the capacitor's impedance will.
At low frequencies, the capacitor will have a very high impedance, so the full input voltage will appear at the non-
inverting input of the op amp.
At very high frequencies, the capacitor will act like a short circuit, and so the non-inverting input will effectively be
grounded, regardless of the amplitude of the input signal.
Therefore, the characteristics of the input circuit are those of a low-pass filter, allowing low-frequency signals through but
not high-frequency signals.
Because this input circuit is in the feedforward path, and because the feedback path is not frequency dependent (only
resistors are part of the feedback path), the entire circuit will assume the overall characteristics of the input circuit.
Thus, this configuration will function as a low-pass filter.
15.
Q152EXPL
The circuit is a low-pass filter. The cut-off frequency is determined by the time constant of the RC network on the input to
the non-inverting input of the op amp. This frequency is:
fc = 1 / (2 X Π X R X C)
fc = 1 / (2 X 3.14 X 33 X 10 3 X 0.022 X 10-6)
fc = 1 / (4.56 X 10-3)
fc = 0.219 x 103
fc = 219 hertz
Reference: Electronic Devices, Conventional Current Version, 9th edition, Thomas L. Floyd, Prentice Hall, 2012
Q153EXPL
A single pole filter, such as the one shown in this circuit, will always have a rolloff characteristic of 20 decibels per
decade (or 6 decibels per octave, which is the same).
A single pole filter is one with a single reactive element (a capacitor or inductor) in either the feedforward or feedback
path. A two-pole filter will have reactive elements in both the feedforward and feedback paths. It will have a rolloff of 40
decibels per decade.
15.
Q154EXPL
A differentiator carries out the mathematical operation of differentiation. It amplifies the rate of change of the input
signal. An input at a constant voltage will give an output of zero. The rising or falling edge of a square wave on the input
gives a spike at the output, while the high or low levels of the square wave, when the voltage is momentarily constant, are
not amplified. ECG monitors use differentiator circuits to help distinguish between the QRS spike of an ECG signal and a
pacing spike, which has a much faster rise time. Differentiators have the same characteristics as high pass filters.
Integrator circuits, on the other hand, carry out the mathematical operation of integration, which is a summing process. An
integral represents the area under a curve. A constant voltage applied to the input of an integrator will result in a ramp
output, representing the increasing area under the graph of a constant voltage. One application of integrators is to
determine the volume of expired air by integrating the flow signal from a pneumotachometer. Flow is measured in units of
volume per unit of time (e.g., liters per minute). Integrating the flow signal over time gives volume. Integrators have the
same characteristics as low-pass filters.
Unity gain buffers are circuits that do not amplify or attenuate a signal, but are used when there is a need for a higher
input impedance for an earlier stage and/or lower output impedance for a later stage. Emitter followers and op amp
voltage followers can be used as unity gain buffer amplifiers.
Oscillators utilize positive feedback to produce a periodic waveform output.
To determine the characteristics of this circuit, first consider the operation of the input circuit at the inverting input of the
op amp.
At low frequencies, the capacitor will act as an open circuit, preventing any voltage from getting to the op amp. At very
high frequencies, the capacitor will act as a short, allowing full input voltage to get to the op amp. Thus, this path is act ing
as a high-pass filter. Because this path is the only one with reactive elements, the overall circuit will function as a high-
pass filter. Only a rapidly changing signal will get through the capacitor to be amplified. The greater the rate of change of
the signal, the more of the signal gets through to the input of the op amp to be amplified. Thus, the circuit is a
differentiator.
13.
Q158EXPL
The cutoff frequency (also referred to as the critical frequency), fc is defined as the point where the output has dropped to
70.7% (-3 dB) of its maximum value. This occurs when Xc, the capacitive reactance of the filter, is equal to R, the
resistance of the filter. Above fc the output drops off at a rate of 20 dB per decade (that is, when the input frequency in
increased ten times).
Reference: Principles of Electric Circuits 9th edition, Thomas L. Floyd, Prentice Hall, 2010, Chapter 18.
Q159EXPL
First, let's look at the differences between a linear regulated power supply and a switching power supply.
Refer to the simplified diagram of the linear regulated power supply. For a linear regulator power supply, note that the
unregulated input is applied to the collector of the series pass transistor. The transistor is in series with the load, and the
transistor and load form a voltage divider. A feedback loop, consisting of the sense circuit and the sense amplifier, provide
feedback to the series transistor. If the output voltage is too high, the inverting input to the sense amplifier will be at a
higher voltage than the reference voltage applied to the non-inverting input. This will cause the output of the sense
amplifier to drop, thus reducing the current at the base of the series transistor, and increasing the collector to emitter (CE)
voltage drop, reducing the output voltage. If the output voltage is too low, the voltage at the inverting input of the sense
amplifier drops, causing an increase to the amplifier output and increased drive to the transistor. The CE voltage drop is
lower, and the voltage to the load goes up. In effect, the series transistor is acting as a variable resistor.
Next refer to the simplified diagram of the switching power supply. The switching power supply substitutes a MOSFET
(metal-oxide semiconductor field effect transistor) for the bipolar transistor, because a MOSFET can switch faster than a
bipolar transistor. The sense amplifier has been replaced with a comparator, which turns the pulse width modulator on and
off. Rather than operating in the linear mode, as occurs in the linear regulated supply, the MOSFET transistor operates as
an on-off switch, thus the term, switching power supply. When the MOSFET is turned on, current flows to the LC filter,
and the output voltage rises. When it turns off, no current flows and the output voltage drops. The MOSFET is switched
on and off very rapidly (typically at greater than 20 kHz) by the pulse-width modulator. As in the linear regulator, the
sense circuit samples the output voltage. If the voltage is too high, the comparator will flip negative, reducing the duty
cycle of the pulse-width modulator, thus reducing the on-time of the MOSFET and the current that flows to the filter
circuit. If the output voltage is too low the comparator will go positive, increasing the duty cycle.
Switching power supplies are more complex and require more components than linear regulated supplies and thus tend to
be more expensive, so choices A and C are not appropriate.
Because of their high switching rates, switching power supplies tend to have high frequency ripple at their outputs, though
higher-end (and thus more expensive) switching power supplies can reduce ripple to levels found in linear regulators.
Therefore, choice B is not the best answer.
Switching power supplies in general are more efficient than linear regulated power supplies, because the series transistor
in the linear supply is acting as a series resistor and dissipates extra power as heat. In switching supplies, the series
transistor is either off (in which case no current flows, and no power is dissipated) or completely on (in which case the
resistance across the transistor is very low, and thus little power is dissipated). Because switching supplies do not dissipate
as much heat, they have the added advantage of not needing large heat sinks. For this reason, choice D is the correct
answer.
17.
Q160EXPL
Relay contacts can be normally open (NO) or normally closed (NC). The diagram shows the normal state (relay coil un-
energized) with D open, E closed, and F open. When energy is applied, they will change to the opposite states.
References:
[1] Principles of Electric Circuits 9th edition, Thomas L. Floyd, Prentice Hall, 2010, Chapter 10
[2] http://www.wadeinstruments.com/relays/control_relay_tutorial.htm.
Q161EXPL
Resonance occurs when the inductive reactance, XL, and capacitive reactance, XC, are of equal magnitude, but XL has an
angle of +90o, while XC has an angle of -90o. Because the capacitor and inductor are in parallel with each other, the
voltage across them is the same. Ideally, the current through each of them is of the same magnitude but is 180o out of
phase. Under this condition, the current through the inductor and the current through the capacitor cancel each other out,
and the total current through the circuit is zero.
If the current were in fact zero, the impedance of the parallel LC circuit would be infinite.
In practice, there will be a small amount of current due to the resistance of the inductor. LC circuits are important in
wireless applications to enable the receiver to tune into the desired frequency.
At frequencies below resonance, XC increases, and XL decreases. Because more current flows through the inductor, the
circuit acts like an inductive circuit, with current lagging voltage. At frequencies above resonance, the opposite occurs.
XC decreases, and XL increases. More current flows through the capacitor, and the circuit acts like a capacitive circuit,
with current leading voltage.
Series LC circuits have very low impedance at resonance. As their impedances are in opposite directions, at resonance
they completely cancel each other out. The total circuit impedance is the coil resistance and current is maximum.
Q162EXPL
The relationship between power and energy is that energy is a unit of work, while power is the rate at which energy is
used (or work is done). Therefore, power is expressed as energy per unit of time. The SI unit of power is the watt, and the
SI unit of energy is the joule. By definition, 1 watt = 1 joule/second.
The abbreviation kWh stands for kilowatt-hours. 1 kilowatt = 1,000 watts, and 1 hour = 3,600 seconds. Because power =
energy/time, then energy = power * time. Therefore, a kilowatt-hour is a unit of energy, as a kilowatt is a unit of power,
and an hour is a unit of time. By definition, a joule is a unit of energy, and a watt is a unit of power, making choice D a
non-energy unit.
The calorie is a pre-SI unit of energy. One calorie is the amount of heat needed to raise the temperature of one gram of
water by 1o C. In modern usage, calories are typically used to measure energy in the form of heat. 1 calorie is
approximately 4.2 joules.
Q163EXPL
The amount of energy stored in a capacitor can be calculated as
E = (1/2) CV2
Thus the energy is
E = (1/2) X (196 X 10 -6 farads) X (1.6 X 103 volts)2
E = 250 joules
Joules are the standard units of energy. Watts are the standard units of power.
Note that the amount of energy that is stored in the capacitor is not the same as the energy delivered to the patient. Some
of the energy is dissipated in the internal resistance of the defibrillator and in the impedance between the paddles and the
patient's skin.
Reference: Chatterjee, Shakti, and Miller, Aubert, Biomedical Instrumentations Systems, Delmar Cengage Learning,
2010, Chapter 8.
Q164EXPL
The diagram shows a Wheatstone Bridge, which is commonly used for precision measurement and is commonly used in
blood pressure transducers and electronic scales. When a bridge is balanced it means that the output voltage is zero.
A Wheatstone Bridge is essentially two voltage dividers in parallel. V out will be zero when the voltage at node A equals
the voltage at node B. This occurs when the ratios of the resistors in each branch of the bridge are equal. That is:
(R1 / R2) = (Rx / R3)
Solving for Rx gives:
Rx = (R1 / R2) X R3
Rx = (3.3 / 4.7) X 2.2
Rx = 1.54 kΩ
Because the same voltage is applied to both branches of the bridge, it does not matter what the excitation voltage is.
Reference: Floyd, Thomas L., Principles of Electric Circuits, 9th edition, Prentice Hall, 2010, Chapter 7
Q165EXPL
All of these devices can be used to measure temperature. However, only a thermistor is made from a semiconductor. Like
other semiconductors, thermistors decrease their resistance as temperature increases, thus giving them a negative
temperature coefficient. Thermistors are widely used as skin temperature probes.
A thermocouple is made up of two dissimilar metals, which generate a voltage when the junction between the two metals
is heated. Part of this phenomenon is explained by the Peltier effect, which refers to the formation of a small voltage at the
junction of two dissimilar metals. This voltage will change in response to changes in temperature. However, while the
Peltier effect, in part, explains the operation of a thermocouple, the term "Peltier probe" is not used for any commercially-
available products, and if it were produced, it would consist of two dissimilar metals, rather than a semiconductor.
Reference: Chatterjee, Shakti, and Miller, Aubert, Biomedical Instrumentations Systems, Delmar Cengage Learning,
2010, Chapter 6.
Q166EXPL
Hall effect sensors produce a DC voltage proportional to the strength of a magnetic field. The Hall effect is present in
conductors, but is more pronounced in semiconductor sensors designed for the purpose. When charged particles move
through a magnetic field, a magnetic force deflects their movement perpendicular to the magnetic field.
In a Hall sensor, current flows through a slab of semiconductor material. With no magnetic field present the electrons
spread out evenly across the width of the slab, and there is no net voltage across the width. If a magnetic field is applied
across the surface of the slab, a magnetic force is applied to the electrons, deflecting them toward one side of the slab.
Thus there are more electrons on one side of the slab than the other, resulting in a difference in potential across the width
of the slab.
The stronger the magnetic field, and the greater the current, the greater the voltage across the sensor.
Magnetic fields can be brought into the proximity in several very simple ways. For example, when closing the door of a
sterilizer, a Hall sensor and small permanent magnet can be placed so that one is on the door itself and the other in a
corresponding position on the door frame. When the door is open, there is no voltage across the Hall sensor, but when the
door is closed and the sensor and magnet are in close proximity, the sensor produces a small voltage.
Hall sensors can also be used to measure the rotational speed of a centrifuge motor. Each time one of the motor’s magnets
passes over the Hall sensor, a pulse is generated. Counting pulses provides an easy way to determine the centrifuge speed.
Reference: http://www.allaboutcircuits.com/vol_2/chpt_12/3.html (accessed 1/6/2012).
Q167EXPL
Stepper motors find wide use in devices, such as infusion pumps, where there is a need for precise control, but not a need
to generate large torques. The rotor does not move continuously as in other motors. Instead, a stepper moves in discrete
steps, with angles ranging from 0.75o to 90o per step, depending upon the particular design characteristics of the motor.
This makes a stepper motor ideal for use with microprocessor systems.
Because they do not run continuously and do not develop high levels of torque, stepper motors typically draw less power
than other types of motors.
Reference: http://www.allaboutcircuits.com/vol_2/chpt_13/5.html (Accessed 1/6/2012).
Q168EXPL
Think of a step input as the first part of a square wave. Imagine that the voltage starts at zero, then rises quickly to some
positive voltage level, and then stays at that level. (Note that a negative voltage would also work.) The rapid voltage rise
consists of a range of high frequency components that quickly fade out when the input reaches its positive level. At that
point the frequency goes to zero.
The frequency response of a circuit is defined by its upper and lower critical (or cutoff) frequencies. These are the
frequencies at which the output voltage is 0.707 of its maximum value, or -3dB.
If a circuit does not have a high enough upper critical frequency, it will not be able to amplify the high frequency
components of the step input. The result will be an output that appears rounded. In order to reproduce the step and make it
appear squared off as it approaches its maximum value, the circuit must have a relatively high upper critical frequency.
Once the step portion of the input is completed and the voltage levels off, the frequency of the input goes to zero, though
it takes a little time for the higher frequency components to die out. At this point, the upper critical frequency is not a
factor, but the low critical frequency is. The lower the low critical frequency is, the longer it will take for the output to
drop toward zero.
Reference: Floyd, Thomas L., Principles of Electric Circuits, 9th edition, Prentice Hall, 2010, Chapter 18 Think of a step
input as the first part of a square wave. Imagine that the voltage starts at zero, then rises quickly to some positive voltage
level, and then stays at that level. (Note that a negative voltage would also work.) The rapid voltage rise consists of a
range of high frequency components that quickly fade out when the input reaches its positive level. At that point the
frequency goes to zero.
The frequency response of a circuit is defined by its upper and lower critical (or cutoff) frequencies. These are the
frequencies at which the output voltage is 0.707 of its maximum value, or -3dB.
If a circuit does not have a high enough upper critical frequency, it will not be able to amplify the high frequency
components of the step input. The result will be an output that appears rounded. In order to reproduce the step and make it
appear squared off as it approaches its maximum value, the circuit must have a relatively high upper critical frequency.
Once the step portion of the input is completed and the voltage levels off, the frequency of the input goes to zero, though
it takes a little time for the higher frequency components to die out. At this point, the upper critical frequency is not a
factor, but the low critical frequency is. The lower the low critical frequency is, the longer it will take for the output to
drop toward zero.
Reference: Floyd, Thomas L., Principles of Electric Circuits, 9th edition, Prentice Hall, 2010, Chapter 18.
Q169EXPL
RAM stands for random access memory and is used for temporary storage of data in a computer system. Static RAM
(SRAM) uses flip-flops to store data. Once the flip-flop is set to a particular output, it maintains that output as long as
power is supplied.
On the other hand, dynamic RAM (DRAM) uses capacitance to store a charge, which represents the data. The result is
that the circuitry for DRAM is much simpler than SRAM, making it possible to pack DRAM much more densely on a
chip, which ends up making DRAM less expensive than SRAM. DRAM also has the added advantage of saving space on
a circuit board, which can be a significant consideration in board design.
The disadvantage of DRAM is that the charge placed on a capacitor tends to leak off after some time. Thus, the memory
must be continually refreshed, or it will be lost. Each time a memory location is read the charge is used up, and the
memory must be rewritten after each reading, or it will be lost. These additional operations end up making DRAM slower
than SRAM.
Reference: Kleitz, William, Digital Electronics A Practical Approach, 8th edition, Pearson Prentice Hall, 2008, Chapter
16.
Q170EXPL
When analyzing basic op amp circuits where the external components are resistors, there are a few basic steps you can
take. The first thing to note is whether there is negative feedback. You can recognize the presence of negative feedback by
a conductive path from the op amp output to the inverting input. If negative feedback is present, the op amp will be
operating as a linear amplifier. The output waveform will look much like the input waveform, though the amplitude may
be different, and the signal may be inverted.
An interesting characteristic of op amps with negative feedback is that the output will reach a level such that the voltage at
the inverting and non-inverting inputs will be the same. For example, if the non-inverting input is grounded, the negative
feedback from the output will drive the voltage at the inverting input to zero — a condition that is often referred to as
virtual ground, because it is at ground potential, even though it is not directly connected to ground.
In this circuit, negative feedback is provided through R 2. The input is applied to the inverting input, so the circuit is an
inverting amplifier. The non-inverting input is grounded, so the voltage at node A will be zero.
Another important characteristic of op amps is that they have extremely high input impedance. A very good
approximation of circuit behavior can be found by assuming that the op amp draws no current.
To analyze the circuit, note that current flows from Vin to node A. Because the voltage at node A is zero, we can calculate
the current through R1 as:
I1 = (Vin / R1)
I1 = (50 millivolts / 10 kilohms)
I1 = 5 microamperes
Because none of the current enters the op amp, it must all go through the feedback resistor, R 2. Because the current is
moving from node A to the output, there will be a voltage drop across R 2. That is, the output voltage will equal:
Vout = VA - IR2
Vout = 0 volts - (5 microamperes X 100 kilohms)
Vout = -0.5 volts
In general, the output of an inverting amplifier can be calculated as:
Vout = -(R2 / R1) X Vin
Reference: Floyd, Thomas L., Principles of Electric Circuits, 9th edition, Prentice Hall, 2010, Chapter 12.
Q171EXPL
Differential amplifiers (diff amps) are designed to amplify the difference between their two inputs. By subtracting one
input from the other, any signal that is common to both inputs (common mode), such as noise or a dc offset, is not
amplified. Only the part of the signal that is different between the two inputs (differential mode) is amplified. CMRR, the
common mode rejection ratio, is defined as the ratio of the differential mode amplification divided by the common mode
amplification, and is typically high in differential amplifiers. Diff amps do not necessarily have a high input impedance.
The input impedance of a diff amp made from an operational amplifier depends on the value of the input resistors, and
there are constraints that limit how large those resistances can be. One common way of addressing this is to buffer the
inputs to the diff amp with non-inverting amplifiers, which do have very high input impedance. This is the basic
configuration of an instrumentation amplifier.
Reference: Carr, Joseph J. and Brown, John M., Introduction to Biomedical Equipment Technology, 4th edition, Prentice
Hall, 2001, Chapter 7.
Q172EXPL
Operating code contains the operating instructions for any computer-based system, including medical devices.
The code must be stored in non-volatile memory, so that if the device loses power, the operating code is not lost. RAM is
volatile and so is not appropriate for this purpose. In some computer systems, boot-up code may be stored in some non-
volatile form, and the main body of the operating system is on a hard drive. Hard drives are not as fast, as reliable, or as
resistant to physical shock as semiconductor memory, so in general they are not used to store operating code for medical
devices.
ROM has been used in the past to provide the operating instructions for medical devices, but EEPROMs of various types
(including flash memory) have some major advantages, and so are used in most modern medical equipment. ROM must
be programmed at the time of manufacture, and cannot be changed if there is a need to change the instructions.
With an EEPROM, if these instructions need to be changed or a new version of the software is developed, the EEPROM
can generally be reprogrammed easily in the field. EEPROMs are also useful for data logging, and any other function
where you want to protect against the loss of data in the event of a loss of power.
Reference: http://accessscience.com/content/Semiconductor-memories/614100 (accessed 1/12/2012).
Q360EXPL
The common-mode rejection ratio (CMRR) of an amplifier is the ratio of its differential voltage gain to its common-mode
voltage gain.
In this case, the differential voltage gain, Ad is:
Ad = 4 volts / 2 millivolts
Ad = 4,000 millivolts / 2 millivolts
Ad = 2,000
Similarly, the common-mode voltage gain, Acm is:
Acm = 1.0 volt / 10 volts

Acm = 0.1
The common-mode rejection ratio, CMRR, is:
CMRR = Ad / Acm
CMRR = 2,000 / 0.1
CMRR = 20,000
This could also be expressed as a common-mode rejection ratio of 20,000:1.
Reference: Malvino, Albert Paul, Electronic Principles, 4th edition, McGraw-Hill Book Company, 1989, page 662
Q377EXPL
In a switching power supply the series-pass element is turned on and off rapidly by the switching element to control the
output voltage. When properly activated, the output voltage, after filtering, will be the desired output voltage.
If the series-pass element shorts, then the full input voltage will be sent to the output terminals.
When the switching element fails, the series-pass element will usually stay turned off at all times. This results in no output
voltage.
Reference: None
Q378EXPL
On a normal, 4-wire, 3-phase electrical system used in the United States, the voltage between conductors will be 208
volts.
Reference: None
Q400EXPL
The line isolation monitor indicates that electrical isolation from ground has been lost. It does not mean that there is
necessarily an immediate threat to patient safety, but it does mean that one level of protection has been lost. Turning off
the LIM circuit breaker is not advisable, as there might be life support equipment, such as a ventilator connected to it.
Shutting down the ventilator would be a far greater threat to the patient, but the situation can not be ignored. It does
indicate that some piece of equipment connected to the LIM is producing excessive leakage current. Simply silencing the
alarm without dealing with the situation is also not a good approach. The best answer is to identify the piece of equipment
that is causing the alarm, and go from there.
Reference:
[1] Aston, R, Principles of Biomedical instrumentation and Measurement, Merrill Publishing, 1990, p. 70
Q416EXPL
The circuit provides negative feedback through R24, but it is not a comparator.
The input goes to the inverting input, while the non-inverting input is grounded,
making the circuit an inverting amplifier.
Reference: None
Q417EXPL
U1A is configured as a comparator. Thus, any time the voltage at pin 3 is greater
than the voltage at pin 2 we would expect the output to be high. A failure of the
+12 V supply would mean that Q1 would be unable to provide a positive voltage to
pin 3, so this is not a promising answer. Note that when operating normally, Q1
provides approximately +3 V to pin 3. The +5 V at the output of U1A is applied to
the cathode of the diode in U2. Because the voltage at the anode (which comes
from the collector of Q2) can not exceed +5 V, the diode in U2 is reverse biased.
If SW1 is open, the inputs to U5A will both be high, which will drive the output
of the NAND gate low. The low is applied to pin 2 of U1A and is lower than the +3
V at pin 3, causing the comparator to flip high. Thus B is the correct answer.
Reference: None
Q418EXPL
There is no negative feedback, thus U1A is configured as a comparator.
Reference: None
Q419EXPL
The input signal is inverted by Q2, then by U2, and again by U7A, resulting in an
output signal that will normally be inverted when compared to the input. In order
for Q2 to be operating in its linear range, the base collector junction must be
reverse biased. And in order for the signal to get from the input side of U2 to
the output side, the diode on the input side must be forward biased. Thus D is
the correct answer.
Reference: None
Q420EXPL
The input signal is inverted by Q2, then by U2, and again by U7A, resulting in an
output signal that will normally be inverted when compared to the input. In order
for Q2 to be operating in its linear range, the base collector junction must be
reverse biased. And in order for the signal to get from the input side of U2 to
the output side, the diode on the input side must be forward biased. Thus D is
the correct answer.
Reference: None
Q421EXPL
If SW1 were closed, the output of U5A would be driven high, causing the
comparator U1A to flip low. This would allow the input diode in U2 to be forward
biased, which would allow the signal to go through. C2 is a bypass capacitor for
Q2. If it were shorted the bias point for the transistor would probably be
shifted. This could result in some distortion to the output signal, but it is
unlikely there would be no output at all. If U1A were giving a constant high
output, the diode in U2 would be reverse biased preventing any signal from
passing through U2. Thus C is the correct answer.
Reference: None
Q431EXPL
Generally, batteries are the most likely component in a UPS to fail. Batteries
will need replacement after some period of time (generally years), so it is best
to do this before the need arises. The manufacturer of the UPS will specify a
maintenance and replacement schedule for the batteries internal to the device.
Your inspection procedure should follow manufacturer's recommendations when it
comes to determining how to properly test the batteries and when to replace them.
The general categories of modern UPS systems are: on-line, line-interactive, and
standby. An on-line UPS uses a "double conversion" method of accepting AC input,
rectifying to DC for passing through the rechargeable battery, then inverting
back to 120 V/230 V AC for powering the protected equipment. A line-interactive
UPS maintains the inverter in line and redirects the battery's DC current path
from the normal charging mode to supplying current when power is lost. In a
standby ("off-line") system, the load is powered directly by the input power and
the backup power circuitry is only invoked when the utility power fails (the
inherent switching delay would not make this a good choice for powering medical
equipment). Most UPS systems below 1 kVA are of the line-interactive or standby
variety, which are usually less expensive.
References:
[1] http://en.wikipedia.org/wiki/Uninterruptible_power_supply
[2] http://pcguide.com/ref/power/ext/ups/typesLineInt-c.html
Q448EXPL
An overloaded amplifier is one that is no longer able to respond linearly to its
input signals. If this happens, the output of the amplifier will be saturated,
and any further increases in the input signal will cause no changes in the output
signal.
If the differential input signal times the amplifier gain is greater than the
power supply voltage, then the amplifier can not respond linearly, because the
amplifier can not deliver an output voltage that is greater than the power supply
voltage.
If the DC offset voltage is too great, then this signal would be amplified, and,
if the result was greater than the differential dynamic range, the amplifier's
output voltage would be pegged at the power supply voltage, and its response
would no longer be linear.
A similar condition exists if the common-mode signal is greater than the common-
mode dynamic range. Again, the amplifier would be unable to respond linearly to
the input signal, and it would be overloaded.
Reference: None
Q451EXPL
Electrical current can cause many hazards. The least hazardous reaction
would be a startle reaction as a person experiences an unexpected
electrical shock. Higher current levels can cause much more serious
problems, ranging from an inability to release an electrical wire, up to
respiratory paralysis, ventricular fibrillation, sustained contraction of
the heart, and burns.
It is important to realize that reactions to current have been found to

vary widely between individuals, and between the sexes. Thus, any
guidelines presented are approximations, and should be treated as such.
The table below gives approximate current levels at the body surface found
to cause the types of reactions listed.
Current Level Reaction
1 mA Threshold of perception
5 mA Maximum harmless current
10 - 20 mA "Can't let go" reaction
50 mA Pain, exhaustion, fainting
100 - 300 mA Ventricular fibrillation
6A Sustained myocardial contraction, burns
Reference: Carr, Joseph J., and Brown, John M., Introduction to Biomedical
Equipment Technology, 2nd edition, Prentice Hall Career and Technology,
1993, page 416
Q462EXPL
An isolated power system is constructed so that the two electrical power lines
supplying voltage for equipment operation (such as 120 VAC) are not referenced
back to ground.
In a normal power system, one line is deliberately connected to ground (the
neutral wire), and so the other line (the hot wire) is referenced back to ground.
Isolated power systems were initially designed for use in operating rooms where
an electrical spark might accidentally ignite a flammable anesthetic. In a normal
power system, an inadvertent connection between the hot wire and ground could
cause a spark (i.e., a macroshock). In an isolated power system, a connection
between one of the power lines and ground (a first fault) will not have any
effect on the operation of the equipment, and will not produce a spark.
Areas that are served by an isolated power system are required to have a Line
Isolation Monitor. This monitor must incorporate an alarm that sounds if the
isolation between the power system and ground deteriorates (a ground fault).
Isolated power systems do not provide protection against microshocks, which are
caused by electrical currents on the order of tens of microamperes. Isolated
power systems are designed to protect against shocks of several milliamperes.
Reference: None
Q475EXPL
Proper grounding of electrical equipment serves two primary functions. The first
is to provide a low-impedance path to ground for any leakage current that may be
present in an electrical device. The second is to provide a method of
disconnecting power to equipment by blowing the device's fuse or circuit breaker
in the event of a catastrophic fault.
A catastrophic fault would be a short of the hot wire to the grounded case.
Without an adequate ground, the case would become energized, and could cause a
very serious shock hazard for the equipment user or patient. By providing a low-
impedance return path, an overload of the fuse or circuit breaker is likely, and
the power to the device would be rapidly disconnected.
Equipment Technology, 2nd edition, Prentice Hall Career and Technology, 1993,
page 418 - 419
Q480EXPL
For a branch circuit, three wires are used. The hot wire is the one carrying the
high voltage (for example, nominally 120 volts AC for a common circuit). The
neutral wire, or grounded conductor, is the wire that is connected to the ground
in the circuit breaker or fuse panel box. The grounding (ground) conductor is the
third wire in the system, and it is used to provide a safety connection to ground
for the chassis of equipment.
(The difference between the grounded conductor and the grounding conductor is
that the grounded conductor is intended to carry current during the normal
operation of equipment, while the grounding conductor is a safety device, and is
intended to carry current only under fault conditions.)
The National Electric Code requires that the grounded (neutral) conductor be
white or natural gray in color, while the grounding (ground) conductor be green,
green with one or more yellow stripes, or bare. The hot wire may be any color, as
long as it is easily distinguished from both the neutral and ground wires.
It is most common to make the hot wire black, with red used as an alternative in
cases where an additional hot conductor is needed.
Reference: National Fire Protection Association, ANSI/NFPA 70:2011 - National

Electrical Code
Q481EXPL
This problem is solved using Ohm's law. In this case, we have two parallel
resistors: First, the 1 ohm grounding resistance; and second, the 500 ohm patient
resistance.
The 1 ohm ground resistance has a current of 100 microamperes flowing through it.
The voltage across it will be:
V = I X R
V = 100 microamperes X 1 ohms
V = 100 X 10-6 X 1
V = 1 X 10-4
This same voltage will also be across the patient, so the current through the
patient will be:
I = V / R
I = (1 X 10-4) / 500
I = 2 X 10-7
I = 0.2 microamperes
Reference: Stoner, David L., Smathers, James B., Hyamn, William A., Clapp, David
E., Duncan, Dean D., Engineering a Safe Hospital Environment, John Wiley and
Sons, 1982, pages 7 - 8
Q482EXPL
A ground wire is designed to provide a safe path to ground for leakage currents,
which could cause a shock or electrocution if they were to flow through a patient
or an equipment user.
Power cords are subject to stress, and sometimes the ground wire in a power cord
can break, or the ground pin of an electrical plug can be broken. The shock
hazard that this presents can be reduced by taking one or more of the following
measures:
* reducing internal equipment leakage current;
* continuously monitoring the continuity of the ground wire, so that corrective

action can be taken in the event of a fault;
* adding an additional ground wire (a redundant ground) in parallel with the

power cord safety ground;
* periodically inspecting the ground-connection integrity of equipment; and
* using an isolated power system that isolates the current-carrying wires in the
equipment from the power system ground.
page 419
Q493EXPL
Fire can result from excessive heat. When electricity flows through a conductor,
heat results. Because the power dissipated in a conductor is equal to the square
of the current flowing through the current, times its resistance, the higher the
resistance, the more power (heat) will be generated.
Ohmic heating, caused by the intentional generation of heat, for example, in a

heating element, is a possible source of heat.
Undersized conductors in a wire can cause heating in a power cord, or in other

wires carrying large currents. The smaller the diameter of the conductor, the
greater its resistance, and thus, the greater the heat generated by its use.
The breakdown of insulation can cause resistive paths to exist where they are not
intended to be. When this happens, heat can be produced unintentionally, and can
be the source of a fire.
page 409
Q601EXPL
The oscilloscope is basically a graph-displaying device – it draws a graph of an
electrical signal. In most applications the graph shows how signals change over
time: the vertical (Y) axis represents voltage and the horizontal (X) axis
represents time. The intensity or brightness of the display is sometimes called
the Z axis.
An oscilloscope’s front panel includes a display screen and the knobs, buttons,
switches, and indicators used to control signal acquisition and display. Front-
panel controls normally are divided into Vertical, Horizontal, and Trigger
sections, and in addition, there are display controls and input connectors.
When you connect an oscilloscope probe to a circuit, the voltage signal travels
through the probe to the vertical system of the oscilloscope. Depending on how
you set the vertical scale (volts/div control), an attenuator reduces the signal
voltage or an amplifier increases the signal voltage. The vertical display has
eight major graticules. Each major graticule is multiplied by the number on the
volts/div knob to represent voltage magnitude.
The signal also travels to the trigger system to start or trigger a “horizontal
sweep.” Horizontal sweep (sec/div) is a term referring to the action of the
horizontal system causing the signal to move across the screen. The horizontal
display has ten major graticules. Each major graticule is multiplied by the
number on the time/div knob to represent time of the waveform.
Triggering the horizontal system causes the horizontal time base to move the
signal across the screen from left to right within a specific time interval. Many
sweeps in rapid sequence cause the movement of the signal to blend into a solid
line. At higher speeds, the dot may sweep across the screen up to 500,000 times
each second.
Together, the horizontal sweeping action and the vertical deflection action
traces a graph of the signal on the screen. The trigger is necessary to stabilize
a repeating signal. It ensures that the sweep begins at the same point of a
repeating signal, resulting in a clear picture.
The frequency in hertz (Hz) is the number of times the signal repeats itself in
one second (the cycles per second). A repeating signal also has a period – this
is the amount of time it takes the signal to complete one cycle. Period and
frequency are reciprocals of each other, so that 1/period equals the frequency
and 1/frequency equals the period, seconds (sec).
Phase shift is common in electronic measurements. The sine wave is based upon
circular motion. There are 360° electrical degrees in one cycle of a sine wave.
Using degrees, you can refer to the phase angle of a sine wave when you want to
describe how much of the period has elapsed. If one half (½) of one complete
cycle of a sine wave appears on the oscilloscope display (across the ten
horizontal graticules), 180° electrical degrees are represented by the displayed
waveform. Moreover, each one of the ten graticules represents 18° (180°/10). If
one quarter (¼) of one complete cycle of a sine wave appears on the oscilloscope
display (across the ten horizontal graticules), 90° electrical degrees are
represented by the displayed waveform, or each graticule represents 9° (90°/10).
Standard pulse measurements are pulse rise time and pulse width. Rise time is the
amount of time a pulse takes to go from a low to high voltage. By convention, the
rise time is measured from 10% to 90% of the full voltage of the pulse. This
eliminates any irregularities at the pulse's transition corners. Pulse width is
the amount of time the pulse takes to go from low to high and back to low again.
By convention, the pulse width is measured at 50% of full voltage.
Reference:
[1] Tektronix, Inc., XYZs of Oscilloscopes: Primer,
http://www.tektronix.com/oscilloscope, retrieved July 18, 2014, pp. 7-11 and 48
Q612EXPL
An oscilloscope’s trigger function synchronizes the horizontal sweep at the
correct point of the signal, which is essential for clear signal display. Trigger
controls allow stabilizing repetitive waveforms and also enable capturing single-
shot waveforms. The trigger makes repetitive waveforms appear static on the
oscilloscope display by repeatedly displaying the same portion of the input
signal rather than having a trace on the screen start at a different place on the
signal.
Changing the amplitude (vertical) or time base (horizontal) scales allows the
signal trace to fit properly within the screen, but the trace would still appear
unsynchronized if it starts each time from a random point in the signal. So, even
though such adjustments are important, they cannot alone provide a stable trace
on the oscilloscope display.
Changing the input coupling allows the DC offset of the signal to be kept (DC
mode) or removed (AC mode). This is again an important adjustment, especially
when a small AC signal of interest is superimposed on a large DC component. But
this adjustment alone would not provide a stable trace.
Reference:
[1] Tektronix, XYZs of Oscilloscopes Primer, available at
http://www.tek.com/learning/oscilloscope-tutorial
Q613EXPL
Bandwidth determines an oscilloscope’s fundamental ability to measure a signal
and is a function of the analog front end hardware of the oscilloscope.
Therefore, it poses a fundamental limitation of the utility of the device to
capture signals that no acquisition/display setting can override. As signal
frequency increases, the capability of the oscilloscope to accurately display the
signal decreases. This specification indicates the frequency range that the
oscilloscope can accurately measure. Without adequate bandwidth, the oscilloscope
will not be able to resolve high-frequency changes. Amplitude will be distorted,
edges will vanish and details will be lost. Without adequate bandwidth, all other
features such as sampling rate, quantization level, and reconstruction methods in
a digital oscilloscope will mean nothing. To safely determine the oscilloscope
bandwidth needed to accurately characterize signal amplitude in your specific
application, in general, the bandwidth of the oscilloscope and measuring probe
system should be at least five times the bandwidth of the input signal.
Reference:
Q623EXPL
The volts per division control is used to perform vertical scaling. The seconds
per division control provides horizontal scaling. These are the two main
oscilloscope controls.
An additional control on the oscilloscope is the trigger control. This control

keeps the oscilloscope from tracing its waveform until the triggering event
(generally, a selected voltage level) is seen. Once triggered, the oscilloscope
trace will start going across the screen.
This triggering capability is particularly useful for analyzing a repeating

waveform. By properly selecting the trigger level, the repeating waveform will
appear to be stable on the display, as the trace will continuously start at the
same point on the waveform each time it repeats. The ability to utilize various
triggering capabilities of an oscilloscope indicates a high level of expertise
with oscilloscopes.
Reference:
Q625EXPL
A digital multimeter (DMM) can generally be used to measure voltage, current or
resistance. In order to measure the current flowing through a resistor, the DMM
must be connected in series with the resistor. To measure resistance, the circuit
cannot be energized, as any external voltage across the resistor would prevent
the DMM from properly detecting the resistance. Given the description in the
question (a connection in parallel across a resistor in an energized circuit),
the only parameter that could be measured is voltage.
When measuring voltage, the DMM leads would be connected to the V and COM jacks.
Many DMMs use the same jack for both volts and ohms, but may perform only one
type of measurement at a time.
Reference:
[1] Ideal Industries Inc., The Basics of Digital Multimeters,
http://www.idealindustries.com/media/pdfs/products/guides/basics_of_digital_multi
meters.pdf, page 11
Q626EXPL
Instantaneous AC is the value displayed on an oscilloscope at some particular
point of the waveform. DMMs display RMS (root mean square) values. Peak and
average-responding methods require that the signal first be rectified. These
methods are generally only useful for measuring sine waves. For more complex
waves the true RMS method provides better results.
RMS values are calculated as described in this question. The AC waveform is

sampled hundreds of times per second, and each individual value is then squared.
The mean of all the squared values is then determined by summing all of the
values over a period of time and dividing by the number of samples taken during
that time. Finally, the square root of the calculated mean value is found and
displayed on the DMM.
Two different waveforms that have the same true RMS value should perform the same
amount of heating. An alternative method of measuring true RMS is to measure the
heat dissipated through a transducer. This heat method is often used when
measuring high voltages.
References:
[1] Dyer, Stephen; Survey of Instrumentation and Measurement; 2001, Wiley-
Interscience, John Wiley & Sons, Inc., pp. 277-292
[2] Ideal Industries Inc., The Basics of Digital Multimeters,
http://www.idealindustries.com/media/pdfs/products/guides/basics_of_digital_multi
meters.pdf, page 12
Q644EXPL
The charger will provide electricity to the battery electrodes in a direction
opposite to the electron discharge. This will reverse the chemical process within
the battery and convert the applied electrical energy into chemical potential
energy. Some chemical reactions, however, are difficult or impossible to reverse.
Cells with irreversible reactions are commonly known as primary cells, while
cells with reversible reactions are known as secondary cells and can be
recharged.
The current that a charger supplies to the secondary battery is normally

expressed as a fraction of the theoretical current needed to charge the specified
battery completely in one hour. This theoretical current is called the nominal
battery capacity rating and is represented as "C." If a charger is rated at 1C,
it will charge the battery in 1 hour.
Thus, charging at the 0.1 rate would charge the battery in 10 hours.
References:
[1] What is the C-rate?, Battery University, CADEX Corp.,
http://batteryuniversity.com/learn/article/what_is_the_c_rate, retrieved
9/10/2014
Q648EXPL
The binary number system is based on the number 2, with each place in a number
representing a power of 2. For example, 101 represents (1 X 2 +2) + (0 X 2+1) + (1 X
20) = (1 X 4) + (0 X 2) + (1 X 1) = 5 (base 10).
In this case:
1101 (binary) = (1 X 2+3) + (1 X 2+2) + (0 X 2+1) + (1 X 2+0)

1101 (binary) = (1 X 8) + (1 X 4) + (0 X 2) + (1 X 1)
1101 (binary) = 8 + 4 + 0 + 4 + 1
1101 (binary) = 13
References:
[1] Binary Number, Wikipedia, http://en.wikipedia.org/wiki/Binary_number,
[2] Binary Math, Professor Messer website, http://www.professormesser.com/n10-
005/binary-math-2/, retrieved September 20, 2014
Q649EXPL
The hexadecimal number system is a base 16 number system. The digits 0 through 9
represent the same values as in the decimal (base 10) number system. To represent
the numbers 10, 11, 12, 13, 14 and 15, the letters A, B, C, D, E and F are used.
F in hexadecimal is 15 decimal, while E in hexadecimal is 14 decimal, therefore:

FFFE (hexadecimal) = (15 X163) + (15 X162) +(15 X161) +(14 X 160)
FFFE (hexadecimal) = (15 X 4096) + (15 X 256) + (15 X 16) + (14 X 1)
FFFE (hexadecimal) = 61440 + 3840 + 240 + 14
FFFE (hexadecimal) = 65534
Or a simpler way: FFFE + 2 = 10000 (hexadecimal) which is (1 X 16 4) = 65536, so

FFFE = 65536 – 2 = 65534
Reference:
[1] Hexadecimal, Wikipedia, http://en.wikipedia.org/wiki/Hexadecimal, retrieved
September 21, 2014
Q650EXPL
The byte is a unit of digital information in computing and telecommunications
that most commonly consists of eight bits. A byte was considered the smallest
addressable unit of memory in a computer. Depending upon the computer, a byte
could represent different numbers of bits, with various computers using 4-, 6-,
7- or 8-bit bytes.
With the adoption of the international standard IEC 80000-13, the byte was
standardized to mean 8 bits.
Reference:
[1] Byte, Wikipedia, http://en.wikipedia.org/wiki/Byte, retrieved September 20,
2014
Q684EXPL
Power supplies fall into one of two main categories: linear and switching mode.
Linear power supplies provide excellent line regulation, load regulation, and
transient recovery, while having a much lower power density and efficiency than
comparable switching mode power supplies. The result is that linear power
supplies are significantly larger than comparable switching mode power supplies.
The impetus for the development of switching mode power supplies came from the
military's desire for lighter weight and higher efficiency power supplies. One
way to control the average power to a load is to control average voltage applied
to it. Then, using low-pass filtering, the variations in output voltage are
smoothed to generate a constant DC output voltage. Changing the average voltage
is done by rapidly opening and closing a switch using high frequency switching
(around 100 kHz). The average voltage generated by this switch behavior depends
on the duty cycle of the switching waveform. Hence, adjusting the pulse width can
be used to control the output voltage. This technique is called Pulse Width
Modulation.
The rectifier and filter components are common parts of both power supply
technologies. The rectifier converts an AC voltage to a DC voltage, while the
low-pass filter is used at the output of all power supplies to remove any AC
components from the DC output voltage. The isolation part is also a must for all
power supplies working from the AC mains to help assure that a patient is not
accidentally exposed to the high voltage in case of a component failure inside
the power supply. For most power supplies, this protection is provided by an
isolation transformer at the AC input to the system.
Reference:
[1] Texas Instruments, AN-556 Introduction to Power Supplies, Application Report,
2004, http://www.ti.com/lit/an/snva006b/snva006b.pdf, retrieved September 20,
2014
Q685EXPL
DC-DC converters are widely used to transform and distribute low voltage DC power
in systems and instruments. DC power is usually available to a system in the form
of a single system power supply voltage or battery. Common power supply output
voltages include 5 volts, 12 volts, 20 volts, 28 volts and 48 volts, although
other DC voltages are sometimes used. DC-DC converters utilize switching mode
power supply technology to convert this DC input supply to high frequency pulses
that can be controlled to generate any desired average voltage. Examples of
circuits using this technology include a buck regulator (step-down regulator), a
boost regulator (step-up regulator) and an inverting regulator (polarity
switching regulator). DC-DC converters may include multiple circuits that can be
used to generate any desired number of different output DC voltages from a single
input DC supply.
Reference:
[1] Texas Instruments, AN-556 Introduction to Power Supplies, Application Report,
2004, http://www.ti.com/lit/an/snva006b/snva006b.pdf, retrieved September 20,
2014
Q697EXPL
Optical encoders are devices that convert a mechanical position into a
representative electrical signal by means of a patterned disk or scale, a light
source and photosensitive elements. With proper interface electronics, position
and speed information can be derived. Encoders can be classified as rotary or
linear. Rotary encoders are used to measure angular displacement, while linear
encoders measure linear displacements.
Encoders are also classified as either incremental (relative) or absolute types,

depending upon whether the encoder is providing information about a relative
change in position, or information about an exact location.
Reference:
[1] Rotary encoder, Wikipedia, http://en.wikipedia.org/wiki/Rotary_encoder,
retrieved October 1, 2014
Q733EXPL
Computer data storage refers to computer components and recording media that
retain digital data for some interval of time. Computer data storage is a
fundamental component of all modern computers. In contemporary usage, computer
data storage can be divided into volatile and non-volatile storage devices. Non-
volatile memory refers to storage devices that retain data when power is removed,
while volatile memory loses any stored information once power is removed.
The two most common non-volatile memories are the hard drive and Read Only Memory
(ROM). The hard drive stores large programs (such as operating systems) or large
blocks of data magnetically on a magnetically sensitive mylar disk. Flash drives,
which are solid-state hard drives, are slowly replacing magnetic hard drives
because of their faster speed and resistance to mechanical shocks.
ROM generally stores small startup (bootstrap) programs and moderately large
programs and blocks of data electronically on an electronic integrated circuit
that is part of the computer's internal circuitry.
Volatile memory storage is used for temporary storage and utilizes Random Access
Memory (RAM). Both dynamic RAM (DRAM) and static RAM (SRAM) are used, with DRAM
being the more common. DRAM stores data on a small capacitor built into the
integrated circuit. Because the capacitor will slowly discharge, DRAM must be
refreshed periodically in order to retain the data it is storing. SRAM does not
need to be refreshed. Typically, DRAM is preferred because of its greater speed,
lower cost and smaller size. DRAM requires fewer transistors to construct,
compared to SRAM.
While ROM and RAM are considered primary storage, because they are directly
accessible by the CPU, there are other storage devices that are considered
secondary or tertiary storage because they are not directly accessible by the
CPU. These kinds of storage devices would typically be hard disk drives, DVD
drives, CD drives, and optical disc drives. All of these are generally both
slower than RAM and are non-volatile (i.e., offer permanent storage
capabilities).
References:
[1] What are primary and secondary storage devices?, PC.net website,
http://pc.net/helpcenter/answers/primary_and_secondary_storage, retrieved
September 5, 2014
[2] Casima, Ryan, Examples of Primary Storage Devices, eHow website,
http://www.ehow.com/list_6190720_examples-primary-storage-devices.html, retrieved
September 5, 2014
[3] Computer Data Storage, Wikipedia,
http://en.wikipedia.org/wiki/Computer_data_storage#Hierarchy_of_storage,
Q734EXPL
Computer data storage refers to computer components and recording media that
retain digital data for some interval of time. Computer data storage is a
fundamental component of all modern computers. In contemporary usage, computer
data storage can be divided into volatile and non-volatile storage devices. Non-
volatile memory refers to storage devices that retain data when power is removed,
while volatile memory loses any stored information once power is removed.
The two most common non-volatile memories are the hard drive and Read Only Memory
(ROM). The hard drive stores large programs (such as operating systems) or large
blocks of data magnetically on a magnetically sensitive mylar disk. Flash drives,
which are solid-state hard drives, are slowly replacing magnetic hard drives
because of their faster speed and resistance to mechanical shocks.
ROM generally stores small startup (bootstrap) programs and moderately large
programs and blocks of data electronically on an electronic integrated circuit
that is part of the computer's internal circuitry.
Volatile memory storage is used for temporary storage and utilizes Random Access
Memory (RAM). Both dynamic RAM (DRAM) and static RAM (SRAM) are used, with DRAM
being the more common. DRAM stores data on a small capacitor built into the
integrated circuit. Because the capacitor will slowly discharge, DRAM must be
refreshed periodically in order to retain the data it is storing. SRAM does not
need to be refreshed. Typically, DRAM is preferred because of its greater speed,
lower cost and smaller size. DRAM requires fewer transistors to construct,
compared to SRAM.
While ROM and RAM are considered primary storage, because they are directly
accessible by the CPU, there are other storage devices that are considered
secondary or tertiary storage because they are not directly accessible by the
CPU. These kinds of storage devices would typically be hard disk drives, DVD
drives, CD drives, and optical disc drives. All of these are generally both
slower than RAM and are non-volatile (i.e., offer permanent storage
capabilities).
References:
[1] What are primary and secondary storage devices?, PC.net website,
http://pc.net/helpcenter/answers/primary_and_secondary_storage, retrieved
September 5, 2014
[2] Casima, Ryan, Examples of Primary Storage Devices, eHow website,
http://www.ehow.com/list_6190720_examples-primary-storage-devices.html, retrieved
September 5, 2014
[3] Computer Data Storage, Wikipedia,
http://en.wikipedia.org/wiki/Computer_data_storage#Hierarchy_of_storage,
Q765EXPL
Cold environments seriously degrade a battery's total capacity. A battery
containing 250 mAh capacity at room temperature might have only half as much
total capacity outdoors during winter. An example of this is a car that starts in
warm weather but will not start on a cold morning. This reduction in capacity is
true for all commonly available battery technologies. Hot weather, on the other
hand, reduces the battery's overall service life (the number of charge/discharge
cycles).
Reference:
[1] BU-502: Discharging at High and Low Temperatures, Battery University website,
http://batteryuniversity.com/learn/article/discharging_at_high_and_low_temperatur
es, retrieved October 27, 2014
Q770EXPL
This is a series circuit consisting of a battery, an internal resistance, and a
100 ohm external resistance. See the diagram below for this circuit.
Using Ohm's Law, the current through the 100 ohm resistor is 6.09/100 = 0.0609 A,
or 60.9 mA. This is the same amount of current that flows through the battery's
internal resistance (RINT). The voltage drop across the internal resistance is
6.13-6.09, or 0.04 V. Knowing the voltage across the internal resistance and the
current through the internal resistance, the value of the internal resistance can
be determined using Ohm's Law.
RINT = (6.13 – 6.09) X 0.0609 = 0.04 X 0.0609 = 0.657 ohms = 657 milliohms
Reference : None
Q772EXPL
The voltage across any two wye-connected phases will be equal to the single-to-
neutral phase multiplied by the square root of 3 (which is 1.732). So the answer
is 120 X 1.732 = 208 V.
Reference:
[1] Three-phase power systems, All About Circuits website,
http://www.allaboutcircuits.com/vol_2/chpt_10/2.html
Q773EXPL
In a 3-phase system, each phase is offset from the other phases by 120 degrees.
This results in a complete cycle of 360 degrees, since 360 divided by three is
120.
References:
[1] Three-phase power systems, All About Circuits website,
Q774EXPL
There are three types of power: true (watts), apparent (volt-amperes or VA), and
reactive (volt-amperes reactive, or VAR). The relationship between the three is
determined using the Phythagorean Theorem, as shown in the diagram below:
Apparent power is always shown as the hypotenuse of a power triangle, while the
two legs are the true power and the reactive power. Using the Pythagorean
Theorem, we find that the apparent power is the square root of 240 2 + 1802 =
square root of 90,000 = 300 VA.
References:
[1] True, Reactive and Apparent Power, All About Circuits website,
Q775EXPL
The overall reactance of the load is (XL – XC) = (220 - 180) = +40 ohms, which
indicates an overall inductive reactance. (By convention, inductive reactance is
positive and capacitive reactance is negative. Thus, if the capacitive and
inductive reactances had been reversed, the overall reactance would have been -40
ohms, indicating an overall capacitive reactance.)
The overall impedance is determined by using the Pythagorean Theorem (a 2 + b2 =

c2) to determine the hypotenuse of a right triangle. This is shown in the diagram
below.
In this case,
Impedance = square root of [Resistance2 + Reactance2].
z = square root [3502 + (220 - 180)2]

z = square root [3502 + 402]
z = square root [122,500 + 1,600]
z = square root [124,100]
z = 352 ohms
Reference:
1] Floyd, Thomas L., Principles of Electric Circuits, 8th edition, Pearson-
Prentice Hall, 2007, pages 727-733
Q785EXPL
Transformer ratios are always given in the form of primary:secondary. In this
example, the number of turns in the primary winding is 8 times larger than the
number of turns in the secondary winding. This also means that the primary
voltage will be 8 times larger than the secondary voltage (so this is a stepdown
transformer). At the same time, the current produced by the secondary side will
be 8 times larger than the current on the primary side.
In this case, the output voltage will be 120/8 = 15 VAC.
Reference:
[1] Step-up and step-down transformers, All About Circuits website,
http://www.allaboutcircuits.com/vol_2/chpt_9/2.html, retrieved October 29, 2014
Q786EXPL
Power is equal to voltage times current, P = V x I. For a transformer, ignoring
losses, the power on both sides of the transformer will be the same. In this
example, since the power on the secondary winding side of the transformer is
equal to the power on the primary side, the secondary side power dissipation is 5
kW.
With a 1:3 turns ratio, the secondary voltage will be 3 times greater than the
primary voltage. Thus, the secondary voltage will be 3 x 120 = 360 VAC. Knowing
the secondary power (5 kW) and the secondary voltage (360 VAC), the secondary
current can be calculated as I = 5000/360 = 13.9 A.
Reference:
Q787EXPL
If the secondary voltage remains constant and the secondary resistance (load)
increases, then by Ohm's law, the secondary current must decrease, since I = V /
R. If the secondary current decreases, the primary current will also decrease in
line with the turns ratio of the transformer.
Reference:
Q792EXPL
Fuses and circuit breakers are designed to protect equipment from excessive
current. Some equipment may also need protection from excessive voltage, which
those components are not able to provide. That is the purpose of a crowbar
circuit.
A crowbar circuit is designed to protect voltage-sensitive loads. A crowbar

circuit will usually have an SCR (silicon-controlled rectifier) across the output
terminals to protect against an overvoltage event.
If the output voltage specifications are exceeded, the SCR is designed to short-
circuit across the load, preventing the excessive voltage from reaching the load.
Eventually, the short circuit draws enough current through the SCR that the fuse
or circuit breaker protecting the equipment will blow or trip.
Reference:
[1] Floyd, Thomas L., Electronic Devices, 9th edition, 2011, Pearson-Prentice
Hall, page 577
[2] SCR Overvoltage Crowbar Circuit, Electronics Infoline website,
http://www.electronicsinfoline.com/Projects/Electronics/Power_Supply_and_Battery/
Crowbar_and_Protection/scr_overvoltage_crowbar_circuit.shtml, retrieved October
29, 2014
Q795EXPL
The decimal number system uses 10 as its base, so numbers are expressed with the
digits 0 through 9. The binary number system uses 2 as its base, so numbers are
expressed using the digits 0 and 1. The octal number system uses 8 as its base,
and numbers are expressed using the digits 0 through 7.
The hexadecimal number uses 16 as its base, and so requires extra characters
other than the digits 0 through 9 to show numbers. To express the numbers 10
through 15, the hexadecimal system uses the characters A through F.
For most hexadecimal/decimal/octal/binary conversions, the typical sequence

begins with conversion into binary. The number 119 can be converted into a 7-bit
binary number as shown.
119 = 64 + 32 + 16 + 0 + 4 + 2 + 1
119 = (1 X 26) + (1 X 25) + (1 X 24) + (0 X 23) + (1 X 22) + (1 X 21) + (1 X 20)
119 (decimal) = 1110111 (binary)
Similarly, 119 can be converted into an octal number as follows:
119 = (1 X 82) + (6 X 81) + (7 X 80)
119 (decimal) = 167 (octal)
Finally, 119 can be converted into a hexadecimal number this way:
119 = (7 X 161) + (7 X 160)
119 (decimal) = 77 (hexadecimal)
Reference:
[1] Binary number, Wikipedia, http://en.wikipedia.org/wiki/Binary_number,
[2] Hexadecimal, Wikipedia, http://en.wikipedia.org/wiki/Hexadecimal, retrieved
October 30, 2014
[3] Octal, Wikipedia, http://en.wikipedia.org/wiki/Octal, retrieved October 30,
2014
[4] Floyd, Thomas L.; Digital Fundamentals; 9th edition, 2006, Pearson-Prentice
Hall, pages 48-78
Q801EXPL
This is an Ohm’s Law question: V = IR or, rearranging, I = V/R.
In this case,
I = (60.1 x 10-6 volts)/0.15 ohms
I = .0000601 / 0.15
I = .0004007 amperes
I = 400.7 microamps
Reference:
None
Q803EXPL
BMETs should always replace batteries with like-technology, comparable
specification batteries.
Replacing the battery with a different technology (in this case, replacing a
lithium-ion battery with an NiMH battery) is incorrect even if the physical size,
voltage and capacity specifications are the same, because different battery
technologies may have differing discharge curves causing differing operational
characteristics (e.g. time from battery alarm to totally dead battery). In
addition, the battery charging circuitry inside the oximeter may be specifically
designed to work with one type of battery, but not a different type. Also,
battery technologies are part of a medical device’s FDA approval and should not
be modified without the device manufacturer’s approval.
The battery chargers are much less likely to be a problem since the batteries did
work for most of one year.
References:
[1] Lipshultz, Alan, Battery Issues from Standpoint of Healthcare Technology
Managers (HTM), Powerpoint presentation,
http://www.fda.gov/downloads/MedicalDevices/NewsEvents/WorkshopsConferences/UCM36
4405.pdf, retrieved October 31, 2014
[2] How to Make Batteries in Medical Devices More Reliable, Battery University
website,
http://batteryuniversity.com/learn/article/how_to_make_batteries_in_medical_devic
es_more_reliable, retrieved October 31, 2014
[3] Battery Maintenance is one of the Top 10 problems faced by today's Biomedical
Engineer Technicians according to the AAMI association, Cadex website,
http://www.cadex.com/en/applications/hospitals, retrieved October 31, 2014
Q810EXPL
Operational amplifiers have a very high gain, along with a high input impedance
and low output impedance.
An amplifier with low input impedance and high output impedance would "drag down"
the signal strength of the signal produced by the preceding stage, resulting in a
lower amplitude and possibly distorted input signal.
Operational amplifiers are designed to have a high CMRR (common-mode rejection

ratio) so that the background signal present on both input leads of the op amp is
not amplified, while the difference between the signals on the input leads is
amplified.
Op amps are frequently "ganged" together to provide more gain. In addition, op
amps can provide isolation when they are used in a buffer configuration.
Reference:
[1] Ardizzoni, John, The Incredible Versatile Op Amp in Medical Applications,
Technical Article MS-1946, Analog Devices, http://www.analog.com/static/imported-
files/tech_articles/MS-1946.pdf, retrieved October 31, 2014
[2] Leach, Marshall, Ideal Op-Amp Circuits, Georgia Institute of Technology,
http://users.ece.gatech.edu/mleach/ece4435/chap01.pdf, retrieved October 31, 2014
[3] Leach, Marshall, Characteristics of Physical Op-Amps, Georgia Institute of
Technology, http://users.ece.gatech.edu/mleach/ece4435/chap02.pdf, retrieved
October 31, 2014
Q811EXPL
The capacity of the battery is the best indicator of the health of the battery.
Battery capacity is normally measured in ampere-hours (AH) and represents the
amount of energy the battery will deliver. A new battery will deliver around 100%
of its rated capacity. As the battery ages, is exposed to heat, or is charged
improperly, the actual capacity will decrease and may be only a small fraction of
its rated capacity.
The charge time of a battery is the measurement of the amount of time it takes a
battery to fully charge. A weak battery generally charges faster than a strong
battery, but there is not a good correlation between the time it takes for a
battery to fully charge and its performance. Also, charge times vary among
different types of batteries.
Battery leakage refers to fluid that is leaked from a battery.
Self-Discharge refers to battery energy loss while not in use. Self-discharge

rate is also a performance indicator. The rate increases as batteries age, as
temperatures rise and with high charge-discharge cycle counts. A battery
typically needs replacement if the self-discharge reaches 30% in 24 hours.
References:
[1] BU-1503 How to Maintain Batteries, Battery University website,
http://batteryuniversity.com/learn/article/bu_1503_how_to_maintain_batteries,
[2] Buchmann, Isidore, Knowing When to Replace Batteries, 2011,
http://www.cadex.com/_content/Knowing_When_to_Replace_Batteries.pdf, retrieved
October 16, 2014
Q829EXPL
When faced with the symptom that medical equipment does not energize, one should
first consider the possibility that no voltage is getting to the equipment. A
methodical approach will often yield quick resolution to the problem. Check the
obvious first. Is the on/off switch on? Is the plug connected to the wall outlet?
Has a circuit-breaker tripped? Has a fuse blown? Is the power cord cracked, cut,
or frayed?
The other problems described (output voltage level, defective diode bridge,
scorched spot on a circuit board) all require more time to check, and may require
disassembling the device. While all of those may need to be done, it makes sense
to check the easiest things first, i.e., making sure that the device is actually
plugged in and turned on, before taking any additional steps.
Reference:
[1] Wolfe, Glen L., Is It Turned On? Troubleshooting Power Supplies, Biomedical
Instrumentation & Technology, January 2007, Volume 41, Number 1, pages 48-49
Q846EXPL
The acronym UPS stands for Uninterruptible Power Supply (also sometimes called an
Uninterruptible Power System). It is a device that automatically provides
emergency electrical power to a connected device when there is an interruption to
the main power source. A UPS differs from an emergency generator in that it is
designed to always provide power, while an emergency generator takes some period
of time to start generating electricity and during that time, the connected
device will have no power coming into it.
A UPS typically operates by charging an internal battery while the mains power is
operational. Once there is an interruption, the power stored in the battery is
almost instantaneously connected to the UPS’s output through a DC-to-AC
convertor, so that there is virtually no perceptible interruption of power. The
UPS will continue to operate until the internal battery is discharged. When
determining the minimum capacity of a UPS to be used in a given situation, the
things to consider are usually either the time required to achieve a graceful
shutdown of the connected equipment, or if the equipment is connected to an
emergency power circuit, the time needed for the backup generator to be brought
online.
A UPS is typically connected to devices that must be highly reliable, such as

computer systems and some medical devices where even a brief interruption can
cause a serious patient injury or death, such as anesthesia machines or
ventilators.
References:
[1] Uninterruptible power supply, Wikipedia,
http://en.wikipedia.org/wiki/Uninterruptible_power_supply
[2] The Eaton UPS and Power Management Fundamentals Handbook, Eaton Corporation,
March 2013, http://pqlit.eaton.com/ll_download_bylitcode.asp?doc_id=16991, pages
24 and 28, retrieved November 9, 2014
[3] Atles, Leslie R., A Practicum for Biomedical Engineering and Technology
Management Issues, Kendall Hunt Publishing Co., Dubuque, 2008, page 767
Q847EXPL
The internal batteries in a UPS (uninterruptible power supply) are the most
vulnerable part of a UPS. Like all batteries, these have a limited service life,
which is typically three to five years. Batteries that no longer are able to
produce 80% of their amp-hour rating should be replaced. At a minimum, the self-
test feature of a UPS should be checked annually to assure that batteries are
capable of delivering the required power.
Most UPSes utilize sealed batteries, which are made so that they will not leak
and will not require the addition of water. These are sometimes referred to as
maintenance-free batteries because water cannot be added to them. However, even
these batteries should be tested at least annually, because they do have a
limited service life and it is important to know that a UPS can perform its job
when a power failure does occur.
The capacitors in a UPS will dry out over time, and so will no longer be
effective. However, the rate at which capacitors degrade is far slower than
batteries, so batteries are by far the most common cause of failure of a UPS. The
diodes in the battery charging circuit will not normally be subject to
overheating, so they do not need to be routinely inspected.
Reference: [1] The Eaton UPS and Power Management Fundamentals Handbook, Eaton
Corporation, March 2013,
http://pqlit.eaton.com/ll_download_bylitcode.asp?doc_id=16991, pages 24 and 28,
retrieved November 9, 2014
Q881EXPL
With switch S1 closed, as shown, the resistance between terminals C and D is
essentially zero. Ohm's Law, V=IR, tells us that with zero resistance, the
voltage V = I(0) = 0. Therefore, the voltage across the closed switch is 0 V.
References:
[1] Grob, Bernard, and Schultz, Mitchel, Basic Electronics, 9th Edition,
Macmillan/McGraw-Hill, 2003, pages 117-122
Q882EXPL
With switch S1 open, the resistance between terminals C and D is essentially
infinite. In a series circuit with multiple resistances, the highest resistance
has the greatest voltage drop. When a voltmeter is connected between terminals B
and D, the series circuit is completed and the full source voltage (15 V) is
dropped across the open switch.
References:
Q883EXPL
Current favors the path of least resistance. The resistance of the leg controlled
by S1 decreases when the S1 goes from position A to position B, because the total
resistance of that leg is now 120 ohms + R1, rather than 180 ohms + R1.
The effect of this is to put a smaller resistance in parallel with the 220 ohm
resistor. When any two resistors are placed in parallel with each other, the
equivalent resistance decreases. The equivalent resistance will always be less
than the resistance of either leg.
Let's consider the effect of changing the value of R1 to see how this would
affect the current through the 220 ohm resistor.
If R1 = 0 ohms, with S1 in the A position, the equivalent circuit is shown below:
The combination of the 220 ohm resistor in parallel with the 180 ohm resistor is
equivalent to a 99 ohm resistor. Using Ohm’s law, we can determine that the
voltage across the 99 ohm resistor will be 3.98 V. With that information, we can
determine that the current through the 220 ohm resistor will be 18 mA.
Similarly, if the switch is moved to the B position, the 120 ohm resistor will
now be in parallel with the 220 ohm resistor. This situation is shown below:
In this case, the equivalent resistance to the parallel combination will be 78

ohms, with 2.61 V across it. This would yield a current of 12 mA through the 220
ohm resistor.
If R1 were a higher value, the values of the equivalent parallel resistances

would increase, but the combination of the 220 ohm resistor in parallel with the
120 ohm + R1 resistances will always be less than the combination of the 220 ohm
resistor in parallel with the 180 ohm + R1 resistance.
As R1 increases in value, the difference between the equivalent resistances

associated with the two choices will decrease, but, there will always be a higher
voltage across the 220 ohm resistor when the 180 ohm resistor is in the circuit,
compared to the 120 ohm resistor.
As a result, the current flowing through the 220 ohm resistor will always be
lower when the switch is in position B compared to position A.
Reference:
Q886EXPL
Negative feedback makes an output smaller (and more stable). Positive feedback
makes an output larger (and less stable). If the negative feedback is increased,
the output will be reduced.
The general equation for a circuit with feedback is:

Vout = Vin {Gff / [1 + (Gfb)(Gff)]}
where Gff is the feedforward gain, in this case, 5, and G fb is the feedback gain,
in this case, 0.1. So for this circuit,
Vout = (100 V){5/[1 + (0.1)(5)]} = (100)(5 / 1.5) = 100 / 0.333 = 333 V
As an example, if the feedback gain increased to 0.2, then:

Vout = (100 V){5/[1 + (0.2)(5)]} = (100)(5/2) = 250 V
So the output drops as the feedback gain increases.
Reference:
[1] Negative Feedback Systems, Electronics Tutorials website,
http://www.electronics-tutorials.ws/systems/negative-feedback.html, retrieved
November 29, 2014
Q889EXPL
Consider each gate separately. Is the output of a particular gate correct for its
given inputs?
Gate A is an AND gate with inputs of 0 and 1. Under those conditions, an AND gate
should have an output of 0, which is what is indicated, so gate A appears to be
functioning properly.
Gate B is an Exclusive-OR (XOR or EXOR) gate with inputs of 1 and 1. When the two
inputs to an XOR gate are both 0 or both 1, the output should be 0, which is what
we see here. So this gate appears to be working properly.
Gate C is a NOR gate. The logic for a NOR gate specifies that it will only have a
1 output when both inputs are 0. Otherwise, the output will be 0. In this case,
the inputs to C are 0 and 0, so its output should be 1. However, the output shown
is 0, so this gate is not operating correctly.
Gate D is a NAND gate. The logic for a NAND gate specifies that it will only have
a 0 output when both of the inputs are 1. For all other conditions, the output
will be 0. The inputs shown are both 0, and the output is 1, so this gate’s
output is correct.
Gate E is another OR gate, this time with inputs of 0 and 1. For an OR gate, the
output will be 0 only when both inputs are 0. Therefore, under the conditions
given, the output should be 1, which is what we see.
References:
[1] Floyd, Thomas L., Digital Fundamentals, 9th Edition, Pearson Prentice Hall,
2006, pages 117-142
[2] Boolean Algebra Truth Tables, Electronics Tutorials website,
http://www.electronics-tutorials.ws/boolean/bool_7.html, retrieved November 30,
2014
Q890EXPL
Consider each gate separately. Is the output of a particular gate correct for its
given inputs?
Gate A is a NOR gate. For a NOR gate, the output will be 1 only when both inputs
are 0. In this case, the inputs are 0 and 1, so the output should be 0, but the
output is a 1, so this gate is not operating properly.
Gate B is an Exclusive-NOR (XNOR or EXNOR) gate. Its output will be 1 if both
inputs are either 0 or 1, but a 0 when the inputs are different. In this case,
the two input lines are both 1s, so the output should be a 1. Since it is, this
gate appears to be operating correctly.
Gate C is a NAND gate. Its output will be 0 when both inputs are 1, and the
output will be 1 when either one or both inputs are 0. In this case, one input
line is a 0, and the other is a 1, so the output should be a 1. Since it is, this
gate appears to be working correctly.
Gate D is an Exclusive-OR (XOR) gate. Its output will be 0 is both inputs are
either 0 or 1, but a 1 when the inputs are different. In this case, both input
lines are 1s, so the output should be 0. Since this is the case, this gate
appears to be working correctly.
Gate E is an OR gate. Its output will be 0 when both inputs are 0, but if either
or both inputs are 1, then the output will be 1. Since in this case both inputs
are 1, and the output is 1, this gate appears to be working properly.
Gate F is an AND gate. Its output will be 0 one or both inputs are 0, and the
output will be 1 when both inputs are 1. In this case, one input line is a 0, and
the other is a 1, so the output should be a 0. Since it is, this gate appears to
be working correctly.
References:
[1] Floyd, Thomas L., Digital Fundamentals, 9th Edition, Pearson Prentice Hall,
2006, pages 117-142
[2] Boolean Algebra Truth Tables, Electronics Tutorials website,
http://www.electronics-tutorials.ws/boolean/bool_7.html, retrieved November 30,
2014
Q932EXPL
Faraday’s law describes how a magnetic field can induce an electrical current. It
is used to describe the operation of transformers, as well as many types of
motors and generators.
Snell’s law describes how light is bent when it travels from one medium to
another, such as when light goes from air into glass. Snell’s law says that n 1 ×
sinΘ1 = n2 × sinΘ2, where n1 is the refractive index of the first medium, n 2 is the
refractive index of the second medium, Θ 1 is the angle at which the light ray
enters the boundary between the two materials (angle of incidence), and Θ 2 is the
angle at which the light ray leaves the boundary (angle of refraction). Snell’s
law explains how light rays are bent through a lens regardless of whether the
lens has a concave or convex shape. The principles of optics is used by many
medical devices, including microscopes of all types.
Ohm’s law is used in electronics to describe the relationship between voltage,

current and resistance.
Lenz’s law is related to Faraday's law. Lenz's law describes how currents that
are induced by a magnetic field will behave in a way that obeys Newton's third
law, which relates to the conservation of energy.
References:
[1] Noblitt, John, Surgical and Laboratory Microscopes, 24X7. November 7, 2014,
http://www.24x7mag.com/2014/11/surgical-laboratory-microscopes, retrieved
November 29, 2014
[2] Faraday's law of inducation, Wikipedia,
http://en.wikipedia.org/wiki/Faraday%27s_law_of_induction, retrieved December 30,
2014
[3] Snell's law, Wikipedia, http://en.wikipedia.org/wiki/Snell%27s_law, retrieved
December 30, 2014
[4] Ohm's law, Wikipedia, http://en.wikipedia.org/wiki/Ohm%27s_law, retrieved
December 30, 2014
[5] Lenz's law, Wikipedia, http://en.wikipedia.org/wiki/Lenz%27s_law, retrieved
December 30, 2014
[6] Newton's laws of motion, Wikipedia,
http://en.wikipedia.org/wiki/Newton%27s_laws_of_motion#Newton.27s_third_law,
retrieved December 30, 2014
Q968EXPL
Most centrifuges use carbon brushes to provide power to the motor armature. Over
time, these brushes will wear down, creating carbon dust, which can lead to high
leakage current. To address this problem, the motor needs to be carefully cleaned
to remove as much of the carbon dust as possible.
If there were shorted motor windings or poor insulation, this could account for
high leakage current. However, both of those problems are much less likely to
occur than carbon dust caused by worn brushes.
While a short to ground inside the power supply could also cause high leakage
current, it would most likely cause the circuit breaker to trip, making the
centrifuge non-operational.
Reference:
[1] Motor repair, DIY Wiki,
http://wiki.diyfaq.org.uk/index.php?title=Motor_repair#Live_case_or_earth_leakage
, retrieved December 31, 2014
Q2074EXPL
Fiber optic cable relies on the transmission of light through a thin glass fiber
to transport signals, while copper cable relies on the transmission of electrons
through a copper wire to achieve similar signal transport. In order to send
electrical signals through a copper cable, there must be a good quality
electrical connection. In general, this means minimal electrical resistance
between the two ends a copper cable, and minimal crosstalk between adjacent
cables.
On the other hand, to achieve good light transmission, the fiber optic cable must
have continuity between the two ends of the cable, and the ends of the cable must
be properly cleaned before putting on the connectors so that there is minimal
degradation of the light sent through the fiber optic cable.
In general, fiber optic cable is much more prone to physical damage than copper
cable. This is because of the relatively fragile nature of the glass fiber.
Copper cable is much more resistant to damage from bending or stretching.
In order to verify fiber optic cable integrity, specialized test equipment is

used, such as an optical time dmain reflectometer (OTDR). The OTDR is an
instrument that is able to locate the distance to a fiber optic cable fault. The
faults that it is able to identify include breaks, bends, and other excessive
signal losses.
Fiber optic cable is not tested with an ohmmeter, because an ohmmeter detects
electrical continuity, and these cables do not use electrical connections for
signal transmission. On the other hand, copper cable is often tested for its
electrical resistance to verify continuity and the integrity of its connections.
Fiber is typically factory terminated, but still needs to be field tested because
the handling experienced by the cable during installation, such as from bending
or stretching, can damage the cable.
Reference:
[1] Fiber Optic Testing, https://www.lanshack.com/fiber-optic-tutorial-
testing.aspx, retrieved December 15, 2018.
[2] Fiber Testing, https://www.viavisolutions.com/en-us/fiber-testing, retrieved

December 15, 2018.
[3] OTDR Testing, https://www.viavisolutions.com/en-us/solutions/wireline/otdr-

testing, retrieved December 15, 2018.
[4] Fiber Optic Testers, https://www.flukenetworks.com/Expertise/Learn-

About/Fiber-Testing, retrieved December 15, 2018
[5] OptiFiber Pro OTDR Family, https://www.flukenetworks.com/datacom-

cabling/fiber-testing/optifiber-pro-otdr, retrieved December 15, 2018.
Q2081EXPL
A 3 1/2-digit DVM can display a total of 4 digits, but the left-most digit can be
only 0 (or blank) or 1. Therefore, a display of 1999 is possible.
Displays of 2999 and 9999 have a total of 4 digits, but the left-most digit is
greater than 1.
Similarly, displays of 19999 and 29999 require 5 digits, and so could not be
displayed on a 3 1/2-digit DVM.
References:
[1] Accuracy, resolution, range, counts, digits, and precision,
https://www.fluke.com/en-us/learn/best-practices/test-tools-basics/digital-
multimeters/accuracy-resolution-range-counts-digits-precision, retrieved January
26, 2019.
[2] What's a half digit, anyway?, https://www.edn.com/electronics-

news/4389451/What-s-a-half-digit-anyway-, retrieved January 26, 2019.
[3] 3.5 and 4.5 Digit Meters Explained, https://www.spellmanhv.com/en/Technical-

Resources/Application-Notes-HVPS/AN-15, retrieved January 26, 2019.
Q2091EXPL
A cable tracer (also known as a cable tracker) allows a technician to find
individual leads among possibly hundreds in a cable trunk, without having to
either strip the insulation from the wires or disconnect at the remote end.
A typical cable tracer injects a signal from a tone generator into a particular
wire that is being tested. By using an amplifier that is inductively coupled to
the wires at the remote end of the cable, the injected tone can be detected. By
carefully moving the amplifier's probe along the individual wires at the end
being tested, the technician will often be able to identify the particular wire
that he or she is trying to find.
An oscilloscope is usually used to display the waveform associated with voltage

at a given point in a circuit.
A spectrum analyzer is used to measure the amplitude of an input signal as a

function of frequency.
A voltmeter is used to measure the amplitude of the voltage found at a given

point in a circuit.
An ammeter is used to measure the amplitude of the current flowing through a

wire.
References:
[1] How does a cable tone-and-probe kit work?,
https://electronics.stackexchange.com/questions/144267/how-does-a-cable-tone-and-
probe-kit-work, retrieved January 27, 2019.
[2] Cable Tracing: Tone and Probe,

https://www.idealnetworks.net/us/en/products/cable-testing/copper-testing/cable-
tracing-tone-and-probe.aspx, retrieved January 27, 2019.
[3] How to trace and track wires using a cable tracker,

https://www.youtube.com/watch?v=gCKOAnnSb3c, retrieved January 27, 2019.
[4] Oscilloscope, https://en.wikipedia.org/wiki/Oscilloscope, retrieved January

29, 2019.
[5] Spectrum analyzer, https://en.wikipedia.org/wiki/Spectrum_analyzer, retrieved

January 29, 2019.
[6] Voltmeter, https://en.wikipedia.org/wiki/Voltmeter, retrieved January 29,

2019.
[7] Ammeter, https://en.wikipedia.org/wiki/Ammeter, retrieved January 29, 2019.
Q2092EXPL
While there are several ways to determine whether a particular set of wires
corresponds to those that end in a particular RJ-45 jack, probably the fastest
way to do this is by shorting two contacts of either RJ-45 jack and then using
the continuity tester option of a multimeter to determine if the wires at the
other end that are suspected of being used are actually shorted together.
Virtually all technicians have (or should have) access to a multimeter with a
continuity tester option that provides either a visual or audible indicator or
both. When the two leads of the multimeter are placed on the two corresponding
wires of the RJ-45 jack, the indicator will activate if those wires are shorted
together at the far end.
While a cable tracer (also known as a cable tracker or toner probe) could also be
used to perforrm this testing, not all technicians will have ready access to a
cable tracer. A toner probe allows a technician to find individual leads among
possibly hundreds in a cable trunk, without having to either strip the insulation
from the wires or disconnect at the remote end.
A punch down tool is used for inserting wires into a punch down block. It cannot
be used for testing the continuity of those wires.
A spectrum analyzer is used to measure the amplitude of an input signal as a

function of frequency.
An oscilloscope is usually used to display the waveform associated with voltage

at a given point in a circuit.
References:
[1] How to Use a Multimeter: Continuity,
https://learn.sparkfun.com/tutorials/how-to-use-a-multimeter/continuity,
retrieved January 27, 2019.
[2] Punch down tool, https://en.wikipedia.org/wiki/Punch_down_tool, retrieved

January 27, 2019.
[3] How does a cable tone-and-probe kit work?,

https://electronics.stackexchange.com/questions/144267/how-does-a-cable-tone-and-
probe-kit-work, retrieved January 27, 2019.
[4] Spectrum analyzer, https://en.wikipedia.org/wiki/Spectrum_analyzer, retrieved

January 29, 2019.
[5] Oscilloscope, https://en.wikipedia.org/wiki/Oscilloscope, retrieved January

29, 2019.
Medical devices
Q157EXPL
An x-ray tube is a vacuum tube diode. In order to produce x-rays, the diode must be forward biased. All diodes, regardless
of type, are forward biased when the anode is positive, with respect to the cathode. The reverse biased condition will have
the anode negative, with respect to the cathode.
In an x-ray tube, current is applied to the cathode, causing it to emit electrons. Because the anode potential is positive with
respect to the cathode, the electrons are attracted to the anode. The anode voltage is in the kV range and may be as high as
150 kV. The high potential difference between the anode and cathode accelerates the electrons to a very high velocity.
When the electrons strike the anode, energy is released in the form of x-rays and heat.
References:
[1] Chatterjee, Shakti and Miller, Aubert, Biomedical Instrumentation Systems, Delmar Cengage Learning, 2010, Chapter
15
[2] Carr, Joseph J. and Brown, John M., Introduction to Biomedical Equipment Technology, 4th edition, Prentice Hall,
2001, Chapter 23.
Q173EXPL
A Doppler-based instrument relies on the principle that a moving object will alter the frequency of a wave that bounces
off it. The Doppler shift is such that if an object is moving toward the receiver, the frequency will be increased, while an
object moving away from the receiver will cause the frequency of the reflected wave to decrease.
Continuous Doppler ultrasonic instruments rely on this principle to detect moving objects, such as blood flowing in an
artery, or the motion of a fetal heart.
Pulsed ultrasound is used to detect stationary structures, such as the location of tumors, or the location of the brain
midline. Tissue heating can also be provided by ultrasound, such as ultrasonic diathermy; however, this system only uses
ultrasound transmission. There is no provision for receiving the reflected signal to determine diagnostic information.
References:
[1] Feinberg, Barry N., Applied Clinical Engineering, Prentice Hall, 1986, page 220.
[2] Street, Laurence J., Introduction to Biomedical Engineering Technology, CRC Press, 2008, page 82.
Q174EXPL
Soda lime crystals are used as part of the breathing circuit in an anesthesia machine. The patient's air circuit is a closed
system, so that the patient constantly rebreathes the same air that was exhaled. This is done to minimize the use of the
anesthetic agent in use. Fresh oxygen is replaced in the air as it is consumed.
When rebreathing takes place, the level of carbon dioxide in the air increases rapidly if steps are not taken to counteract
this increase. This will cause an increased respiration rate, or even more significant consequences, if not controlled.
The soda lime crystals in an anesthesia machine will absorb the carbon dioxide in the rebreathed gas, and so prevents its
buildup to unacceptable levels.
Reference: Street, Laurence J., Introduction to Biomedical Engineering Technology, CRC Press, 2008, page 184.
Q175EXPL
To determine the frequency, range of an aortic blood pressure waveform, first consider the lower range.
Because the arterial blood pressure is always greater than zero (for example, a typical value might be 120/80), there must
be a DC component to the waveform. If the waveform were purely an AC waveform, with no DC component, the average
of the waveform would equal zero.
The upper end of the waveform is the subject of some consideration. For practical purposes, the arterial waveform can be
adequately recorded by considering only harmonics up to the tenth harmonic of the heart rate. For a heart rate of 120 beats
per minute, or 2 beats per second, this would translate to a bandwidth up to 20 hertz. However, there is information at
higher frequencies, and there is no absolute cutoff. A good compromise for the upper range of interest is 30 to 50 hertz.
Reference: Webster, John G., Medical Instrumentation: Application and Design, 4th edition, Wiley, 2010, pages 311-312.
Q176EXPL
Therapeutic ultrasound is used to provide deep heating. As ultrasound energy is absorbed by tissue, heat is generated.
Ultrasound is absorbed most by tissues that are high in protein, such as collagen, and relatively low in water content.
Therapeutic ultrasound devices operate in the range from 0.75 megahertz to 3 megahertz. The most common operating
frequency in the U.S. is 1 megahertz.
Reference: Peat, Malcolm, Current Physical Therapy, B.C. Decker, 1988, page 212.
Q177EXPL
While the impedance seen by a defibrillator through its paddles can vary considerably from patient to patient, generally,
when properly applied to a patient using conductive gel, the impedance seen by the paddles is about 50 ohms.
Reference: Feinberg, Barry N., Applied Clinical Engineering, Prentice Hall, 1986, page 416.
Q178EXPL
For pulses applied directly to the heart by a constant-current amplitude pacemaker, the pulse width typically used is
between 0.1 and 1.2 milliseconds. The amplitude of the pulses will be between 8 and 10 milliamperes.
Reference: Webster, John G., Medical Instrumentation: Application and Design, 4th edition, Wiley, 2010, pages 592.
Q179EXPL
Gamma cameras and scintillation counters are devices used as part of nuclear medicine studies. These devices detect the
amount of radioactivity emitted by radioactive substances taken up by specific organs during medical tests.
The substances administered to patients are designed to be taken up by specific organs because of their function. For
example, radioactive iodine is taken up by the thyroid gland (as is regular iodine). The amount of the iodine found in the
gland during the study is measured by these devices and indicates how well the thyroid is performing.
Location and density of organs would usually be measured by x-rays.
Motion of an organ might be measured using fluoroscopy or diagnostic ultrasound.
Reference: Carr, Joseph J., and Brown, John M., Introduction to Biomedical Equipment Technology, 4th edition, Prentice
Q180EXPL
The velocity of ultrasonic waves in various body tissues is shown below:
Q181EXPL
A spectrophotometer is a laboratory instrument that measures the absorption of light of various wavelengths by a sample
of a substance. By determining the light absorption characteristics of the sample, a determination can be made about what
is in the sample.
To select only a narrow band of wavelengths of light to pass through the substance, a monochromator is used. The
monochromator uses a diffraction grating to break up light into its wavelengths, as a prism does. By rotating the
diffraction grating, different wavelengths of light will be selected to go through the sample, which is contained in a
cuvette.
Q182EXPL
The nitrogen washout test has a patient breathe pure oxygen to remove nitrogen from the lungs. By breathing pure
oxygen, the nitrogen remaining in the lungs will be "washed out" with each successive breath and replaced by the inhaled
oxygen. The amount of nitrogen remaining in each exhaled breath is determined and plotted. By examining the wash out
curve, the volume of air initially in the lungs can be calculated. This volume of air is the functional residual capacity.
References:
[1] Cromwell, Leslie, Weibell, Fred J., and Pfeiffer, Erich A., Biomedical Instrumentation and Measurements, 2nd
[2] Webster, John G., Medical Instrumentation: Application and Design, 4th edition, Wiley, 2010, pages 401 – 403.
Q183EXPL
Positive end expiratory pressure (PEEP) is used by a ventilator to keep the lungs more inflated than they would be on their
own, by keeping a constant pressure in them at all times. This helps increase the functional residual capacity of the lungs.
Reference: Chatterjee, Shakti and Miller, Aubert, Biomedical Instrumentation Systems, Delmar Cengage Learning, 2010,
page 351.
Q184EXPL
For a "cut" waveform, an electrosurgery unit produces almost a pure sine wave output. This waveform heats tissue, and
results in cutting action, with minimum hemostasis.
At times during surgery, a surgeon wants to produce hemostasis (stoppage of bleeding). To do this effectively, a "coag"
(short for coagulation) waveform is used. This waveform consists of a very short duration pulse followed by a
significantly longer period with no output. This entire waveform is repeated rapidly.
The quality of the coag waveform is indicated by the crest factor. This is the ratio of the peak output voltage at the top of
the pulse to the average, or RMS, voltage of the entire waveform over time.
A cut waveform has a crest factor very close to 1. In the "blend" mode, an electrosurgery unit produces an output
waveform that is a mixture of the pure cut and pure coag waveforms. As more and more coag is added, the crest factor
increases.
Reference: Street, Laurence J., Introduction to Biomedical Engineering Technology, CRC Press, 2008, page 255.
Q185EXPL
The bipolar leads are the electrocardiogram waveforms recorded by measuring between leads located on the right arm and
left arm (lead I), the right arm and left leg (lead II), and the left arm and left leg (lead III).
The unipolar leads examine the electrocardiogram recorded by measuring the electrocardiogram between leads located on
the right arm, and the sum of the left arm and left leg leads (aVR), the left arm, and the sum of the right arm and left leg
leads (aVL), and the voltage difference between the left leg, and the sum of the right arm and left arm leads (aVF).
Q186EXPL
The typical way that respiration rate is measured is by impedance pneumography. This technique uses the ECG electrodes
attached to a patient's chest, and sends a small current through those electrodes to measure the impedance of the chest.
As the patient breathes in, the chest expands. The larger size of the chest will cause the impedance measured between the
electrodes to increase slightly. Then, as the patient breathes out, the chest will contract, resulting in a lower impedance.
By measuring the time between the highest and lowest values of chest impedance, the patient monitor can detect the
respiration rate. For most patients, the monitor will be set to alarm if respirations stop. This is an apnea alarm.
For a typical adult, the baseline impedance (the impedance seen between the two chest electrodes) is about 500 ohms. The
change in electrical impedance seen during the respiration cycle ranges from 0.1 ohms (100 milliohms) to 1 ohm (1,000
milliohms). Therefore, the best choice is 500 milliohms, which is the only value of the ones offered in this question that is
within the range of 100 to 1,000 milliohms.
Reference:
[1] Gupta, Amit K., Respiration Rate Measurement Based on Impedance Pneumography, Application Report SBAA181-
February 2011, Texas Instruments, page 2, http://www.ti.com/lit/an/sbaa181/sbaa181.pdf, retrieved May 3, 2015.
Q187EXPL
Determining the fetal heart rate is critical to the analysis of the condition of the fetus during labor. To find the heart rate, a
variety of techniques can be used.
The least invasive is to use an ultrasound transducer placed on the mother's abdomen. This transducer picks up the motion
associated with the heart as it beats and translates that to a heart rate. However, this technique will sometimes not produce
reliable results as the fetus moves, and its heart moves in and out of the ultrasound beam.
A more reliable heart rate is obtained by using a scalp electrode. This is a very sharp, spiral electrode that can be screwed
into the fetal scalp and provides a direct electrical connection. This technique is generally only used during the later stages
of labor when the fetus has descended sufficiently into the birth canal, so that the electrode can be applied to its head. This
technique produces a very reliable fetal ECG, and a very reliable heart rate.
A third technique relies on applying electrodes on the mother's abdomen, and using signal processing, trying to subtract
the maternal ECG from the abdominal signal to give the fetal ECG, from which the heart rate can be derived. This
technique was used in the early 1970s, because it was a non-invasive technique and could be done at any stage of labor.
However, the extensive signal processing requirements for this technique make its actual application unreliable. It has
fallen into disfavor as ultrasound transducers using correlation techniques have become more reliable and gained favor.
Q188EXPL
The nitrogen washout test has a patient breathe pure oxygen to remove nitrogen from the lungs. By breathing pure
oxygen, the nitrogen remaining in the lungs will be "washed out" with each successive breath and replaced by the inhaled
oxygen.
The amount of nitrogen remaining in each exhaled breath is determined and then plotted. By examining the washout
curve, the volume of air initially in the lungs can be calculated. This volume of air is the functional residual capacity.
References:
edition, Prentice Hall, 1980, pages 228 - 229
[2] Webster, John G., Medical Instrumentation: Application and Design, 4th edition, Wiley, 2010, pages 401 – 403.
Q189EXPL
The electromyogram is a recording of muscle electrical activity.
Muscles produce electrical signals that have a much larger bandwidth than signals like the electrocardiogram or blood
pressure waveforms. To accurately reproduce EMG signals, an amplifier must have a frequency response from about 10
hertz up to at least 3,000 hertz.
References:
[2] Webster, John G., Medical Instrumentation: Application and Design, Wiley, 4th edition, 2010, pages 270 – 271.
Q190EXPL
The accuracy of reproduction of a blood pressure waveform depends very much on having a plumbing system that will
accurately pass the frequencies in the waveform.
If the system's resonant frequency is too close to the frequencies found in the waveform, distortion will result as the
system will amplify the frequencies near resonance without amplifying frequencies away from the resonant frequency. As
a result, the system's response is non-linear.
An ideal system will have a resonant frequency as high as possible, so that the resonant frequency is well above the
frequencies found in the blood pressure waveform.
Resonance is affected by all aspects of the plumbing system. Changing the length and diameter of the tubing or catheter
can have a dramatic effect on the resonant frequency. Small air bubbles can introduce major distortion, because the air is
much more compressible than the liquid in the system, and this will lower the resonant frequency.
References: Carr, Joseph J., and Brown, John M., Introduction to Biomedical Equipment Technology, 4th edition,
Prentice Hall Career and Technology, 2001, pages 263 – 266.
Q191EXPL
A diagnostic grade electrocardiogram should have a frequency response between 0.05 and 100 hertz (- 3 dB points). A
monitoring grade signal usually has the upper frequency limit reduced to about 45 hertz to make it less vulnerable to 60
hertz noise.
The American Heart Association has developed a standard for electrocardiographs that addresses not only frequency
response, but linearity, gain, chart speeds, event markers, and calibration pulses, among other features of the device.
References:
[1] Webster, John G., Medical Instrumentation: Application and Design, Houghton-Mifflin Company, 1978, pages 281 -
282
[2] Chatterjee, Shakti and Miller, Aubert, Biomedical Instrumentation Systems, Delmar Cengage Learning, 2010, pages
228 – 230.
Q192EXPL
When an electrode comes into contact with the skin, any movement of the electrode relative to the skin surface will lead
to the generation of artifact caused by the change in voltage at the electrode interface. A column electrode uses a layer of
conductive jelly between the skin and the actual silver-silver chloride electrode. This jelly maintains a good conductive
path between the skin and the electrode, even when the electrode is moved slightly.
Signal strength and impedance are not changed by this type of electrode. Baseline wander may be helped by using this
type of electrode, but this is generally a much less severe problem than motion artifact.
Hall Career and Technology, 1993, pages 31 – 32.
Q193EXPL
Electroencephalograms (EEG) are generally much smaller than ECG signals. The frequencies found in an EEG signal
range from 0.5 to 100 hertz. The typical amplitudes of EEG signals range from 1 microvolt all the way to 100 microvolts.
Q194EXPL
Heating metal liberates electrons through a process known as thermionic emission. In an x-ray tube, electrons are emitted
by the cathode, which is heated by the filament. As the filament temperature increases, the number of electrons coming
off the cathode increases, and so the current in the tube increases, assuming appropriate voltage is applied to the tube.
References:
[1] Feinberg, Barry N., Applied Clinical Engineering, Prentice Hall, 1986, pages 253 - 254
[2] Chatterjee, Shakti and Miller, Aubert, Biomedical Instrumentation Systems, Delmar Cengage Learning, 2010, page
450.
Q195EXPL
= (Q040EXPL)
Q196EXPL
Thermistors are temperature-sensitive resistors made of semiconductor material. Because of their predictable and accurate
response to temperature changes, they are frequently used to measure temperatures. For example, a thermistor can be
found at the tip of a Swan-Ganz catheter, and is used to measure the temperature change associated with the measurement
of cardiac output using a cooled injectate.
Unlike most materials, they show a negative coefficient of resistivity as a function of temperature. That is, as the
temperature of the thermistor increases, its resistance decreases.
As with most materials, the linearity of the change in resistance is a function of the temperature change. Too large a
change will cause the resistance change to become non-linear.
Reference: Feinberg, Barry N., Applied Clinical Engineering, Prentice Hall, 1986, pages 71 – 72.
Q197EXPL
X-rays are produced by the collision of electrons with the anode of an x-ray tube. These electrons are emitted by a
cathode, then accelerated to a very high speed by the applied voltage, so that they will collide with the anode.
The smaller the area of the anode, the better focused the x-ray beam will be, and the sharper the image produced.
However, the generation of x-rays produces a very large amount of heat, and if large currents were applied at only a very
small spot on the anode, the heat produced would be enough to melt the anode.
As a compromise, a larger area of the anode is used to dissipate heat. The sharpness of the images produced is determined
by three factors: the angle of the target, the size of the actual focal spot, and the size of the cathode filament.
In practice, the actual focal spot size is determined by the heat dissipation requirements of the anode. The size of the
cathode filament is determined by the quantity of electrons that need to be produced. The final factor, the angle of the
target, is the one over which a tube designer has the most control, and so that is the primary determinant of the sharpness
of the final images.
Reference: Feinberg, Barry N., Applied Clinical Engineering, Prentice Hall, 1986, pages 261 – 262.
Q198EXPL
Therapeutic ultrasound is used to provide deep heating. As ultrasound is absorbed by tissue, heat is generated. Ultrasound
is absorbed most by tissues that are high in protein, such as collagen, and relatively low in water content.
The propagation of ultrasound from one tissue to another depends upon matching the acoustic impedance of the tissues.
This impedance is proportional to the density of the tissue. Where this density changes significantly, such as the interface
between bone and soft tissues (i.e., muscle), the ultrasound will be partially absorbed, partially reflected, and partially
transmitted. The local absorption will cause local heating.
Therapeutic ultrasound devices operate in the range from 0.75 megahertz to 3 megahertz. The most common operating
frequency in the U.S. is 1 megahertz.
Reference: Peat, Malcolm, Current Physical Therapy, B.C. Decker, 1988, page 212.
Q199EXPL
Interference is reduced by minimizing the amount of electrosurgery unit-produced radio frequency current that gets into
the ECG system. Several techniques can be used to produce this result.
Placing the electrosurgery unit's return electrode as close as possible to the surgical site minimizes the distance that the RF
current must travel through the body, and so minimizes its spread to remote parts of the body.
The same principle applies to keeping the ECG electrodes as far from the surgical site as possible. And, by keeping the
electrodes equally distant, the same RF current should flow through both, creating a common-mode signal, which should
not be amplified by the ECG monitor.
Applying all the ECG electrodes to the same side of the body is again an attempt to keep the RF currents in the ECG
electrodes as similar as possible.
Using shielded ECG patient cables and lead wires helps reduce the amount of RF energy picked up by these wires through
their effect as an antenna.
Reference: Webster, John J., Medical Instrumentation: Application and Design, Wiley, 4th edition, 2010, page 262.
Q200EXPL
The speeds available on a typical electroencephalograph are 15, 30 and 60 millimeters per second. The standard chart
speed used for most EEG recordings is 30 millimeters per second.
Q201EXPL
A photometer is used to compare the intensity of a specific wavelength of light against a reference, and based upon the
difference in intensity, computes the amount of a substance in a sample.
For example, a filter photometer (or colorimeter) sends light through a filter to select a specific wavelength of light. This
light is divided into two parts. One portion of the light travels through a reference path, and falls on a reference
photoelectric cell, generating a voltage. The other portion of light travels through a cuvette filled with a sample, and falls
on a sample photoelectric cell, generating another voltage.
By comparing these two voltages, determinations can be made about the concentration of the substance being measured in
the cuvette.
A flame photometer burns a sample, and examines the intensity of light, again compared to a reference. This is typically
used to measure concentrations of sodium and potassium in samples of blood. As a reference, a known amount of a
lithium salt is introduced into the sample. When burned, the lithium, sodium, and potassium all produce different
wavelengths of light. By comparing the intensities of light at the appropriate wavelengths, determinations can be made
about the concentrations of the target substances.
Q202EXPL
The measurements taken by a blood gas analyzer are usually the partial pressure of oxygen in arterial blood (PaO2), the
partial pressure of carbon dioxide in arterial blood (PaCO2), and the pH of the blood sample.
Hall Career and Technology, 2001, pages 317 – 318.
Q203EXPL
Respiration brings oxygen into the lungs, where it can enter the bloodstream, and removes carbon dioxide from the
bloodstream, and sends it out of the lungs. If the rate and depth of respiration decrease, then more carbon dioxide (CO2)
will be retained in the bloodstream, and less will be exhaled.
As a result, the partial pressure of CO2 in the arterial blood will increase.
Reference: Carr, Joseph J. and Brown M., Introduction to Biomedical Equipment Technology, 4th edition, Prentice Hall,
2001, page 315.
Q204EXPL
For a healthy, young adult, the normal range of the partial pressure of oxygen in arterial blood, PaO2, is about 80 to 100
millimeters of mercury.
References:
[1] Webster, John G., Medical Instrumentation: Application and Design, 4th edition, Wiley, 2010, page 450
[2] ABG Tutorial, M2H Nursing, Margaret Hansen, 2009, http://www.m2hnursing.com/ABG/normal_values.php,
retrieved May 3, 2015.
Q205EXPL
Chromatography relies on the separation of a mixture of substances by dipping filter paper or aluminum oxide into the
liquid mixture. The different substances will migrate up the paper at different speeds, depending upon their molecular
weights. As the substances separate, different colored bands will form. By examining these bands, the substances in the
original mixture can be determined.
Hall Career and Technology, 2001, pages 432 and 445.
Q206EXPL
A plethysmograph examines changes in volume of a limb to determine the blood flow into that limb.
A true plethysmograph puts a limb into a sealed container with a constant volume. By placing a cuff on the limb with a
pressure above the venous pressure, but below the arterial pressure, blood can enter the limb, but not leave. By recording
pressure changes in the chamber over time, and plotting these changes, the volume of blood entering the limb over time
(the blood flow) can be determined.
Q207EXPL
Nuclear medicine relies on the introduction of radioactive substances into the body. The type of substance selected is
chosen to target a specific organ. For example, radioactive iodine is used to test the function of the thyroid, which takes up
iodine to perform its normal functions.
Radiology uses x-rays, which are not radioactive, to take pictures of internal parts of the body.
Nuclear magnetic resonance, generally called magnetic resonance imaging, uses a strong magnetic field and radio waves
to distort the movement of atoms. By doing so, images of various organs can be created.
Sonography uses ultrasound to take pictures of internal body organs.
Hall Career and Technology, 2001, pages 609 and 619.
Q208EXPL
A photometer relies on the measurement of the intensity of a specific wavelength of light going through a sample, and
comparing that to the same wavelength of light travelling through a reference path. The difference in intensity can be used
to determine the relative concentration of a substance to be measured in the sample.
A scintillation projector is not a piece of medical equipment.
A mass spectrometer is a device that separates a stream of charged particles (ions) into a spectrum according to their
mass-to-charge ratios, and determines the relative abundance of each type of ion present. It relies on the introduction of a
heated sample gas into a vacuum chamber. This gas flows in a stream that is bombarded by electrons, which then causes
the gas to disperse according to the mass-to-charge ratios of the various components of the gas.
A gamma camera has gamma rays produced by radioactive substances introduced into the body interact with a large
sodium iodide crystal in the camera. This interaction produces flashes of light, which are then amplified with
photomultiplier tubes. In this way, the distribution of the radioactive substance can be detected, and used to evaluate the
function of organs.
Q209EXPL
Ultrasound imaging uses ultrasonic waves that are sent into the body. As these waves are reflected, they can be used to
reconstruct images of the internal structure of the body.
Computerized axial tomography (CAT) scanners use x-rays sent through the body at many angles. As they leave the body,
the intensity of these x-rays is detected by scintillation counters. These intensity measurements are processed with a
computer to reconstruct the internal structure of the body.
Magnetic resonance imaging (MRI) immerses the body in a strong magnetic field, and then sends radio waves into the
body. This disturbs the motion of the nuclei of the hydrogen atoms (found in water molecules), and this disturbance can
be recorded and used to determine the internal structure of the body.
Digital radiology uses x-rays that are recorded using a computer to store the images. These are comparable to traditional
x-ray images produced on film. The x-ray source is a single point source, and a flat image, similar to a photograph, is
produced of the internal structure of the body.
Q210EXPL
X-ray tube anode current depends upon both the filament temperature and the voltage between the anode and cathode. As
the filament temperature increases, the number of electrons available for the anode current increases. Filament
temperature is a function of the filament current.
In addition, for a given temperature, the current is dependent upon the anode voltage. Increasing the anode voltage will
cause more current to flow.
Reference: Feinberg, Barry N., Applied Clinical Engineering, Prentice Hall, 1986, page 255.
Q211EXPL
A hemodialysis machine passes blood through a coiled tube that is bathed in a dialysate solution consisting of water,
dextrose, and salts of calcium, magnesium, potassium and sodium. The tube is semipermeable, so that osmotic pressure
forces the toxins urea, creatinine, and uric acid out of the blood, and into the dialysate solution. The blood without these
toxins is then returned to the body.
Q212EXPL
A heart-lung machine is used to circulate a patient's blood outside of the body during cardiac surgery. This allows the
patient's body to keep receiving the oxygen it needs to stay alive.
To accomplish this job, the blood is circulated using a pump, and the blood is oxygenated using a gas exchanger. The gas
exchanger allows the blood to pick up oxygen and remove carbon dioxide, just as it would in the lungs.
Q213EXPL
During cardiac surgery, the patient's blood is connected to an extracorporeal tubing circuit so it flows through a heart-lung
machine instead of the heart. In this way, the surgeon can operate on the heart.
By cooling the patient (making the patient hypothermic), the patient's metabolism decreases, as does the need for oxygen.
By significantly lowering their oxygen requirement, the vitality of those tissues that do not receive the normal amount of
oxygen during the surgery can be protected.
Reference: None
Q214EXPL
The fluid in the tubing system used to take invasive blood pressure measurements has a significant mass. If the transducer
is not at the same level as the patient's heart, then the fluid column will alter the readings seen.
If the transducer is below heart level, then a negative pressure head will make the readings seen by the transducer higher
than they actually are in the heart. Conversely, if the transducer is above heart level, then a positive pressure head will
make the readings seen by the transducer lower than they really are in the heart.
Q215EXPL
Bradycardia is a slower than normal heart rate.
Missed beats will result in a lowering of heart rate.
Asystole, or the stoppage of the heart, will result in a heart rate of zero.
Ventricular tachycardia will result in a higher than normal heart rate.
The upper limit on a heart rate alarm is the highest heart rate that will not cause an alarm to be generated. When the heart
rate goes above the upper limit, an alarm will be generated.
Reference: None
Q216EXPL
Fetal monitors measure the fetal heart rate and the contractions of the uterus. The monitor is designed to monitor the status
of the fetus during labor to assure that the fetus is responding appropriately to the stress of the birth process caused by the
mother's uterine activity.
Reference: Street, Laurence J., Introduction to Biomedical Engineering Technology, CRC Press, 2008, pages 113 - 115
Q217EXPL
The Swan-Ganz catheter is a catheter that is threaded through the right side of the heart so that its tip ends up in the
pulmonary artery. The catheter has a balloon on the end, which can be inflated. When inflated, the blood flow from the
right ventricle is blocked, and instead, the catheter tip sees the referred pressure from the left atria.
The pressure in the left atria corresponds to the left ventricular end diastolic pressure. The pressure recorded with the
balloon inflated is known as the pulmonary artery wedge pressure.
Q218EXPL
The most common method for measuring cardiac output is the use of the thermodilution technique. With this technique, a
small quantity of a cooled solution, such as saline or 5 percent dextrose in water, is injected via a catheter in the heart.
As the injectate flows past a thermistor located further down the catheter, the thermistor is cooled, and then, once blood
flows past, the thermistor reheats to body temperature. The cooling and heating over time are translated into a curve using
a cardiac output computer. The area under this curve is proportional to the cardiac output.
An older technique for measuring cardiac output involves the injection of a dye, and examining the density of the dye as it
flows through the bloodstream. The dye dilution technique is rarely used today because of the simplicity and reliability of
the thermodilution technique.
Q219EXPL
A blood pressure cuff that is too narrow will not transmit sufficient pressure into the patient's arm to properly occlude the
brachial artery. As a result, the pressure in the artery will be lower than the pressure in the cuff. Therefore, because the
readings taken are based on the cuff pressure (which is assumed to be equal to the artery pressure), the readings will be
higher than the actual blood pressure.
Webster, John G., Medical Instrumentation: Application and Design, 4th edition, Wiley, 2010, pages 326 - 327
Q220EXPL
An electrosurgery unit can be used to coagulate, fulgurate, or cut.
Coagulation involves the sealing of small blood vessels to stop bleeding.
Fulguration is a technique used for the superficial dehydration or coagulation of tissue. To perform this, the active
electrode is held a short distance from the tissue, causing a spark to jump to the tissue.
Cutting involves the use of electrosurgery current to heat tissue, causing the cells to break apart, making it appear that the
tissue itself is dissolving as the active electrode is advanced through the tissue.
References:
[1] National Fire Protection Association, NFPA 99, 2012 edition - Health Care Facilities Code
[2] Street, Laurence J., Introduction to Biomedical Engineering Technology, CRC Press, 2008, pages 211 - 216
Q221EXPL
A transducer is a device that converts one form of energy to another form of energy. A biological transducer converts a
biological signal, such as blood pressure, into a signal that can be processed and analyzed. Typically, this conversion
would be into an electrical form, so that an electronic amplifier or electronic display could be used to observe the signal.
Q222EXPL
A cathode ray tube generates a stream of electrons from the cathode, past horizontal and vertical deflection plates, onto a
phosphor screen. The screen illuminates when struck by the electrons, creating patterns on the screen. The position of the
electron beam is controlled by the horizontal and vertical deflection plates. The voltage on these plates will shift the path
of the beam, as the electrons in the beam are repelled by the negatively charged plate, and attracted by the positively
charged plate.
Q223EXPL
Ultrasound is generated by the physical motion of a piezoelectric crystal in response to an applied voltage.
A pulse generator is used to generate electrical pulses, usually for testing a circuit.
The Doppler effect is the change in frequency caused by the interaction of a waveform with a moving object. The Doppler
effect is used by ultrasonic flow detectors.
Electrostatic discharges are not used to generate ultrasound.
Q224EXPL
The normal cardiac output for an adult male is about 3 to 5 liters per minute.
A lower value would indicate an abnormality.
Q225EXPL
Q226EXPL
Q227EXPL
Successful magnetic resonance imaging pictures depend upon the patient's body remaining perfectly still over a relatively
long (several minutes) period of time. Any motion will distort the apparent source of the signals recorded by the MRI,
resulting in poor quality images.
If images are being made of the chest area, then one source of motion that is uncontrollable by the patient is the motion
caused by the heart's beating. To compensate for this, the MRI can be synchronized to the ECG, so that the measured
signals can be taken when the heart is always in the same position in the chest.
Reference: None
Q228EXPL
The Swan-Ganz catheter is a catheter that is threaded through the right side of the heart so that its tip ends up in the
pulmonary artery. The catheter has a balloon on the end, which can be inflated. When inflated, the blood flow from the
right ventricle is blocked, and instead, the catheter tip sees the referred pressure from the left atria.
The pressure in the left atria corresponds to the left ventricular end diastolic pressure. The pressure recorded with the
balloon inflated is known as the pulmonary artery wedge pressure.
The catheter also has a lumen with an opening a few centimeters before the catheter tip. This opening is used as a site to
inject cooled fluid (usually either saline or 5% dextrose in water) into the bloodstream. As the cooled fluid flows past the
catheter tip, a cardiac output computer can be used to calculate the cardiac output based upon the area under the
temperature change curve recorded at the catheter tip.
Q229EXPL
Placing an active electrosurgery electrode against tissue so no sparking takes place will heat the tissue. This causes the
water inside the tissue cells to boil away, causing the cells to be destroyed. Because this dries the tissue, this technique is
called desiccation.
Reference: National Fire Protection Association, NFPA 99, 2012 edition - Health Care Facilities Code
Q230EXPL
A piezoelectric material produces motion in response to an applied voltage. The only type of diathermy that relies on
motion is ultrasonic diathermy. Microwave, shortwave and infrared waves are all electromagnetic waves. Sound waves
and ultrasonic waves are the result of the motion of air or another material.
Reference: Peat, Malcolm, Current Physical Therapy, B.C. Decker, 1988, page 212
Q231EXPL
The synchronized mode allows a defibrillator to time its discharge with the occurrence of the R wave. The period when
the heart is repolarizing is considered the vulnerable portion of the heart cycle. A defibrillator discharge at that time could
cause a heart that is in atrial fibrillation to go into potentially deadly ventricular fibrillation. Electrically, the period when
the heart is repolarizing is seen as the T wave of the electrocardiogram. Therefore, when using synchronized
cardioversion, the defibrillator is designed to discharge before the T wave occurs.
Defibrillation is used to reverse fibrillation or some tachycardias by causing the heart to become totally depolarized all at
once, with the hope that once the heart repolarizes, it can do so in a way that normal rhythm is restored.
When the heart is in ventricular fibrillation, there is no R wave, and so synchronization is not possible.
During atrial fibrillation, there is an R wave present, because the ventricles are operating normally (although usually under
conditions of bradycardia, because the ventricles are not stimulated by the atria). However, the atria are not beating as a
synchronized unit, but instead are undergoing fibrillation. This is the condition that cardioversion (or the synchronized
discharge of the defibrillator) usually tries to correct.
During either junctional or ventricular tachycardia, there is an R wave present, but the ventricles are not operating
synchronously with the atria. Cardioversion can also be attempted to correct this arrhyhtmia.
Q232EXPL
Q233EXPL
A pulse oximeter measures the oxygen saturation of hemoglobin in the blood, usually by sending light through a fingertip,
although sometimes a toe or the pinna of the ear is used. Sensors placed on the forehead can also be used. These are
claimed to respond more quickly than sensors on the digits under conditions where a patient has poor perfusion in the
limbs.
The oximeter probe sends two wavelengths of light through the finger, using different colored light emitting diodes. By
comparing the transmission of light at these two wavelengths, a determination can be made about the relative amount of
oxyhemoglobin compared to the total amount of hemoglobin, allowing the calculation of oxygen saturation.
A transcutaneous oxygen monitor uses an oxygen electrode placed on the skin to determine the partial pressure of oxygen
in the blood. The oxygen sensor is usually accompanied by a heater that helps dilate the blood vessels near the skin
surface, so there is more blood available to allow the measurement of the oxygen partial pressure.
A blood gas analyzer uses a sample of blood that has been removed from the body, and is processed in a laboratory. This
device is used to determine the partial pressure of oxygen in arterial or venous blood.
An oculoplethysmograph is used to determine the pressure inside the eye. It is usually used to diagnose glaucoma, which
causes an increase in the internal eye pressure.
pages 343 – 344
Q234EXPL
References:
[2] Webster, John G., Medical Instrumentation: Application and Design, 4th edition, Wiley, 2010, pages 246 - 247
Q235EXPL
A-mode ultrasonic images send ultrasonic waves into the body and detect the reflected waves. The result is a pulse that
varies in time and indicates the discontinuity of tissues along the axis of the wave's travel. A-mode is also known as
amplitude mode.
While A-mode images are a single dimensional image, B-mode produces two-dimensional images. It is also known as
brightness mode. B-mode images are produced by rotating a transducer, or using a series of transducers arranged as a
phased array. Each transducer sends ultrasonic waves into the body, and the reflections are detected by the transducer. As
the transducer rotates, it will pick up reflections from different areas of the body. These images are stored on a storage
tube, so that a complete two-dimensional image of a body region can be detected. The image is fan-shaped, because of the
way the transducer's angle changes as it is rotated.
M-mode ultrasound is used to detect the motion of body parts, such as heart valves. An M-mode system combines the
transducer used in an A-mode system with a display much like that of a cardiac monitor. As motion occurs, the extent of
that motion is displayed as a graph over time.
Webster, John G., Medical Instrumentation: Application and Design, 4th edition, Wiley, 2010, page 578
Q236EXPL
When x-rays are sent through an object, some of the rays are blocked, while others continue through the object to the x-
ray film, exposing it. Areas where the x-rays have reached the film will be heavily exposed (turn black in the final image),
while areas where the x-rays have not reached the film, such as where bone is present, will be very lightly exposed (turn
white in the final image).
A small amount of radiation is neither transmitted or blocked, but instead is scattered as it bounces off objects inside the
body.
This scattered radiation will appear on the film as a general haze. It can not be predicted where the scattered rays will
land, so they are not useful as diagnostic information. Instead, they expose areas of the film that normally would not
become exposed.
To prevent this scattering, the Bucky grid is used. It consists of a gridlike structure made with very thin strips of lead
forming many channels. X-rays that travel straight will go through the grid, but those that are scattered will hit the lead
walls of the channels and be absorbed, so they never reach the film. Thus, the final image on the film will be sharper than
it would otherwise appear.
References:
[1] Cromwell, Leslie, Arditti, Mort, Weibell, Fred J., Pfeiffer, Erich A., Steele, Bonnie, and Labok, Joseph, Medical
Instrumentation for Health Care, Prentice Hall, 1976, page 289
[2] Chatterjee, Shakti and Miller, Aubert, Biomedical Instrumentation Systems, Delmar Cengage Learning, 2010, page
459
Q237EXPL
A photometer is used to compare the intensity of a specific wavelength of light against a reference, and based upon the
difference in intensity, computes the amount of a substance in a sample. For example, a filter photometer (or colorimeter)
sends light through a filter to select a specific wavelength of light. This light is divided into two parts. One portion of the
light travels through a reference path, and falls on a reference photoelectric cell, generating a voltage. The other portion of
light travels through a cuvette filled with a sample, and falls on a sample photoelectric cell, generating another voltage.
By comparing these two voltages, determinations can be made about the concentration of the substance being measured in
the cuvette. Generally, as the concentration (or path length) increases, the transmittance of light through the sample
decreases, because the absorbance of light by the sample increases.
A flame photometer burns a sample, and examines the intensity of light, again compared to a reference. This is typically
used to measure concentrations of sodium and potassium in samples of blood. As a reference, a known amount of a
lithium salt is introduced into the sample. When burned, the lithium, sodium, and potassium all produce different
wavelengths of light, and by comparing the intensities of light at the appropriate wavelengths, determinations can be made
about the concentrations of the target substances.
Q238EXPL
Gas sterilization uses ethylene oxide gas. This gas is highly toxic, and is a very effective sterilant. It is useful for
sterilizing materials that can not take the high heat associated with steam sterilizers or dry heat sterilizers. Typical objects
that might be sterilized in a gas sterilizer include plastics, rubbers, synthetics, fabrics, and certain sharp-edged metal
objects that become dull in high temperature environments.
Q239EXPL
Gas sterilization uses ethylene oxide gas. This gas is highly toxic, and is a very effective sterilant. It is useful for
sterilizing materials that can not take the high heat associated with steam sterilizers or dry heat sterilizers. Typical objects
that might be sterilized in a gas sterilizer include plastics, rubbers, synthetics, fabrics, and certain sharp-edged metal
objects that become dull in high temperature environments.
Q240EXPL
pH is a measure of the number of hydrogen ions in a solution, which are the cause of acidity or alkalinity. pH is measured
on a scale of 0 to 14, with lower numbers indicating an acidic condition, and higher numbers indicating an alkaline
condition. A neutral substance, such as pure water, has a pH of 7. Normal blood pH is about 7.4. Acidosis would be
characterized by a blood pH below 7.35. Blood rarely has a pH below 7.0, so even when acidosis occurs, the blood is still
slightly alkaline. Stomach acid is very acidic, with a pH of 1.5.
Hall Career and Technology, 2001, page 442 - 443
Q241EXPL
Oxygen levels are measured using a platinum cathode electrode and a reference electrode. These two electrodes are placed
in an electrolyte, which allows oxygen to diffuse to the electrodes.
If a voltage of about 0.7 volts is applied between the platinum cathode and the reference electrode, with the platinum wire
negative, reduction of oxygen takes place at the platinum cathode. The oxygen-reduction current is directly proportional
to the partial pressure of oxygen, which has diffused through the electrolyte.
A Clark electrode has both the platinum cathode and the reference electrode integrated into a single unit. When used to
measure oxygen concentrations in a gas, as on an oxygen analyzer used by respiratory therapists, the electrode is
surrounded by a polyethylene membrane. This membrane allows oxygen to freely diffuse through it, but keeps the
electrolyte, which is in contact with the two electrodes and permits electrical conduction between them, from drying out.
References:
[2] Carr, Joseph J. and Brown M., Introduction to Biomedical Equipment Technology, 4th edition, Prentice Hall, 2001,
page 444
Q242EXPL
When someone has a heart attack (myocardial infarction), a portion of the heart muscle dies. To assist the patient's
recovery, physicians can use an intra-aortic balloon pump. This device is designed to provide rest to the remaining, viable
heart muscle, by taking over a portion of the heart's pumping action.
This pump uses a catheter with a balloon that is threaded into the aorta. By inflating the balloon at the proper time after
the heart has reached its maximum contraction (systole), the pump tries to reduce the coronary work load, reduce the
heart's oxygen requirements, and improve the perfusion of the coronary arteries. This is accomplished by reducing the
mean arterial pressure seen by the pumping left ventricle, and instead, calling on the balloon pump to generate some of the
force required to pump the blood, and maintain the needed circulation.
References:
[1] Carr, Joseph J., and Brown, John M., Introduction to Biomedical Equipment Technology, John Wiley and Sons, 1981,
page 143
[2] Chatterjee, Shakti and Miller, Aubert, Biomedical Instrumentation Systems, Delmar Cengage Learning, 2010, pages
422 - 427
Q243EXPL
All ultrasound units work by sending ultrasonic acoustic waves into the body and detecting the reflected waves.
Ultrasonic waves are reflected back whenever there is a change in the speed of ultrasound transmission between two
structures.
The speed of transmission is generally proportional to the density of the structure, so ultrasound travels faster in water
than air, and faster in bone than in water. When the waves encounter two different structures or organs with different
densities within the body, some reflection takes place.
This reflection is used to form an image, which indicates the internal structure of the body.
Doppler frequency shifts are used by ultrasonic flow detectors to determine information about movement inside the body,
such as the flow of blood, or the movement of heart valves. However, most ultrasonic flow detectors do not generate an
image.
Acoustic wave transmission and electromagnetic waves are not used to obtain image information with ultrasound
instruments.
Q244EXPL
A mass spectrometer is a device that separates a stream of charged particles (ions) into a spectrum according to their
mass-to-charge ratios, and determines the relative abundance of each type of ion present. It relies on the introduction of a
heated sample gas into a vacuum chamber. This gas flows in a stream that is bombarded by electrons, which then cause
the gas to disperse according to the mass-to-charge ratios of the various components of the gas.
The dispersion typically takes place under the influence of a strong magnetic field.
Reference: Webster, John G., Medical Instrumentation: Application and Design, 4th edition, Wiley, 2010, pages 426 - 427
Q245EXPL
The x-ray tube is responsible for generating the actual x-rays. This happens when a stream of electrons hits the anode at
very high speed.
The collimator limits the size of the x-ray beam to only the area that is intended to be exposed. The beam leaving the x-
ray tube is usually very wide, and would cover a far larger area than needed for a typical radiographic study. To limit the
x-rays, and thus any unnecessary exposure to those x-rays, to only the area that needs to be exposed, a collimator is used.
A Bucky grid is used to reduce the scattering of x-rays as they interact with tissues within the body. This scattering can
cause the image to lose its sharpness.
The pulse duration timer is used to control the amount of time that the x-ray unit is actually generating x-rays. It does not
influence the shape of the x-ray beam.
578
Q246EXPL
References:
[2] Carr, Joseph J. and Brown, John M., Introduction to Biomedical Equipment Technology, Prentice Hall, 4th edition,
2001, page 200
Q247EXPL
An electrocardiograph is used to record a patient's electrocardiogram (ECG), the voltage produced by the heart as it is
beating.
An electroencephalograph is used to record a patient's electroencephalogram (EEG), the voltage produced by the brain
during its activities.
A defibrillator is used to deliver a high energy electrical pulse to the heart in order to stop ventricular or atrial fibrillation.
It does this by forcing the entire heart to depolarize and contract simultaneously. As the heart recovers from this
depolarization, it is hoped that the heart's normal rhythm will be restored.
A pacemaker produces electrical pulses that stimulate the heart, in an attempt to initiate a faster heart rate than the
diseased heart itself is capable of producing, because of a cardiac defect.
Q248EXPL
A plethysmograph is used to determine the blood flow in a limb by examining changes in the volume of that limb.
A pulmonary function analyzer is used to measure various lung volumes and capacities. These help determine the current
health of the lungs and the pulmonary system.
A pheresis system is used to separate blood into its components. Typically, it is used to remove white blood cells and
platelets from whole blood through a centrifugation process. These components are removed, often for infusion into
cancer patients, and the remaining blood is returned to the donor.
An electromyograph is used to record an electromyogram (EMG), which are the electrical signals produced by muscles
when they are activated.
References:
[1] Feinberg, Barry N., Applied Clinical Engineering, Prentice Hall, 1986, page 188 - 189
[2] Street, Laurence J., Introduction to Biomedical Engineering Technology, CRC Press, 2008, pages 83 - 87
Q249EXPL
An electroencephalogram (EEG) is used to detect electrical activity in the brain. This activity may be changed because of
problems within the brain, such as tumors or epilepsy.
Arrhythmias are irregularities in the heart beat.
Murmurs are atypical heart sounds made when blood is flowing past heart valves that are not functioning properly. The
murmur is caused by blood flowing back through the valve.
Dermatosis is a disease of the skin, such as a rash.
Q250EXPL
A typical x-ray tube consists of an anode, cathode, and filament. The filament heats the cathode, which then releases
electrons through thermionic emission. A very high voltage is applied between the anode and cathode, causing the
electrons to rapidly accelerate into the anode. When they hit the anode, x-rays are produced.
A diode is a simple tube consisting of an anode, cathode, and filament.
A triode is a diode with the addition of a control grid between the anode and cathode. The control grid has a negative
voltage on it, allowing it to control the amount of current flowing between the anode and cathode.
A thyratron is type of triode in which the control grid acts as a gate, starting conduction of the tube, but not controlling the
amplitude of the current. It is the vacuum tube equivalent of a silicon-controlled rectifier (SCR).
A photomultiplier tube is used to detect small amounts of light by amplifying light entering the tube to a much larger
electrical signal through a multiplication process.
Q251EXPL
A thermistor with a negative temperature coefficient will show a decrease in resistance as temperature increases.
Q252EXPL
The test fixture for an electrosurgical unit should try to duplicate the conditions under which the unit will operate.
Because an electrosurgical unit operates at a high frequency, to get accurate readings, a thermocouple RF (radio
frequency) ammeter is used to provide a true RMS (root mean square) reading. The meter should have a range between 0
and 1.5 to 2.0 amperes to accommodate the expected currents that are generated by the electrosurgical unit.
The load resistors should be non-inductive, to assure that only resistance is presented to the electrosurgical unit, and not
reactance.
The load resistors should be between 200 and 500 ohms, depending upon the value suggested by the manufacturer of the
electrosurgical unit.
Q253EXPL
A defibrillator is used to deliver a high energy electrical pulse to the heart in order to stop ventricular or atrial fibrillation.
It does this by forcing the entire heart to depolarize and contract simultaneously. As the heart recovers from this
depolarization, it is hoped that the heart's normal rhythm will be restored.
Q254EXPL
The central venous pressure (CVP) is generally measured with a catheter introduced into the vena cava, where it enters the
right atria. It generally has a range of 0 to 12 centimeters of water.
Because the central venous pressure does not vary much with the cardiac cycle, it is generally presented only as a single
number, which corresponds to the mean pressure. The pressure does vary with respiratory swings, because the
intrathoracic pressure varies considerably during inspiration and expiration.
Reference: None
Q255EXPL
is not at the same level as the patient's heart, then the fluid column will alter the readings seen. For this reason, it is
important to zero the transducer with the zeroing stopcock kept at heart level. Once correctly zeroed, it is important to
keep the relative position of the patient's heart and the transducer constant.
If the transducer is below heart level, then the weight of the fluid column between the heart level and the transducer level
will cause a positive pressure head that will make the readings seen by the transducer higher than they actually are in the
heart. Conversely, if the transducer is above heart level, a negative pressure head will make the readings seen by the
transducer be lower than they really are in the heart.
References:
[1] Rawlings, Charles A., Electrocardiography, Spacelabs, 1991, page 83
pages 261 - 262
Q256EXPL
Tidal volume is the volume of air inspired or expired during a normal, quiet, respiration cycle.
Q257EXPL
A defibrillator is synchronized with the R wave of the electrocardiogram in order to deliver a pulse to perform
cardioversion, usually to counteract atrial fibrillation. By synchronizing the defibrillator's discharge on the R wave, the
pulse will not be delivered during the heart's vulnerable period, which is during the T wave, when the heart is repolarizing.
A pulse delivered during this period could cause ventricular fibrillation.
To prevent delivering the pulse during the T wave, the defibrillator is usually set to deliver the cardioversion pulse about
30 milliseconds after the R wave peak.
Reference: Feinberg, Barry N., Applied Clinical Engineering, Prentice Hall, 1986, page 420
Q258EXPL
The standardizing, or calibration, pulse on an electrocardiograph is always 1 millivolt high.
Q259EXPL
Gauge pressure is the pressure indicated by a pressure measuring device relative to atmospheric pressure. It is a relative
pressure, rather than an absolute pressure.
Absolute pressure would be measured with respect to a vacuum.
Q260EXPL
A Doppler effect-based instrument relies on the principle that a moving object will alter the frequency of a wave that
bounces off it. The Doppler shift will be such that if an object is moving towards the frequency receiver, the frequency
will be increased, while an object moving away from the receiver will cause the frequency of the reflected wave to
decrease.
Continuous Doppler ultrasonic instruments rely on this principle to detect moving objects, such as blood flowing in an
artery or vein, or the motion of a fetal heart.
An electronic stethoscope uses the Doppler effect to detect blood flow or heart motion.
An electroencephalograph is an electrical signal generated by the brain, which helps to diagnose abnormalities in brain
activity. There is no motion involved in these measurements, and so the Doppler effect does not apply to an EEG.
Reference: Feinberg, Barry N., Applied Clinical Engineering, Prentice Hall, 1986, page 220
Q261EXPL
The color code associated with electrocardiogram leads is:
Electrode Color
Right Arm (RA) White
Left Arm (LA) Black
Left Leg (LL) Red
Chest (C) Brown
Right Leg (RL) Green
Q262EXPL
The right leg electrode is used as the reference input for an electrocardiograph. (This is also referred to as the common
electrode.)
References:
page 198
Q263EXPL
The purpose of isolating a patient from ground is to reduce the chance of a shock hazard. When grounded, the patient
offers an opportunity for leakage currents to travel through the patient to ground, which could cause a shock.
Shielded leads help reduce the possibility of interference from other electrical signals, but do not isolate the patient from
ground.
Electrically isolated inputs, typically using optical isolation or an input-stage isolation transformer, are a very effective
way of isolating the patient from ground and can provide substantial protection against leakage current hazards.
Input guarding helps reduce the common-mode signal that might be riding on top of a desired signal. It does this by
placing a second shield inside the outer shield of the ECG cable, and driving this shield with a signal designed to
counteract the common-mode signal. This technique does not isolate the patient from ground.
Field-effect transistors have a very high input impedance, but they are usually used in circuits that are referenced to
ground, and so they do not isolate the patient from ground.
Reference: Carr, Joseph J. and Brown M., Introduction to Biomedical Equipment Technology, 4th edition, Prentice Hall,
2001, page 163
Q265EXPL
The bandwidth in the diagnostic mode for a cardiac monitor is from 0.05 to 100 hertz. The bandwidth in the monitoring
mode is from about 0.5 to 40 hertz (although this can vary for different monitors).
Using the monitoring mode instead of the diagnostic mode can help reduce artifact caused by 60 hertz electrical signals,
and by patient muscular activity.
Reference: Rawlings, Charles A., Electrocardiography, Spacelabs, 1991, page 83
Q266EXPL
Arterial blood pressure is measured with a sphygmomanometer. Two types of manual sphygmomanometers are available.
An aneroid gauge uses a Bourdon tube, which is a hollow tube wound like a spring. When pressure is applied to the tube,
it uncoils, and the amount that it uncoils is proportional to the applied pressure.
A mercury column uses a hollow tube placed in a pool of mercury. When pressure is applied to the top of the mercury
pool, some of it is forced into the hollow tube. The greater the pressure, the higher the mercury will rise in the tube.
Q267EXPL
Pressure is equal to force divided by area. Pressure is measured in units such as pounds per square inch, or grams per
square centimeter.
The force with which a person is able to depress the plunger of a syringe is relatively independent of the size of the
syringe. However, the cross-sectional area of the syringes varies greatly, with a smaller syringe having a smaller cross-
sectional area. Therefore, if the force is constant, then the pressure will be highest when the cross-sectional area is lowest.
That is, the smaller the syringe size, the higher the pressure that is developed at the tip of the needle.
Reference: None
Q268EXPL
A piezoelectric crystal is a crystal that responds by producing a voltage in response to a physical force imposed on it.
Conversely, when a voltage is placed on the crystal, vibrations result.
A typical application for a piezoelectric crystal is in an ultrasound application. The crystal can be excited with a voltage,
producing ultrasonic vibrations that are directed into a body. Reflections from within the body can then be detected with
the same crystal, which will produce voltages in response to the received ultrasonic wave energy.
The Peltier effect refers to the cooling of metals under certain conditions when current is applied across them under
specific conditions.
The photoelectric effect is the generation of electricity by certain semiconductors when light is applied to them. This is the
effect used by the solar cells found in calculators, for example.
Reference: Webster, John G., Medical Instrumentation: Application and Design, 4th edition, Wiley, 2010, page 58
Q269EXPL
Extracorporeal Membrane Oxygenation (ECMO) is a technique used to provide gas exchange to the blood using an
external device. Like a hemodialysis machine, blood is removed from the body and processed by a machine.
A hemodialysis machine passes blood through a coiled tube that is bathed in a dialysate solution consisting of water,
dextrose, and salts of calcium, magnesium, potassium, and sodium. The tube is semipermeable, so that osmotic pressure
forces the toxins urea, creatinine, and uric acid out of the blood, and into the dialysate solution. The blood without these
toxins is then returned to the body.
An ECMO machine removes the blood and passes it through an oxygenator, which adds oxygen to the blood and removes
carbon dioxide. A semipermeable membrane keeps the blood contained in the machine, but allows the gases to flow freely
across the membrane, similar to the function of the human lung. Other than the removal of carbon dioxide, this machine
does not remove any other waste products from the blood.
pages 319 - 320
Q270EXPL
The pure cut waveform of an electrosurgical unit is a pure sine wave. The typical frequencies of such a waveform range
from 500 kilohertz up to 2.5 megahertz, although the range of frequencies can be outside these limits, depending upon the
manufacturer and model.
Reference: Webster, John G., Medical Instrumentation: Application and Design, 4th edition, Wiley, 2010, pages 630 - 631
Q271EXPL
Gas sterilization is used for devices that do not tolerate heat well, and so can not be sterilized in a steam sterilizer or a dry
heat sterilizer. For example, plastics and rubbers are typically sterilized in a gas sterilizer.
The cool sterilization cycle in a gas sterilizer is heated to a temperature slightly above room temperature, but below body
temperature. Typically, this would be about 30o C (86o F).
Reference: None
Q273EXPL
For a "cut" waveform, an electrosurgery unit produces almost a pure sine wave output. This waveform heats tissue, and
results in cutting action, with minimum hemostasis.
At times during surgery, a surgeon wants to produce hemostasis (stoppage of bleeding). To do this effectively, a "coag"
(short for coagulation) waveform is used. This waveform consists of a very short duration pulse followed by a
significantly longer period with no output. This entire waveform is repeated rapidly.
The quality of the coag waveform is indicated by the crest factor. This is the ratio of the peak output voltage at the top of
the pulse to the average, or RMS, voltage of the entire waveform over time.
A cut waveform has a crest factor close to 1. In the "blend" mode, an electrosurgery unit produces an output waveform
that is a mixture of the pure cut and pure coag waveforms. As more and more coag is added, the crest factor increases.
Reference: None
Q274EXPL
Q275EXPL
The impedance shown by capacitors is lower as the frequency increases. Electrosurgery relies upon the transmission of
high-frequency signals through cables, all of which have some stray capacitance. The higher the frequency of the signal,
the more stray capacitance must be taken into account and minimized to prevent accidental leakage of the signal into an
unintended path. This unintended path could result in a burn. Therefore, it is generally desirable to keep the ESU
frequency as low as possible to minimize the influence of stray capacitance.
At the frequencies involved, there is no difference in the potential leakage current hazard, or cutting ability, or the amount
of artifact generated on an ECG monitor.
Reference: None
Q276EXPL
Electrosurgery currents have a high enough power associated with them to cause deliberate burning of tissues. When
controlled, this burning results in the cutting and coagulation action that is desired. However, when not controlled
properly, the current can take an alternate path, and cause a burn in an unintended location on the patient's body.
A grounded return pad can increase the possibility of a burn. If the pad were to become detached from the patient, then the
electrosurgery current would try to find an alternate path to ground. If another part of the patient's body were touching a
grounded object, then that part of the patient could experience an unintended current, and a burn could result at the
alternate grounding site.
Reference: None
Q277EXPL
A defibrillator uses a high energy electrical pulse to put the entire heart into depolarization simultaneously. To function,
the electrical energy must enter the heart. With externally applied electrodes, a large portion of the applied energy will not
enter the heart. Therefore, external defibrillation pulses may need to be as high as 400 watt-seconds (or joules) to produce
the desired result.
Internal paddles are typically used to start the heart after cardiac surgery. In this case, the pulse is applied directly to the
heart, and so all of the energy will go into the heart, not into the surrounding tissue. Therefore, much less energy needs to
be applied.
For safety reasons, the output power of the defibrillator when internal paddles are in use is limited to 50 watt-seconds (or
joules).
Reference: None
Q278EXPL
The synchronized mode allows a defibrillator to time its discharge with the occurrence of the R wave. The period when
the heart is repolarizing is considered the vulnerable portion of the heart cycle. A defibrillator discharge at that time could
cause a heart that is in atrial fibrillation to go into potentially deadly ventricular fibrillation. Electrically, the period when
the heart is repolarizing is seen as the T wave of the electrocardiogram. Therefore, when using synchronized
cardioversion, the defibrillator is designed to discharge before the T wave occurs.
Defibrillation is used to reverse fibrillation or some tachycardias by causing the heart to become totally depolarized all at
once, with the hope that once the heart repolarizes, it can do so in a way that normal rhythm is restored.
To identify the R wave, a patient's electrocardiogram (ECG) signal must be obtained. The source of this signal may be the
defibrillator paddles placed on the patient's chest, or a connection to the bedside monitor allowing the ECG signal from
that monitor to be fed into the defibrillator's synchronization circuit, or from a separate ECG cable and electrode set
placed on the patient's chest to allow detection of the ECG signal.
A pressure signal is not used as a synchronization signal because its features can not be correlated as reliably as the
electrical ECG signal to the electrical activity of the heart.
Reference: None
Q279EXPL
Q280EXPL
Ultrasound consists of acoustic waves. These waves propagate through materials by a physical process of compression
and rarefaction, just like sound waves in air do.
Q281EXPL
The sensitivity of a commonly used medical transducer is given as 5 microvolts/V/mm-Hg. This means that for every
millimeter of mercury the pressure applied to the transducer increases, the output signal will increase by 5 microvolts
times the applied excitation voltage.
Because 10 mmHg is equivalent to 1 cmHg, this sensitivity is equal to 50 microvolts/V/cmHg.
Q282EXPL
Radioactivity can be detected by the interaction of the products of radioactive decay with either photographic film, the
ionization of gases, or light flashes when the radioactivity interacts with certain minerals.
In an ionization chamber, the radiation produces gas ions that travel between two charged capacitor plates. The flow of
these ions causes a current flow, which can be detected by an appropriate amplifier and indicates the intensity of the
radiation.
Q283EXPL
In order to accurately reproduce an ECG waveform, the bandwidth should be sufficient to allow the waveform to be
reproduced with the fidelity needed to perform a clinical diagnosis. It is important not to go as low as DC, because that
would allow artifact from the skin-electrode interface to be amplified, possibly causing a wandering baseline. To properly
reproduce very low voltage internal pacemaker spikes on the ECG recording or a 1 mm ST segment elevation, the ECG
will need to pass a frequency of almost 100 Hz on the high end. Therefore, the appropriate range for an ECG's bandwidth
is 0.05 to 100 Hertz.
As for choice indicating a bandwidth of 45 Mbps, be aware of the difference in definitions for "bandwidth" in
telecommunications/computer networking versus biomedical instrumentation. In the former, it is the width of a
communications channel.
A bandwidth compression device relates to WAN (wide area network) compression. Putting compression devices at both
ends of a link allows increased throughput without buying more bandwidth.
References:
[1] ANSI/AAMI EC11:1991/(R)2001/(R)2007, Diagnostic Electrocardiographic Devices, AAMI, 2000, section 3.2.7.2
[2] Greene T, "Compression devices show why smaller is better," Network World, 06/16/2003
Q284EXPL
Lead II (right arm to left leg) yields the highest amplitude QRS portion of the ECG for a patient with a normal heart
condition. Lead I, right arm to left arm (choice a) and Lead III, left arm to left leg (choice d) are valid standard lead
selections in the Einthoven triangle but have a smaller amplitude than Lead II in the classic normal electrocardiogram.
The Einthoven triangle is a good review of electrode position and ECG vectors associated with the three basic limb leads.
This comes in handy when troubleshooting lead problems.
References:
[1] Cromwell, Leslie, et al, Biomedical Instrumentation and Measurements, Prentice Hall, 1973, page 92
[2] Guyton, Arthur C., Basic Human Physiology, Saunders, 1977
Q285EXPL
Hemodialyzers use a semi-permeable membrane as the barrier with the ability to allow excess water and waste materials
to pass through, while keeping red blood cells and other valuable blood components to be returned to the body safely.
Counter current flow, an ionic gradient, and pressure differential enhance the exchange. Reverse osmosis units (RO) are
often used to purify the water used in mixing with a salt concentrate to form dialysate.
References:
[1] Jacobson B and Webster JG, Medicine and Clinical Engineering, Prentice-Hall, 1977, page 579
[2] Carr, Joseph J. and Brown, John M., Introduction to Biomedical Equipment Technology, 4th edition, Prentice Hall,
2001, page 450
Q286EXPL
A blood sample diluted in isotonic saline is vacuum-drawn through a small orifice (less than 100 micrometers), while
electrical conductivity is measured across the orifice by means of two electrodes placed in the solution (on opposite sides
of the orifice). With no blood cell in the orifice, a high conductivity (i.e. low resistance) is measured between the
electrodes. As a cell is drawn through (and partially occludes) the orifice, the resistance between the electrodes increases,
due to the fact that cells have higher electrical resistivity than the saline. This is the principle behind classic Coulter blood
cell counters.
Each cell that passes through the orifice produces a sudden increase in resistance, an electrical pulse that can be measured.
The number of pulses of a certain height counted for a certain volume displacement through the orifice gives the cell
count of a specific type of cell. Because the white cell (WBC) is larger than either the RBC or platelet, their pulses are
highest.
References:
[1] Jacobson, Bertil and Webster John G., Medicine and Clinical Engineering, Prentice-Hall, 1977, pages 287 - 288
[2] Karselis, Terence C., Clinical Laboratory Instrumentation, F.A. Davis, Philadelphia, 1994, pages 333 - 340
Q287EXPL
Q288EXPL
Q289EXPL
Fifty ohms is a good approximation of torso impedance. Five hundred ohms is usually used as the approximation of skin
impedance for an ESU.
Reference: Aston, Richard, Principles of Biomedical instrumentation and Measurement, Merrill Publishing, 1990, page
277
Q290EXPL
Electrosurgery Units (ESUs) deliver high-voltage, high-frequency electrical energy as sparks that can be used to cut
through or coagulate tissue. The sparks are created when the high voltage between the ESU tip and the patient causes the
air between them to ionize, providing a conductive path from the tip to the patient. During coagulation, the current flow
can be seen as random sparks between the tip and the patient.
Argon beam coagulators provide a stream of argon gas between the tip and the patient. Argon has a lower ionization
potential than air, which means it conducts at a lower voltage. Rather than the random sparks generated during standard
ESU coagulation, the argon provides a narrow channel for current flow, which allows the surgeon to more easily cover a
wide area containing many small bleeders.
Reference: Web site of the American Society for Gastrointestinal Endoscopy,

http://www.asge.org/nspages/practice/patientcare/technology/02-argon.cfm
Q291EXPL
In spirometry, vital capacity is the sum of the Inspiratory Reserve Volume, Tidal Volume, and Expiratory Reserve
Volume-in other words, the volume change of the lungs from a maximum exhalation to a maximum inhalation.
The best way to review these quantities (which are measured during pulmonary function testing) is to study the classic
volume-time spirogram that shows all the lung volumes and their subdivisions. Two references to such a chart are shown
below.
The subdivisions are grouped into volumes and capacities. There are four volumes: Inspiratory Reserve Volume, Tidal
Volume, Expiratory Reserve Volume, and Residual Volume. There are also four capacities: Vital Capacity, Inspiratory
Capacity, Functional Residual Capacity, and Total Lung Capacity. Two or more volumes make up a capacity.
References:
[1] Wanger Jack, Pulmonary Function Testing, Williams and Wilkins, 1992, pages 63 - 70
[2] Carr, John J. and Brown, John M., Introduction to Biomedical Equipment Technology, 4th edition, Prentice Hall,
2001, page 314
Q292EXPL
MRI (Magnetic Resonance Imaging) technology uses changing magnetic fields and measures the effect on hydrogen ions
in the area of the scan. While some functional MRI scans work with other ions, the classic scan is able to determine tissue
density using the hydrogen ion. Because there is little water in bone, such dense structures do not appear in an MRI
image.
MRI is an imaging technique used primarily in medical settings to produce high quality images of the soft tissues of the
human body. MRI is based on the principles of nuclear magnetic resonance (NMR), a spectroscopic technique used by
scientists to obtain microscopic chemical and physical information about molecules. The technique was called magnetic
resonance imaging rather than nuclear magnetic resonance imaging (NMRI), because of the negative connotations
associated with the word nuclear in the late 1970s. MRI started out as a tomographic imaging technique, i.e., it produced
an image of the NMR signal in a thin slice through the human body.
PACS refers to picture archiving and communications system, a digital-based image management technology.
References:
[1] Hornak JP, The Basics of MRI, http://www.cis.rit.edu/htbooks/mri
[2] http://www.imagingeconomics.com/supplements/rad_as_bus/1999_jul/oper_pacs.html
Q293EXPL
The amplitude and frequency of the waveform would indicate alpha waves on an EEG. The 21 channels are typical of an
electroencephalograph.
Polymorphic means "presenting many forms," as the EEG does with changing levels of consciousness. A classic chart
(referenced below) of EEG wave types indicates alpha, beta, theta, and delta waves, their frequencies, amplitudes, and
mental states in which they occur.
Reference: Snyder EJ, "The Electroencephalogram (EEG)," Biomedical Instrumentation and Technology, Hanley and
Belfus, Philadelphia, PA., July/August 1990, pages 295 - 298
Q294EXPL
Q295EXPL
X-rays are a form of high-energy electromagnetic radiation-ionizing radiation that cause cell damage. There is no safe
level of X-radiation, which is why we shield ourselves (with lead) from unwanted exposure.
Ionizing radiation is radiation in which an individual particle (for example, a photon, electron, or helium nucleus) carries
enough energy to ionize an atom or molecule (that is, to completely remove an electron from its orbit). These ionizations,
if enough occur, can be very destructive to living tissue. All ionizing radiation causes cell mutation, a phenomenon that
we use to our benefit in radiation therapy to destroy some forms of cancer.
In the electromagnetic spectrum, ultraviolet light, X-rays, and gamma rays are all ionizing radiation, while visible light,
microwaves, and radio waves are not.
References:
[1] http://www.mywiseowl.com/articles/Ionizing_radiation
[2] Bushong, SC, Radiologic Science for Technologists, 6th edition, Mosby, 1997
Q296EXPL
The purpose of a pacemaker is to provide periodic stimulation to the heart. This is typically done with short pulses timed
for the desired heart rate. Neither sinusoidal nor continuous outputs would work. Internal pacemakers are often adjusted
using magnets, but external pacemakers can be adjusted directly, as they are outside the body.
Reference: Aston, Richard, Principles of Biomedical instrumentation and Measurement, Merrill Publishing, 1990, pages
284 - 286
Q297EXPL
A fetal monitor tracks the heart rate of the fetus (most commonly using ultrasound) and the contractions of the mother
(using a transducer that measures pressure called a toco-transducer). Changes in the fetal heart rate with respect to the
contractions help clinicians determine whether the fetus is in distress.
References: Carr, John J. and Brown, John M., Introduction to Biomedical Equipment Technology, 4th edition, Prentice
Hall, 2001, page 485
Q298EXPL
Impedance pneumography is a technique for detecting breaths by measuring the change in impedance across the chest that
occurs during the breathing cycle. When used in conjunction with ECG monitoring, breath rate is measured between two
of the ECG electrodes.
Impedance changes can be determined by measuring voltage changes across a voltage divider network. In this case,
changes in the voltage drop across the chest indicate changes in impedance.
High amplitude current is not used, because it could present a shock or burn hazard to the patient. Low frequency current
could interfere with ECG monitoring, which utilizes a bandwidth from 0.05-100 Hz.
Reference: Carr, John J. and Brown, John M., Introduction to Biomedical Equipment Technology, 4th edition, Prentice
Hall, 2001, pages 318 - 320
Q299EXPL
The method used to keep a baby warm will depend on its weight, gestational age, and health, as well as on the availability
of staff and equipment. Hyperthermia technically occurs when the newborn's body temperature rises above 37.5 degrees C
(99.5 degrees F), because the environment is too hot for the baby or the baby is overdressed. It may be necessary for the
warmer to heat above 37 degrees to maintain the baby's temperature at that level, but temperatures of 45 or 55 degrees are
extremely dangerous. 39 degrees C is the typical high air temperature attainable with such devices.
Reference: Thermal protection of the newborn, http://www.who.int/reproductive-health/publications
Q300EXPL
Q301EXPL
Free-flow is the condition where the fluid from an IV delivery set is allowed to flow unrestricted. IV sets typically have a
manual flow restriction valve, but these are not set when used with an infusion pump. Removal of the set from the pump
without setting the manual valve can result in free-flow, unless the pump (and set) have a fail-safe device that clamps the
set upon removal from the pump.
In the 1980s and 1990s, The Joint Commission was concerned about the number of patient injuries that were the result of
free-flow conditions. As a result, TJC issued a Sentinel Event Alert focusing on the elimination of these types of pumps. It
reinforced this by incorporating the elimination of these infusion pumps into its 2003 National Patient Safety Goals. The
result was that these pumps have been almost entirely eliminated from hospitals.
References:
[1] Sentinel Event Alert, Issue 15: Infusion Pumps: Preventing Future Adverse Events, November 30, 2000,
http://www.jointcommission.org/sentinel_event_alert_issue_15_infusion_pumps_preventing_future_adverse_events/defa
ult.aspx, retrieved May 30, 2015
[2] Infusion Free-flow Apparently Still a Risk, Institute for Safe Medication Practices, June 14, 2007,
http://www.ismp.org/newsletters/acutecare/articles/20070614.asp, retrieved May 30, 2015
Q302EXPL
When gallbladder or kidney stones are too large to pass spontaneously, a lithotripter can be used to break them into
smaller pieces. The patient is put into a water bath and high energy ultrasound pulses are focused on the location of the
stones, which causes them to break apart.
Reference: http://www.surgerydoor.co.uk/medical_conditions/Indices/L/lithotripsy.htm
Q303EXPL
One characteristic of laser emissions is that the energy levels of the photons are the same. There is a direct correlation
between energy level, frequency, and color. There is a wide variety of laser types, with emissions possible in the
ultraviolet, visible and infrared ranges, all of which are part of the electromagnetic spectrum.
333 - 337
Q305EXPL
The shorter the tubing and the stiffer (non-compliant) it is, the better the transmission of the pressure waveform. Air
bubbles of any size compromise the fidelity of the signal. Answer c is the most acceptable answer.
Q308EXPL
The flow signal indicates the volume of air that moves into or out of the lungs during a given time period. By integrating
this signal over time, we add up the volume for each given time interval, giving the total volume.
385 - 389
Q309EXPL
A piezoelectric crystal generates a voltage when deformed, and deforms when a voltage is applied. Diagnostic ultrasound
is a form of mechanical energy that consists of high-frequency vibrations - vibrations that have their origin in a
piezoelectric crystal. The easiest way to explain this phenomenon is by way of pulsed ultrasound: for part of the cycle, the
crystal generates energy that is propagated into the patient's body; for the other part of the cycle, the crystal acts as a
receiver, waiting to receive energy echoed back from structures within the patient's body. This information is then
processed into a visual image for diagnosis.
Reference: Geddes, Leslie A. and Baker, Lee E., Principles of Applied Biomedical Instrumentation, 3rd edition, John
Wiley and Sons, 1989, page 170
Q310EXPL
For decades, defibrillators have used monophasic waveforms. With a monophasic waveform, current flows in one
direction, from one electrode to the other, stopping the heart so it has the chance to re-start on its own. With a biphasic
waveform, current flows in one direction in the first phase of the shock and then reverses for the second phase.
Defibrillators that deliver biphasic waveforms are rapidly replacing defibrillators that deliver monophasic waveforms.
Lower energy biphasic shocks appear to cause less myocardial injury and subsequent post-resuscitation myocardial
dysfunction thus potentially improving the likelihood of survival. Recommendations of the International Liaison
Committee on Resuscitation (ILCOR) state that biphasic energies less than or equal to 200 joules are as efficacious as
escalating higher energy monophasic shocks.
Choices "C" and "D" are incorrect, because the relatively new automated external defibrillators (AED) utilize biphasic
waveform technology, and most all defibrillators can administer shocks through disposable pads.
References:
[1] http://circ.ahajournals.org/cgi/content/full/97/16/1654
[2] http://www.resus.org.au/AdvisoryStatementEnergyLevelsDefib.pdf
[3] http://www.biphasic.com/lessons/lesson4.cfm
[4] Cummins et al., "Low-Energy Biphasic Waveform Defibrillation: Evidence-Based Review," Circulation,
1998;97:1654-1667
[5] Gliner BE, Jorgenson DB, Poole JE, et al. Treatment of Out-of-Hospital Cardiac Arrest With a Low-Energy
Impedance-Compensating Biphasic Waveform Automatic External Defibrillator, The LIFE Investigators, Biomed Instrum
Technol 1998;32(6):631-44
Q312EXPL
Also known as a Clark electrode (after its inventor), polarographic sensors depend on a chemical reaction between oxygen
and a buffered solution. The reaction releases electrons in proportion to the partial pressure of oxygen. This current flow
generates a small voltage, which is proportional to oxygen partial pressure.
427 - 428
Q314EXPL
Anesthesia ventilators recirculate exhaled air back to the inhalation circuit as a way to reducing the amount of anesthetic
that must be used. However, CO2 in the exhaled air must be removed before it is returned to the patient. Soda lime is the
material that absorbs the CO2, and the more it absorbs, the more its color changes.
78 - 79
Q315EXPL
Energy stored in a capacitor is given by the equation:
W=(1/2)CV2
Solving for voltage and plugging in the numbers gives:
V = SQRT(2W/C)
V = SQRT[(2)(200 joules) / (16 microfarads)]
V = SQRT[400 joules / 16 microfarads]
V = SQRT[400 joules / 0.000016 farads]
V = SQRT[25,000,000 volts2]
V = 5,000 volts
The question actually asks not for stored energy, but for delivered energy. Some of the energy stored in the capacitor is
dissipated at the skin-paddle interface, so delivered energy may actually be somewhere around 70% of stored energy. To
calculate the delivered energy, we would need to know the relative impedance of the thorax and the skin-paddle interface.
Thus, to deliver 200 J, the voltage would have to be a little higher than 5000 volts, but certainly not as high as 50,000
volts.
Reference: Aston, Richard, Principles of Biomedical instrumentation and Measurement, Merrill Publishing, 1990, p. 262
and pages 267-270.
Q316EXPL
Bipolar electrosurgical instruments use the two parts of the forceps as the active electrode and the return path. This design
directs the primary current flow only in the area intended. Only stray energy may find its way to a return plate (if used).
Q317EXPL
During infusion of fluids to a patient, a secondary bag may be hung at a greater height than the primary bag. If more than
one bag of solution is connected together by wye connections on the supply side of an infusion pump, the highest bag
(which has the greatest head pressure) is the first to flow to the pump's input. The greater pressure from the secondary bag
will block flow from the primary bag until the secondary bag has emptied. The primary set needs to have a check valve or
the secondary bag will empty into the primary bag.
Reference: Carefusion, Alaris Secondary Setup tip sheet
Q319EXPL
Cardiac Index is defined by dividing the Cardiac Output by the Body Surface Area. This measure normalizes the value. A
larger person is more likely to have a greater Cardiac Output, so by dividing by the BSA, it standardizes the value.
Multiplying the stroke volume by the mean aortic pressure provides a measure of the stroke work of the heart. Subtracting
the diastolic pressure from the systolic pressure is the pulse pressure. If you divide the pulse pressure by three and add it
to the diastolic pressure, you get an approximation of the mean pressure.
Reference: Guyton, Arthur C., Basic Human Physiology, W.B. Saunders Co., 2nd edition, 1977, Page 247
Q320EXPL
Apnea is a lack of breathing. An anesthesia machine will alarm if it senses no attempt to breathe when it is in this mode. If
a patient stops breathing, the heart rate may eventually be affected, but the more immediate sensing mechanism would be
the monitoring of the flow of gas in the breathing circuit on the anesthesia machine, thus the alarm for apnea.
Reference: Chatterjee, Shakti, and Miller, Aubert, Biomedical Instrumentation Systems, Delmar Cengage Learning, 2010,
page 359
Q321EXPL
A resonator is used to develop a laser beam. Photons are excited and electromagnetic energy is used to shape and amplify
the beam within the resonator. One of the most expensive and involved repairs to a medical laser is replacement of a
defective resonator.
Reference: http://rp-photics.com/laser_resonators.html
Q322EXPL
Carbon dioxide lasers use a wavelength of 106.6 micrometers, which is readily absorbed by water and soft tissue, rather
than being reflected by them. This characteristic allows the CO2 laser to generate intense heat in soft tissue, similar to an
electrosurgery unit, making it effective for general surgery applications. However, because it is absorbed by water, it is
not able to pass through fluid in the eye, and so is not used for eye surgery.
On the other hand, neodymium-YAG lasers are used effectively in many types of eye surgery. However, for reshaping the
cornea to correct vision problems, excimer lasers are used.
Energy from CO2 lasers does not easily pass through fiber-optic cables and therefore is most commonly used for surgery
on exposed surfaces of the body.
(Note: 1 micrometer = 1 micron = 10-6 meters. The term micron, while still widely used in English, is no longer officially
recognized by standards bodies.)
References:
[1] Chatterjee, Shakti, and Miller, Aubert, Biomedical Instrumentation Systems, Delmar Cengage Learning, 2010, page
505
[2] Street, Laurence J., Introduction to Biomedical Engineering Technology, CRC Press, 2008, pages 216-217
Q323EXPL
Electrophysiologists identify areas of heart muscle that are the cause of abnormalities through heart mapping and
stimulation. Ablation, the scarring or destruction of the areas of the heart muscle causing those abnormal cardiac
contractions, can be achieved through RF (radio frequency) energy, cryo-ablation (freezing the tissue), or laser ablations.
Swan-Ganz catheters are used for monitoring pressures of the right side of the heart and also providing a way to measure
cardiac output using thermodilution.
Stents are used in cardiac catheterization to hold open arteries that previously had been blocked.
Reference: Webster, John G., Medical Instrumentation, 4th edition, 2010, page 632
Q324EXPL
In the asynchronous mode, a ventilator will cycle at a set rate.
In the demand mode, the ventilator waits for the patient to initiate a breath and then assists in delivering the breath.
A drop in the oxygen saturation may be used by a clinician to evaluate the effectiveness of the ventilator therapy, but does
not automatically change the settings at which the ventilator operates.
While in the future, we expect closed loop systems may provide interaction between infusion pumps, pulse oximeter
readings, and other physiological parameters and medical devices, ventilators currently in use require that the settings be
adjusted by clinicians.
Reference: Webster, John G., Medical Instrumentation, 4th edition, 2010, page 620
Q325EXPL
Isolation of the RF (radio frequency) output of the ESU (electrosurgical unit) has been very effective in reducing the risk
of alternate site burns. The isolation is from building ground, which is the same as the equipment’s chassis ground. In this
way the majority of the energy is directed to the return pad, which spreads out the current density.
Right leg drive is a function of an ECG monitoring system to reduce or eliminate the effect of common-mode signals on
the recorded ECG.
Reference: Carr, Joseph J. and Brown, John M., Introduction to Biomedical Equipment Technology, 4th edition, 2001,
page 496
Q326EXPL
The application of positive airway pressure, sometimes referred to as CPAP (continuous positive airway pressure) or
BiPAP (bilevel positive airway pressure) is helpful in the treatment of sleep apnea.
Atrial fibrillation is a type of heart arrhythmia.
Renal failure is a failure of the kidneys to function properly.
Nosocomial infections are infections acquired in a hospital setting.
References:
[1] Webster, John G., Medical Instrumentation, 4th edition, 2010, page 620
[2] Street, Laurence J., Introduction to Biomedical Engineering Technology, CRC Press, 2008, page 179
Q327EXPL
MRI (Magnetic Resonance Imaging) scanners typically use electromagnets to generate strong electromagnetic fields. For
a device to be designated as safe to use near an MRI, it must be demonstrated that it will not be pulled into the magnet,
that it can perform its function while the magnet is operating, and that it should not operate at frequencies that would
interfere with the scanner's ability to acquire an accurate image.
Reference: Health Devices, 34(10), October, 2005, ECRI Institute, page 334
Q328EXPL
Blood glucose is measured from a blood sample using the measurement of by-products of a chemical reaction. The by-
products are measured using electrochemical sensors.
Neither lasers nor pulse oximetry are useful for the measurement of blood glucose levels.
HPIV (human parainfluenzia viruses) are a group of viruses that cause respiratory infections.
Reference: Wang, Joseph, Chemical Reviews, 2008, volume 108, number 2, page 815
Q329EXPL
A BIS (BiSpectral Index) monitor uses EEG information from electrodes placed at specific locations to calculate a value
that relates to a level of the patient's awareness.
BIS monitors do not measure heart rate, infection rate, or the risk factors for DVT (deep vein thrombosis).
Reference: Street, Lawrence J., Introduction to Biomedical Engineering Technology, CRC Press, 2008, page 95
Q357EXPL
Skin irritation can develop from an adverse reaction between a patient's skin and any of the chemicals that may be placed
on the skin. A patient may develop an adverse reaction to any skin cleaner, degreaser, or other "skin-prep" product.
It could also result from a sensitivity to the adhesive used by the electrode.
Another possibility is a reaction to any of the chemicals, including chloride ions, which are present in the electrolyte gel
that provides a conductive path between the skin and the actual electrode.
Reference: None
Q359EXPL
Artifact is a distortion of the actual signal by an interfering signal. Severe artifact can result in an inability to make an
accurate diagnosis because of the large amount of distortion of the waveform.
A very common cause of artifact is any patient motion, whether voluntary or involuntary. This motion can cause artifact
both by generating muscle electrical signals, which can interfere with the ECG, or by causing motion of the electrode,
which can disturb the half-cell potential established at the electrode-skin interface. Both a nervous patient and a talking
patient could cause muscle-related artifact.
Similarly, a loose electrode is also more subject to movement, and disturbance of its half-cell potential.
A defective ECG amplifier might be more susceptible to interference than a properly working amplifier. For example, the
common-mode rejection ratio of the amplifier might have deteriorated, and this would allow strong common-mode
signals, such as those generated by a 60 hertz electric field, to interfere with the desired signal.
Q361EXPL
60-hertz electric fields surround all patients. To prevent them from inducing voltages in electrocardiograph leads, steps
must be taken to keep the common-mode rejection ratio (CMRR) of the system as high as possible, and the common-
mode signal (the 60-hertz signal) as low as possible. If these conditions are not met, then there is more likely to be
interference displayed on the ECG trace.
If an amplifier with a poor CMRR is used as part of the monitor, then excessive interference might result.
If electrodes are not applied properly, then the impedance seen by the electrodes might be different. The different input
impedances created by these conditions will cause a deterioration of the CMRR.
An electric bed with no ground connection would not benefit from the shielding effect that proper grounding can help
bring about. The ground wire connects to the case of the motor. The windings inside the motor generate a very strong
electric field. If the ground wire is broken, the case will no longer provide the shielding necessary to reduce the leakage of
this electric field, and interference could result.
Reference: None
Q362EXPL
Accurate measurement of the output of an electrosurgery unit requires equipment that responds accurately to radio
frequency (RF) voltages. At these higher frequencies, the reactance of inductors and capacitors can become significant,
and interfere with proper measurement.
A high wattage light bulb is a good, quick way to get a gross indication of the output of an electrosurgery unit. However,
it is not a calibrated test instrument, because its resistance changes with different applied voltages, and its brightness can
not be measured easily.
An AC voltmeter is also not a good choice for a measurement instrument. These instruments present a very high
impedance load to the electrosurgery unit, and so do not provide an accurate representation of the performance of the ESU
under its typical load conditions. In addition, most standard AC voltmeters have a very limited bandwidth. They are
designed to work in the 60 hertz range found in typical house wiring, rather than the 1 megahertz range of an ESU's
output.
A radio transmitter wattmeter typically does not in itself provide an appropriate load for an ESU. These instruments
generally operate by looking at the voltage and current going into the output stage of a radio transmitter, rather than the
actual power it is delivering into a calibrated load.
An RF ammeter in series with a non-inductive resistor is a good way to measure the output of an ESU. The RF ammeter
will respond accurately to the output frequencies of the ESU. The non-inductive resistor will present a purely resistive
load to the ESU, and so its impedance will not be affected by changes in the output frequency or waveform of the ESU.
Q363EXPL
When testing an external cardiac pacemaker, it should be tested with a load that is typically seen in relation to the leads
that are carrying the pacemaker's current into the heart. The typical lead impedance would range from 200 up to 2,000
ohms. A lead impedance outside this range indicates a problem. An impedance lower than 200 ohms would usually
indicate an insulation defect, while an impedance greater than 2,000 ohms would suggest the possibility of a failure of the
conductor inside the pacemaker lead.
Therefore, the load impedance used to check the operation of an external pacemaker would need to be within that 200 to
2,000 ohm range. For example, one commercial pacemaker analyzer (see reference below) has a default load impedance
of 500 ohms, although it offers several choices, all within the 200 to 2,000 ohm range.
References:
[1] Swerdlow, Charles D. and Friedman, Paul A., Advanced ICD Troubleshooting: Part II, Medscape Pacing and Clinical
Electrophysiology, http://www.medscape.com/viewarticle/524834_3, retrieved March 14, 2015
[2] SigmaPace 1000 External Pacemaker Analyzer Operators Manual, Fluke Biomedical, pages 4-12 and 5-14,
http://assets.fluke.com/manuals/sigmapacomeng0000.pdf, retrieved March 14, 2015
Q364EXPL
The most common cause of error in the measurement of cardiac output is an operator error. Thermal dilution
measurements of cardiac output rely upon the rapid introduction of a bolus of cooled fluid into the heart. If this is not
done, the fluid will not mix properly with the blood, and the temperature change seen at the thermistor at the tip of the
catheter will appear over a much longer period of time than it should.
If the injection is non-continuous, then instead of a single region of blood being cooled, two distinct regions of blood
passing by the catheter tip may be cooled. The warmed area of blood in between those two cooler regions will yield the
notch on the temperature curve.
While it is possible that the cardiac output computer is defective, this is much less likely than an operator error.
While an occluded catheter could cause a problem, it is not as likely to result in a notch condition. If the catheter were
occluded, it would be difficult to deliver the injectate, and, if the occlusion were released, then the injectate would flow
freely.
Pacemaker pulses would not generate thermal interference, so they can not cause the notch in the temperature curve.
Reference: None
Q365EXPL
Most malfunctions in electronic systems are the result of mechanical stress. In general, the electronic components
themselves tend to be far more reliable than the mechanical components. When monitoring a patient's electrocardiogram,
the components most subject to mechanical stress are the lead wires, cables, and electrodes. All of these are frequently
manipulated, and so are subject to being stressed excessively and breaking. The adhesive associated with electrodes will
lose its stickiness over time, as the patient perspires, or as skin particles and other dirt attach themselves to the electrode.
Reference: None
Q366EXPL
The accurate measurement of cardiac output depends upon having a good signal-to-noise ratio. The signal being measured
by a thermodilution cardiac output computer is the change in temperature of the blood passing the thermistor at the tip of
the catheter in the pulmonary artery. The noise is any change taking place in the normal temperature of the blood as a
result of any factors unrelated to the injection of the cooled injectate into the bloodstream at the start of the thermodilution
procedure.
When measuring cardiac output, it is assumed that the output is constant over the period of measurement. If this is not the
case, then the readings will be in error. Because cardiac output measurements frequently vary over a relatively short
period of time, it is common practice for those measuring cardiac output to use three injections of cooled fluid, and
average the result of each of these measurements. (Any exceptionally high or low values are thrown out before
averaging.)
The larger the temperature difference between the injectate and the blood, the larger the signal being measured. Having an
injectate at least 10o C cooler than blood temperature improves the results, as it enhances the signal-to-noise ratio.
Five percent (5%) dextrose in water (D5W) is a very common injectate. Its viscosity is low enough that it can be injected
rapidly into the catheter, and it has no unusual heating or cooling characteristics. The choice of a saline or D5W injectate
depends to some extent on patient condition, and to some extent on physician preference. However, both are very
commonly used injectates, and both work equally successfully.
The catheter balloon must be fully deflated to allow successful measurement. If the balloon is fully or partially inflated,
then the blood flow past the catheter will not be normal, and errors in the computation of cardiac output will result.
If the patient has deep respirations, the changes in the intrathoracic pressure can cause a significant change in the actual,
instantaneous cardiac output. This variation will affect the reproducibility of the measurements taken, depending upon
which point during the respiratory cycle they were made.
Reference: None
Q367EXPL
is not at the same level as the patient's heart, then the fluid column will alter the readings seen.
If the transducer is below heart level, then a negative pressure head will make the readings seen by the transducer higher
than they actually are in the heart. Conversely, if the transducer is above heart level, then a positive pressure head will
make the readings seen by the transducer lower than they really are in the heart.
Q368EXPL
The question describes a waveform that is significantly distorted. It asks about a possible cause for that distortion.
If the catheter has migrated out of place, and is no longer in its intended artery, the displayed waveform will reflect the
pressures at the new location. However, the waveform would not appear damped because of the new location.
If the transducer were not at the proper level, or the system had not been zeroed or calibrated properly, the readings would
be inaccurate, but the waveform would not appear distorted.
Warm-up time is not a significant factor in modern blood pressure measurement equipment. However, if warm-up time
was required, and was not allowed, it could account for a drift of the zeroing, or for a drift of the calibration factor, but it
could not account for the damped waveform.
Air bubbles are a very common cause of damping of the waveform, and inaccurate readings. Air is much more
compressible than liquid, and so its presence in the liquid pressure measurement line can lead to very significant
distortion.
Hall, 2001, pages 263 - 266
Q369EXPL
The question describes a change in the arterial blood pressure waveform that has occurred suddenly. This would be caused
by a sudden change in the operating conditions of the system.
If blood started backing up into the pressure line, probably because the flush solution was no longer flushing properly,
there would probably be a gradual, rather than a sudden, change. Unless a clot had suddenly developed at the tip of the
catheter (which is possible, because the flush solution is not working), it would not account for a sudden change in the
waveform.
Warm-up time is not a significant factor in modern blood pressure measurement equipment. However, if warm-up time
was required, and was not allowed, it could account for a drift of the zeroing, or for a drift of the calibration factor, but it
could not account for a sudden change in the waveform.
A loose connection is a likely cause for a sudden change. If the connection were loose, and reached the point where the
system suddenly opened up, or allowed the introduction of air, a sudden change would occur in the waveform as the
pressure line went from a closed system to an open system.
Moisture in the transducer's electronic components might account for a sudden change in the displayed waveform.
However, it is not a very likely cause of such an event. Modern pressure measurement systems keep the transducer
effectively isolated from liquids, and it is very unlikely that moisture could enter the transducer.
Reference: None
Q370EXPL
The question indicates that the recorded expired minute volume is lower than the actual expired minute volume.
The humidifier is used to add moisture to the inhaled air, to prevent drying of the patient's lungs. If it were defective, it
would not change the amount of air the patient was breathing, and would not affect the recorded volumes.
The pressure transducer is used to assure that the pressures at which air is forced into the patient's lungs are appropriate. If
the pressure is too high, damage to the lungs can result; if it is too low, insufficient air will get into the lungs. While a
defective pressure transducer might account for a low delivered volume, it could not account for a discrepancy between
the recorded volume and the actual volume.
If the inspiratory valve were bad, an insufficient amount of air might enter the lungs. This also could not account for a
reading that differs from the actual volume of air being expired.
The volume of air moving into or out of the patient is detected by the airflow transducer. If this transducer was defective,
then the volumes calculated by the ventilator would be inaccurate.
Reference: None
Q371EXPL
Good pulse oximetry readings depend upon having adequate blood flow under the sensor. A patient suffering from
exposure and hypothermia would have his body shutting down blood flow to the limbs and other portions of the body that
are not essential, in order to preserve as much heat as possible in the brain and the trunk.
The pinna of the ear, where the pulse oximeter is connected, will suffer from significantly reduced blood flow during
hypothermia. It is most likely that the difficulty in obtaining a signal is due to the patient's condition, not to the oximeter.
Using a different pulse oximeter will not solve the fundamental problem, that is, the lack of blood flow in the ear.
Similarly, a different ear probe will not solve the problem, because inadequate blood flow is not addressed by changing
the probe.
There is no indication that the pulse oximeter is not receiving power, so changing to a different electrical outlet would not
solve the problem.
Switching to a different type of sensor, such as a nasal sensor, is a good solution. The patient's nose will probably have
more blood flowing through it than the patient's ear, so it is more likely to be able to generate a good signal. If no nasal
sensor is available, the nurse could try to increase blood flow in the ear. The best way to do this is to warm the ear.
Reference: None
Q373EXPL
An infusion controller that has a back pressure alarm (or distal occlusion alarm) is indicating that the controller is not able
to overcome the pressure required to infuse fluid into the patient.
Changing the batteries is an inappropriate response to this condition. Batteries should be recharged if a low battery alarm
sounds, or replaced if recharging does not provide an adequate battery life.
Lowering the IV solution will decrease the pressure at which fluid is entering the patient, and is likely to increase the
frequency of back pressure alarms, rather than decreasing their frequency.
Changing the infusion container should be done when an empty bottle alarm sounds. It will not affect the back pressure
alarm.
Checking the infusion site is an appropriate response to this alarm. If the line is occluded or kinked, the controller will not
be able to generate enough pressure to force fluid into the patient, and a back pressure alarm will sound.
Reference: None
Q374EXPL
Accurate blood pressure measurement relies on appropriately occluding the brachial artery with a blood pressure cuff. If a
cuff is too small, the pressure at the surface of the arm will not be the same as the pressure at the artery, and a high
reading will be seen. If a cuff is too large, the artery will not open properly during the blood pressure measurement cycle,
and a low reading will result.
A kinked or occluded tubing will result in an inability to measure blood pressure, or erratic readings. It will not result in
low readings.
A leak in the tubing will result in erratic readings, or in readings that take a longer-than-expected time to be taken as the
monitor tries to maintain the pressure in the cuff.
Using a cuff that is too large will result in the lower-than-expected blood pressure readings seen in the problem statement.
Patient movement during the blood pressure determination cycle is likely to result in erratic readings or an inability to
obtain readings.
Reference: None
Q375EXPL
Infiltration is a problem that plagues intravenous infusions. Infiltration occurs when a catheter placed in a vein penetrates
the wall of the vein and delivers the IV fluid into the extravascular space instead of mixing it with the blood in the vein.
Despite many attempts to produce devices that accurately detect infiltrations, none have proven to be reliable. At present,
the only reliable method of detecting infiltrations is a frequent visual inspection of the infusion site.
Reference: None
Q376EXPL
Accurate transmission of ultrasonic waves requires a stable, incompressible transmission medium.
Tap water, distilled water, and sterile water all contain small amounts of air. Air bubbles tend to absorb ultrasound, so that
the full energy of the ultrasound transducer is not transmitted to the detector.
De-gassed water has no air bubbles, and so it will accurately transmit the power sent through it. Therefore, it is used as a
coupling medium to transmit the energy generated by the ultrasound unit's transducer to the ultrasound meter's detector.
Reference: None
Q379EXPL
Experience indicates that most problems related to equipment are the result of operator error. Only after it has been
verified that correct operating procedure does not produce the expected result should a technician assume that the
equipment is at fault.
Improper blood collection technique is a distinct possibility that needs to be considered when blood hemoglobin and white
blood cell counts are abnormal. This is an operator-dependent parameter that may produce poor results.
A low refrigerator temperature or too high a flow rate would generally not produce abnormal results for both hemoglobin
and white blood cell counts. An old lysing agent might affect both parameters, but most laboratories take extreme care to
dispose of outdated reagents, so this is a less likely cause for the problem described than a collection technique error.
Reference: None
Q380EXPL
An oxygen monitor uses an electrode with a platinum wire tip to detect the partial pressure of oxygen. When properly
arranged, a current will flow between this electrode and a silver-silver chloride reference electrode. The current that flows
is the result of an oxidation-reduction reaction that takes place at the platinum electrode when a voltage of about 0.7 volts
is placed across the two electrodes. A Clark electrode is type of oxygen electrode that combines the platinum and
reference electrodes into a single unit.
A pO2 electrode is used to measure partial pressure of oxygen in blood gas measurement. If the pO2 electrode were
defective, it would not respond at all to the oxygen level in the air. However, this electrode is responding slowly.
The galvanic cell supplies the 0.7 volts needed between the electrodes to provide the voltage necessary for the oxygen-
reduction reaction to take place. If this cell is old, and can no longer produce the needed voltage, the reaction will take
place much more slowly than usual. This is what is happening in the problem given.
A calomel electrode is a very stable electrode that is used as a reference electrode for some measurement systems. In those
types of systems, the voltage produced by the measuring electrode is compared to the voltage produced by a reference
electrode. To prevent errors, the reference voltage must be extremely stable, leading to the use of a calomel electrode.
Calomel is also known as mercurous chloride.
A Severinghaus electrode is used to measure the partial pressure of carbon dioxide.
Reference: Webster, John G., Medical Instrumentation: Application and Design, Houghton-Mifflin Company, 1978, pages
549-551
Q381EXPL
A pulse oximeter generally uses a probe placed on the tip of a finger that transmits light through the fingertip. The relative
transmission of light at different wavelengths is measured to help determine the oxygen saturation level of the blood in the
finger. (Other types of sensors are also available, but the finger sensor is the most common.)
Anything that interferes with the transmission of the light through the fingertip distorts the spectrum of the light passing
through it, or causes a lower-than-needed blood flow to the finger that can make it impossible to obtain oxygen saturation
readings. In addition, physical damage to the equipment can be a source of this difficulty.
A bad sensor connection is a possible cause for the inability to obtain a signal. The sensor on an oximeter is often
subjected to substantial abuse, and breakage of the sensor's connector is not an uncommon problem.
The measurement of oxygen saturation relies on the presence of enough blood at the sensor site to obtain a reading. If
blood flow is restricted, the oximeter may not be able to obtain a reading.
A patient receiving vasoconstrictive drugs also may not have enough blood flowing at the sensor site to obtain a sigal.
These drugs cause less blood to flow through the vessels in the peripheral portions of the body, making oxygen saturation
readings difficult to obtain.
Reference: None
Q383EXPL
The conditions described indicate that the system is resonating. At resonance, the systolic readings will be significantly
higher than the actual readings. A resonant system will amplify the frequency components near its resonant frequencies.
Normally, for a relatively short pressure line, the system's resonant frequency will be well above the frequency
components in the arterial blood pressure waveform, and so there is no significant distortion of the waveform. As the
pressure line gets longer, the resonant frequency of the measurement system will become lower. If the frequency drops to
the point where there are significant frequency components in the arterial pressure waveform at or near the resonant
frequency, these will be amplified, and the waveform will be distorted or appear to be noisy. This is because some
frequency components of the input waveform are amplified much more than other components. At its resonant frequency,
the pressure measurement system will be underdamped.
In this case, because the systolic pressure is higher than its actual value, the system is probably in resonance. The most
common cause for this is that the catheter tubing is too long.
Electrical interference from other equipment would not cause noise on the mechanical blood pressure waveform.
If the system is overdamped, then the higher-frequency components of the waveform will be diminished, and the
monitor's calculated systolic value will not reach the actual systolic value. The most common cause for an overdamped
waveform is an air bubble.
If the monitor is out of calibration, the systolic and diastolic readings might be incorrect, but this would not account for
the noise on the displayed waveform.
Q384EXPL
An end tidal CO2 monitor measures the level of carbon dioxide in the exhaled air of a patient. To work properly, it needs
to receive a sufficient volume of exhaled air to make a determination.
A low flow alarm indicates that the monitor is not getting enough air to make a determination. The exhaled air that enters
the monitor does so by traveling through a sample tube. A common cause of low flow is blockage in that tube. Therefore,
a reasonable first step would be to ask the equipment operator to change the sample tube to ensure that this is not the
problem. Changing the sample tube can be done relatively quickly, with minimal disturbance to the monitor or patient.
Turning off the monitor is not a reasonable step. The monitor is generating an alarm condition, and the appropriate
response is to correct the reason for the alarm, not to ignore it and hope it will go away.
Recalibrating the monitor is also inappropriate. The low flow alarm may be caused by the calibration of the monitor being
incorrect. However, it is unreasonable to assume that the monitor's alarm is caused by being out of calibration before
investigating other, more reasonable causes.
The exhaust tubing carries the sample of air that has entered the monitor back out of the monitor and into the gas
scavenging system. If it were blocked, it could account for a low flow alarm. However, a disconnected tubing would not
impose any resistance to flow, and so this could not be a cause for a low flow alarm.
Reference: None
Q385EXPL
KVO on an infusion pump stands for "keep vein open." This is a very low infusion rate, usually 2 milliliters per hour or
less, designed to keep enough fluid moving through the catheter to keep a blood clot from forming at the end of the
catheter.
Many infusion pumps are designed to go into the KVO rate after they have delivered their programmed infusion.
Reference: None
Q386EXPL
Infiltration is a problem that plagues intravenous infusions. Infiltration occurs when a catheter placed in a vein penetrates
the wall of the vein and delivers the IV fluid into the extravascular space instead of mixing it with the blood in the vein.
Despite many attempts to produce devices that accurately detect infiltrations, none have proven reliable. At present, the
only reliable method of detecting infiltrations is a frequent visual inspection of the infusion site.
Therefore, because the technician determined that the pump was operating properly, it is not appropriate to readjust the
back pressure alarm, as infiltrations can not be detected reliably by such an alarm anyway. In addition, it is inappropriate
to perform more extended testing, because there is no reason to believe the pump is at fault.
Of the two remaining choices, taking no action or providing the nurse with an explanation of the pump's operation, the
second is the most appropriate. The nurse needs feedback from the technician to understand whether or not the equipment
was operating properly. Because the equipment was operating properly, the nurse needs to understand the limitations of
the equipment so that the nurse's expectations are consistent with the abilities of the equipment. The nurse must
understand that it is important not to rely on equipment detecting a serious condition that it is incapable of detecting, and
that the nurse must check infusion sites carefully and frequently to ensure that a patient injury does not result from an
accidental infiltration.
Reference: None
Q387EXPL
The return pad monitoring circuit is designed to verify that the return pad circuit is complete and that it is attached to the
patient. If the pad becomes detached from the patient, there is a higher likelihood of a patient burn caused by the
unintended flow of radio frequency (RF) current through an alternate return site. The AAMI standard for electrosurgical
units requires that the alarm activate if the impedance of the return pad circuit exceeds 1000 ohms.
The alarm circuit will only detect defects in the return pad circuit; it will not detect inappropriate power settings in either
the cut or coagulation modes.
This alarm circuit also does not detect problems with the bipolar forceps, because bipolar forceps pass current between the
two ends of the forceps. No current should flow in the patient return pad when these forceps are being used.
If the patient return pad becomes partially or completely detached from the patient, the impedance in the circuit will rise
above the internal threshold set for activation of the alarm. Therefore, this is a likely cause for the activation of the alarm.
The impedance of the patient return pad circuit is relatively independent of the proximity of the return pad to the active
electrode; therefore, even if this pad were relatively far away from the surgery site, the alarm would still not activate.
Reference: None
Q388EXPL
Pacing can be performed transthoracically by using a pacemaker connected to pads applied to a patient's chest. While this
system is much easier to set up than a pacemaker using a lead wire connected directly to the patient's heart (transvenous
pacing), transthoracic pacing requires much higher current levels to be effective.
Successful capture of the heart (depolarization of the heart by an artificial stimulus) depends upon passing enough current
through the heart to force it to depolarize uniformly. When a current is applied to the chest, a large portion of that current
never enters the heart. Thus, more current is required to perform transthoracic pacing as compared to transvenous pacing.
Transvenous pacing may require currents up to 20 milliamperes to be effective. Transthoracic pacing may require currents
up to 200 milliamperes to successfully capture the heart.
In this case, the current being delivered is 20 milliamperes, and it is not electrically capturing the heart. Considering the
current that could be required is much higher, it is likely that the output current needs to be increased to initiate capture.
The pacer's rate needs to be faster than the intrinsic heart rate to successfully capture the heart, but once it exceeds the
heart rate, capture should take place. The pacer's batteries show no evidence of being depleted. If the 20 milliamperes
could not be successfully delivered when it was requested, then it might be reasonable to conclude that the batteries were
depleted. Finally, if the pacing current is sufficient, it will capture the heart regardless of its synchronization with the
patient's R-wave. In fact, because the pacer's rate is higher than the patient's intrinsic heart rate, the pacer can not be
synchronized with the patient's heart rate, because then the pacer would be forced to operate at a slower than prescribed
rate.
Q389EXPL
The display shows that both the systolic and diastolic pressures have increased by 70 mmHg. Because the increase was
equal for both parameters, it is very reasonable to suspect that the zero level of the transducer has changed substantially.
In this case, the transducer's level would be lower than its original level.
The transducer should have been set up at heart level, which is considered to be midaxillary level. If the transducer is
below this level, the pressure readings will be higher than the actual pressures because of the extra pressure head on the
transducer created by the difference in fluid levels between the transducer and the heart. If the transducer is above heart
level, then the pressure readings will be below the actual pressures.
It is unreasonable to assume that the patient's pressures have increased by 70 mmHg in a 15-minute period. Therefore,
adjusting the alarms to reflect this "new reality" would be inappropriate.
Flushing the line will clear any clots that may be forming at the end of the catheter. But if a clot were forming, it would
not raise the pressure seen by the monitor.
While the patient's pressure readings would indicate hypertension if they were correct, again, it is unreasonable to assume
that the pressures have changed that dramatically over such a short period of time. Until appropriate steps are taken to
verify the accuracy of the transducer's readings by verifying the height of the transducer, it would be inappropriate to
suggest that medical treatment be started.
Reference: None
Q390EXPL
A bump in the temperature curve on a cardiac output computer indicates a reversal of the temperature change that
accompanies the circulation of the cooled injectate past the thermistor on the pulmonary artery (Swan-Ganz) catheter.
If the injectate is administered smoothly and quickly, it will all flow past the thermistor one time (neglecting recirculation
once the blood has traveled through the entire circulatory system), so the curve will go up and then come down once. If
the injectate is not administered smoothly, then the curve may rise and start to fall as the first portion of injectate passes
the thermistor, and then rise and fall again, creating a bump, as the second portion of the injectate passes the thermistor. In
this case, the temperature reversal is taking place on the upslope of the curve, where it is still rising, and has not yet
reached its maximum value.
Assuming that the injectate has been delivered properly, then the bump must be caused by some other mechanism that
accounts for two separate portions of injectate passing the thermistor.
If the lumen of the pulmonary artery catheter developed a hole so that the injectate came out of it in two spots, this might
account for the bump. However, this type of defect is extremely rare.
Electrical noise on the signal could not account for the change in temperature seen. Because this problem was seen five
times in a row, and because noise would not be correlated with the administration of the injectate, it could not account for
the bump.
If the patient has a right-left cardiac shunt, where blood from the left side of the heart enters the right side without
circulating through the body, this could account for the bump seen. This happens when there is a hole in the septum
separating the right and left sides of the heart. In this case, some injectate would reach the thermistor by traveling along its
normal path from the right ventricle to the pulmonary artery. Other injectate could reach the thermistor by entering the
right ventricle from the left ventricle after it has already gone past the thermistor once. If this happened, a bump would be
seen.
Patient movement during the procedure would not cause the bump described in the question.
Reference: None
Q391EXPL
In order for a non-invasive blood pressure monitor to reliably detect a patient's blood pressure, the cuff size and the
position must be correct.
If the cuff is too small, the pressure readings will tend to be too high. If the cuff is too large, the readings will tend to be
too low.
The blood pressure cuff has an index mark that should be placed over the brachial artery. If this is not done, the signals
generated by the cuff, which the monitor is trying to interpret, might not be interpretable. If that happened, the monitor
would not be able to detect the pressure and would generate an error code.
In this case, the question indicates that the monitor is unable to detect the pressure, not that the pressure is in error.
Therefore, it is appropriate to suspect a cuff position problem, not a cuff size problem.
Cycle interval would not affect the ability of the monitor to detect blood pressure.
The pump motor could be a problem if it were failing to inflate the cuff sufficiently. However, it is less likely that the
pump motor is defective, and it would take far more time to test, compared with verifying and correcting the cuff position.
Checking the cuff position can be done very quickly.
Reference: None
Q392EXPL
The dialysate in a dialysis machine should be at body temperature during normal operation.
Normal body temperature is 37o C, so this machine clearly is not at the appropriate temperature. Therefore, choice D is
inappropriate.
Thermistors are generally a very accurate means of measuring temperatures. Therefore, choice C is inappropriate.
To determine whether the thermistor should be replaced, or the machine's display needs to be recalibrated, it is necessary
to determine whether the thermistor's resistance is appropriate. The thermistor should have a resistance of 5 K at 23o C.
At a temperature of 34o C, the resistance should be:
R34o = R23o X {1 - [(34o - 23o) X temperature coefficient]}

R34o = (5 K) X {1 - [(11o) X (-1% / oC)]}
R34o = (5 K) X {1 - 11%}
R34o = (5 K) X {1 - (11/100)}
R34o = (5 K) X {89/100}
R34o = 4.45 K
So, the thermistor's resistance should read 4.45 K at 34oC, but instead reads 3 K. Therefore, it is appropriate to change the
thermistor, and not to recalibrate the machine's temperature display.
Reference: None
Q396EXPL
A Bucky grid is a series of thin lead strips, that moves between the patient and the film in order to absorb scattered
radiation during a radiographic exposure. Because the grid moves, the lead strips are blurred on the film. If the grid motor
is broken such that the grid is stationary, the lead strips will appear as stripes on the film.
Choice B would keep certain wavelengths of x-radiation from reaching the film. Choice D would result in an overly light
film. Thermionic emission is the phenomenon by which electrons are freed from a heated filament in an x-ray (or any kind
of vacuum) tube.
References: http://www.plus2physics.com/electrons_and_photons/study_material.asp?chapter=4; Jacobson B and Webster

JG, Medicine and Clinical Engineering, Prentice-Hall, 1977. p. 409
Q397EXPL
The problem described is intermittent. In the event of choices a, c and d, there would be no image at all. A bad connection
or faulty video cable could cause the type of problem described.
Reference:
[1] Nash S, "A Systematic Approach to Electronic Troubleshooting for Medical Equipment," Biomedical Instrumentation
& Technology, AAMI, May/June 1995, pps. 236-242
Q399EXPL
Considering the Einthoven Triangle, we can tell that the problem has something to do with the left arm lead. That is
common to leads I and III. Lead II, which gives a clean trace, is acquired between the left leg and right arm, so we know
those leads are OK. Realistically, the problem could be caused by the left arm electrode, or even the cable that the left arm
lead wire plugs into.
Reference:
[1] Cromwell L, et.al., Biomedical Instrumentation and Measurements, Prentice-Hall, 1980, p. 115
Q401EXPL
While it is true that poor cuff technique and air in a transducer setup can result in erroneous readings, one should also
keep in mind that direct, invasive blood pressure measurements and indirect measurements with a cuff are based on
completely different principles. It should not be surprising, and it is not unusual, for the results of such measurements to
be a little different.
References: Nara, Andrew, Burns, Michael, and Downs, W. Gregory, Blood Pressure (SpaceLabs Medical Biophysical
Measurement Series), 1991, pages 91 - 93
Q403EXPL
A hyperthermia device will heat the patient. The control mechanism, in this case, is a skin temperature probe. If the
patient’s temperature is below the set temperature, the hyperthermia unit will deliver more heat. If the probe becomes
disconnected from the patient, the temperature reading may very well be below the skin temperature of the patient.
Because the hyperthermia unit has no way of knowing that the probe is disconnected, it responds as though the patient
temperature is too low, and continues to deliver more heat, which can lead to overheating of the patient. (Sometimes the
overheating will reach a point where the unit shuts down because it has exceeded the temperature setting of a back-up
thermostat. In this case, the complaint from the clinical staff may be that the unit is not delivering heat.)
References: Dollberg S and Hoath SB, in Neonatal Intensive Care (SpaceLabs Medical Biophysical Measurement Series),
1995, P. 40
Q404EXPL
When using an isolated-output electrosurgical and a properly connected return pad, the risk of alternate site return path
burns is very low. With the length of surgical procedures increasing, the chance of a pressure necrosis becomes more of a
risk. Pressure necrosis, or pressure sores (decubitus ulcers) occur in immobilized patients due to chronic pressure in
tissues overlying bony prominences. This is most likely what occurred to the patient.
An alternate site return path burn would not be likely, because in an isolated-output ESU, the return pad is isolated from
ground. In an older design ESU, one side of the output circuit is grounded. The patient plate on those models was usually
connected to the chassis, which was in turn connected to the AC power mains ground. If a point on the patient’s body
became grounded with a significantly lower resistance, a major current would be diverted to the spurious ground. If the
current density through the point that is grounded was high enough, burns would occur.
Hyaline membrane disease, also called respiratory distress syndrome (RDS), is a common problem of premature babies. It
occurs when there is not enough of a substance in the lungs called surfactant. Surfactant is normally released into the lung
tissues where it helps lower surface tension in the airways. This helps keep the lung alveoli (air sacs) open. When there is
not enough surfactant, the tiny alveoli collapse with each breath. As the alveoli collapse, damaged cells collect in the
airways and further affect breathing ability. These cells are called hyaline membranes. The baby works harder and harder
at breathing, trying to re-inflate the collapsed airways.
References: Carr J and Brown J, Introduction to Biomedical Equipment Technology, 4th edition, Wiley, 2001, p. 496
Q406EXPL
Pulse oximeters work by measuring the infrared and red light transmission through a part of the body, such as a finger or
ear lobe. During systole, there is a surge of oxygen-rich blood in the capillaries, which results in greater relative
absorbance of red light vs. infrared; however, the lower the oxygen saturation of hemoglobin in the blood, the lower
absorbance of red light, and the greater absorbance of infrared.
Venous blood and tissue also absorb at these wavelengths, but the pulsatile nature of arterial blood flow allows it to be
separated out from the signal due to venous blood and tissue. However, the signal from arterial blood is relatively small,
and thus the measurement of oxygen saturation is sensitive to both technique and to physiological conditions. Specifically,
if the sensor is not positioned properly it can result in improper readings.
Low tissue perfusion can also cause improper readings, because the arterial pulsations are not big enough to allow for
accurate measurement. Edema (swelling) can also create a problem, essentially by increasing the absorbance of red and
infrared due to tissue, thus decreasing the relative strength of the pulsatile arterial signal. Thus, any of the listed conditions
could result in the problem described.
Reference: Berghuis, Paul, et. al. Respiration (SpaceLabs Medical Biophysical Measurement Series), 1991, pages 78 - 93
Q407EXPL
Low augmentation means that the pressure assist from the balloon pump is not as effective as it could be. If gas leaks from
the system, and there is not an effective compensation mechanism, such as an automatic refilling of the balloon with
helium, referred to as "autofill" by most manufacturers, the augmentation is reduced.
The purpose of an intra-aortic balloon pump (IABP) is to augment the heart’s coronary blood flow with counterpulsation
(or diastolic augmentation). A balloon (at the end of a catheter) is placed in the descending thoracic aorta via the femoral
artery. Its inflation and deflation are timed to the cardiac cycle (generally synchronized with the ECG). The balloon
inflates in diastole immediately following aortic valve closure. The augmentation of diastolic pressure, to a level higher
than systolic pressure, increases coronary perfusion as well as that of other tissues. The balloon deflates at the end of
diastole, immediately before left ventricular contraction, abruptly decreasing the afterload and improving left ventricular
ejection.
Any of the above problems could cause low augmentation:
a. The balloon is mounted on a vascular catheter, which has multiple pores. Helium gas is shuttled from the balloon pump
console into the balloon catheter, escapes through the pores, and inflates the balloon. Helium is a molecularly light gas,
which minimizes shuttle transfer time. If there is a helium leak, the balloon will not be inflated correctly, possibly
resulting in low augmentation.
b. A patient who is febrile (too hot) can cause condensation in the shuttle gas catheter, with low augmentation a potential
result.
c. If the patient's heart rate is too high (tachycardia), there might not be enough time to fill and deflate the balloon. To
ensure proper synchronization between counterpulsation and the patient’s hemodynamics, complex console logic
computer systems are used.
d. The IABP’s "autofill" feature causes the system to automatically fill the safety chamber (external to the patient) with
the appropriate amount of helium, then restart automatically. If this is not working correctly, the result could be low
augmentation.
References:
[1] The CS300 Abbreviated Operator's Guide, Maquet Getinge Group, http://ca.maquet.com/file_assets/abbreviated-
operators-guides/en/CS300-IABP-AOG-EN.pdf, retrieved May 17, 2015
[2] System 98 Intra Aortic Balloon Pump, Abbreviated Operator's Guide, Datascope,
http://clinicalengineering.duhs.duke.edu/wysiwyg/downloads/system98.pdf, retrieved May 17, 2015
Q408EXPL
A steam sterilizer is a device that uses moist heat under pressure to kill microorganisms. Water (as in a pressure cooker) is
converted into steam at 212 degrees F.
If the door gasket were ripped (a common problem), the complaint would have been that steam is blowing out past the
door. Choice "C" is not likely either, based on the complaint. If the control system lost power, the unit would not operate
at all. Choice "B" refers to an ethylene oxide (ETO) gas sterilizer, not a steam autoclave.
Choice "D" is the best answer. If there is no steam, the sterilization chamber will not reach temperature.
References:
[1] Jacobson B and Webster JG, Medicine and Clinical Engineering, Prentice-Hall, 1977, page 336;4
[2] http://cal.vet.upenn.edu/surgery/2220.htm
Q409EXPL
As centrifuges run, carbon brushes slowly wear down, resulting in an accumulation of carbon dust in and around the
motor. Carbon is partially conductive, and the build-up of dust creates a conductive path to ground. If the build-up
becomes excessive, leakage current can also become excessive. Note that it is not the worn brushes themselves that cause
the high leakage, but the dust that accumulates due to brushes being worn down. Isolation transformers are typically used
with essential equipment that intrinsically has high leakage that can not be otherwise reduced. A new centrifuge is likely
to have leakage current that is within electrical safety standards, and a good cleaning is likely to return it to that condition.
Reference: Karselis TC, Clinical Laboratory Instrumentation, F.A. Davis, Philadelphia, 1994, pages 421 - 423
Q410EXPL
If you can not see this ever happening to you, or ever happening period--think again! Because BMETs can find
themselves in some awkward situations they need to be aware of the limits of their expertise. Sure, you may know that the
EEG is depressed in patients under general anesthesia or that all EEG channels show some baseline artifact with the gain
at maximum, but should you be playing doctor? Clinical diagnosis of such a problem is most appropriately done by a
neurologist (MD).
You may know how to repair the equipment and you may even know how to use it, but even a certified
electroencephalographer is not qualified to make such a determination. Certainly you should assist in resolving the
problem with the neurologist, but know your limitations.
References:
[1] Niedermeyer, E and Lopes Da Silva, F, Electroencephalography: Basic Principles, Clinical Applications, and Related
Fields, Urban & Schwarzenberg, Baltimore, MD, 1982
[2] Dondelinger R, "Electroencephalographs," Biomedical Instrumentation and Technology, AAMI, Arlington, VA.,
Sept/Oct 2009, pages 388 - 391
Q411EXPL
This is due to hydrostatic pressure. Think in the reverse—if the transducer is zeroed and balanced at the level of the
patient’s heart, then lowered below the level of the patient, what happens? The fluid column adds pressure to the dome of
the transducer, giving us a higher reading. The scenario described above is just the reverse. To avoid errors due to
hydrostatic pressure, it is essential to position the transducer’s zero port (stopcock open to atmospheric pressure) at the
same horizontal level as the tip of the catheter (reference level).
The reference level is usually that of the mid-axillary line, an imaginary vertical line (patient in the standing position)
drawn through the middle of the armpit, parallel to the midline. As long as the relationship between the reference level
(level at which the transducer is zeroed) and the transducer remains constant after zeroing, the pressures will be registered
accurately.
Reference: Nara, Andrew, Burns, Michael, and Downs, W. Gregory, Blood Pressure (SpaceLabs Medical Biophysical
Measurement Series), 1991, page 76
Q413EXPL
If there is no pressure loss in the patient circuit, there can be no actual volume loss. Therefore, we have a measurement
problem. Choice C is the best answer.
Reference: McPherson SP & Spearman, Respiratory Therapy Equipment, 4th edition, Mosby, 1990, page 246
Q423EXPL
Contrast media liquid can easily seep into the joints of the housing of a power
injector, shorting electrical connections inside. If this is found to be the
case, circuit boards can be removed, washed, dried, and reinstalled. Further
testing can continue.
Another option is to send the device back to the manufacturer for diagnosis and
repair, but this can be costly and time-consuming.
The cleanliness of the outside housing is very unlikely to affect the function of
the device.
If the problem had been one of no communication between the imaging system and
the injector, choice D might be worth checking; however, this was not the
complaint. A power injector is typically synchronized with an imaging system,
timing the injection to begin a few seconds before the x-ray exposure (or imaging
system scan).
References:
[1] Dondelinger R, "Part II: Interior Troubleshooting," Biomedical
Instrumentation and Technology, AAMI, Arlington, VA., Mar/Apr. 2005, pages 121-
122
[2] http://www.appliedradiology.com/uploadedFiles/Newsletters/Bracco/10-
10_Bracco_newsletter.pdf
Q424EXPL
Even with disposable probe covers, there is too great a risk of cross-
contamination (either by the thermometer or by the caregiver). In addition, using
a rectal thermometer in an oral application would likely conflict with any given
hospital's infection control policy. The better approach would be to have
clinicians borrow the proper equipment from another area of the hospital on a
temporary basis, then purchase or rent equipment if necessary.
References:
[1] Body Temperature, WebMD website, http://firstaid.webmd.com/body-temperature,
retrieved May 15, 2015
[2] Livornese, Lawrence, et. al., Hospital-acquired Infection with Vancomycin-
resistant Enterococcus faecium Transmitter by Electronic Thermometers, Anals of
Internal Medicine, 15 July 1992, Vol. 117, No. 2,
http://annals.org/article.aspx?articleid=705658, retrieved May 20, 2015, note
that full article is only available to subscribers
Q425EXPL
Live testing means testing for ambient anesthetic agents during a surgical
procedure, with all personnel present. Theoretically, there should be no agents
to affect the people performing or assisting in the procedure – the patient
should be the only one affected.
According to the National Institute for Occupational Safety and Health (NIOSH),
waste anesthetic gases may leak from a patient's anesthetic breathing circuit
into the air of operating rooms during anesthesia. They may also be exhaled by
patients recovering from anesthesia. Such gases include nitrous oxide and
halogenated anesthetics such as halothane, enflurane, isoflurane, desflurane,
sevoflurane, and methoxyflurane. The halogenated anesthetics are often
administered along with nitrous oxide.
Live testing is the only way to account for all the environmental variables that
could cause gas leaks. Among them are the anesthesia machine’s scavenger system,
the patient's face mask (usually the source of the largest potential leak),
patient circuit hose connections, high pressure nitrous oxide (N 2O) connections in
room, room air ventilation exchange, wall suction system, and vaporizer
connections. Generally, high pressure hose connections and (low pressure)
anesthesia machine components are checked separately.
Reference: http://www.cdc.gov/niosh/docs/2007-151/pdfs/2007-151.pdf
Q426EXPL
An LVAD (left-ventricular assist device) is used to partially or completely
replace the function of a failing heart. VADs pump blood into the arterial system
with either a pulsatile or non-pulsatile pump. The former mimics the natural
pulsing action of the heart, while the latter, referred to as a continuous-flow
pump, does not.
A continuous-flow pump would not produce a pulsatile arterial pressure for the
physiological monitor to detect and measure. The pressure waveform would probably
be a steady positive pressure value between 70 and 100 mmHg; therefore, the
monitor would alarm because it expects a pulsatile arterial waveform.
If the monitor was set to display MAP, or mean arterial pressure, it might not
alarm, because MAP is a steady pressure value (normally between 70 and 110 mmHg).
At a normal resting heart rate, MAP can be approximated as:
MAP = [(2 x diastolic) + systolic] / 3
References:
[1] Chatterjee, S. and Miller, A., Biomedical Instrumentation Systems, DELMAR,
Centage Learning, Clifton Park, NY, 2010, pages 321 - 322
[2] http://www.cvphysiology.com/Blood%20Pressure/BP006.htm
[3] http://onlinelibrary.wiley.com/doi/10.1111/j.1525-1594.2004.00086.x/full
[4] http://www.globalrph.com/map.cgi
Q427EXPL
An electrosurgery unit's (ESU's) REM (return electrode monitor) system is a
safety feature that will stop power output in the event the return electrode
(typically a disposable gelled adhesive pad) is not securely attached to the
patient. A large dispersive pad allows the high frequency current to exit the
patient without inducing burns. The REM system continuously measures resistance
at the return electrode site and compares it to a safe resistance (between 5 ohms
and 135 ohms).
References:
[2] http://www.cmia.org/docs/valleyviewfx.pdf
Q432EXPL
The technological life cycle of computing equipment is so much shorter than that
of medical equipment that it is possible medical equipment designed to work with
a five-year-old infrastructure will not work with the latest technology. Someone
probably forgot to check this detail, which is why it is imperative to involve
all stakeholders in such an enterprise-wide technological project as upgrading a
wireless infrastructure.
When medical device vendors develop a new wireless product (as the ventilator
company did), most go through the following process. First, the vendor selects a
wireless LAN infrastructure to use when designing and testing its new product.
The choice of wireless LAN or infrastructure vendor can be based on market
requirements, like infrastructure vendor market share, or performance, especially
when high performance life-critical applications are involved.
Regardless of why an infrastructure vendor was chosen, when that new product is
released it may specify that infrastructure vendor's network. The degree of
specification can range from the general (a specific manufacturer and certain
standards) to detailing down to product models and firmware/software releases.
This all occurs when the device initially goes to market - the device
manufacturer can not predict its compatibility with wireless LAN structures yet
to be designed.
In all likelihood, the ventilators already employ a dedicated gateway server on

the network. It would also be quite a coincidence if the ventilators'
authentication keys (for network security) expired at the same time the network
changed.
References:
[1] Kabachinski J, "Translating the Concepts Behind Gateways," Biomedical
Instrumentation and Technology, AAMI, Arlington, VA., May/June 2006, pages 201 -
204
[2] http://medicalconnectivity.com
Q433EXPL
Modern biphasic defibrillators measure chest impedance and adjust energy delivery
so that it remains constant regardless of chest impedance. Therefore, energy
delivered to either test load should be the same (200 joules, in this case).
A defibrillator analyzer checks, among other things, the energy output (in
joules) of a defibrillator. Energy delivered to the test load (50 ohms for legacy
technology monopolar devices) simulates the energy delivered to a patient.
Recognizing that different patients exhibit different values of transthoracic

(chest) impedance, manufacturers design biphasic defibrillators to provide the
specified energy level (200 J max), regardless of the chest impedance. The body's
resistance to defibrillator current flow has been measured to be anywhere from 25
ohms to 180 ohms. Analyzers that allow for different test loads are essentially
checking to ensure that the defibrillator adjusts dynamically and automatically
to provide the set energy output to these different values of impedance.
References:
[1] http://www.frca.co.uk/article.aspx?articleid=100573
[3] http://www.resuscitationcentral.com/defibrillation/biphasic-waveform
[4] http://www.cnrood.com/PHP/products/product/Defibrillator-+-Pacer-
Analyzers.html
Q434EXPL
While answer C is a possibility, D more closely fits the description of the
problem. A localized burn would not be associated with the large surface area of
the device's blanket (in which case the patient might just become too warm
overall).
Forced air blanket warmers are devices that are used on patients in critical care
and perioperative areas to maintain normal body temperature or treat hypothermia.
These systems use heated air to warm the patient through convection. A warmer
system has three components - heater, disposable air blanket, and hose. The hose
delivers warm air from the thermostatically controlled heater to the blanket. The
blanket is designed to evenly distribute the heat from the warmed air inside it
to the parts of the patient's body in contact with that blanket.
Complications of forced air warming devices have been reported when a blanket is
not attached to the hose. If this happens, it could cause either: 1) the warm air
to blow directly onto one area of the patient’s body for a period of time; or 2)
the nozzle of the disconnected hose to heat up and come in direct contact with
the patient's body.
Other complications could result if the wrong blanket is used or if the patient
is ischemic. Vasodilation would not in itself cause such a burn. On the contrary,
vasoconstriction (poor blood perfusion) has been shown to predispose patients to
cutaneous thermal injury.
References:
[1] http://www.apsf.org/newsletters/html/2002/fall/09reportevents.htm
[2] http://ats.ctsnetjournals.org/cgi/reprint/69/6/1933.pdf
[3] http://onlinelibrary.wiley.com/doi/10.1002/jhrm.5600230205/abstract
[4] http://www.nursingcenter.com/_PDF_.aspx?an=01271211-200901000-00014
Q436EXPL
It is unlikely that so many pumps would exhibit issues of technology
incompatibility at the same point in time. More realistically, the pumps have not
been turned on or reset for use with a new patient in the period of time since
the update was sent by the server. This is why they appear to be missing from the
electronic inventory (as seen by the server's pump management software).
Unfortunately, the best thing to do in this situation is to have the users

physically locate the pumps (Answer "B"). This is the last place anyone wants to
start as it is the most labor-intensive option and places the burden of
responsibility on the users of the equipment. However, let us examine the typical
"equipment shortage" conundrum:
At some point, due to low inventory of IV pumps in the Central Distribution

department, a clinician will not be able to get a requested pump needed for
patient care. Determined not to let this happen again, the clinician may get into
the habit of keeping "spare" pumps on the clinical unit. Of course, other
clinicians around the hospital tend to do the same thing, which causes a very
real shortage. As pumps "disappear" from the active inventory, clinicians often
point to the Central Distribution department and Biomedical to solve the problem.
A hospital will sometimes rent pumps to make up for the "loss of inventory."
A reasonable approach to the problem of the 30 missing pumps would be to have

Nursing and the Central Distribution department work together to locate them.
Once the pumps are located, they can then be turned on to see if they in fact
will communicate to the server. Typically, a pump has to be powered on and within
range of the wireless network for communication to occur.
While the pharmacy server with which the pumps communicate may have some sort of
tracking program, this may only indicate where the pump was last used, or last
powered on. If pumps do reappear at a later date, the software will likely
automatically download, but this might interfere with the need for immediate use
of the pump.
References:
[1] Medical Technology for the IT Professional, ECRI, 2009, pages 25 – 29
[2] http://ajcc.aacnjournals.org/content/19/1/28.full.pdf
Q437EXPL
While you would probably want to know both "A" and "C," it would be very helpful
to know whether the transducers were working properly before being sent to
Central Sterile Processing. Generally, ultrasound transducers are cleaned by the
user, and are not sterilized routinely. If the transducers were sent to CSP in
preparation for being sent out of the hospital to a repair facility, because the
facility would only accept sterilized devices, then the transducer was probably
broken before being sent to CSP, and sterilization did not cause the problem.
Typically, ultrasound transducers are damaged because they have been dropped or
improperly handled. Alternatively, the staff might have asked that the
transducers be sterilized because they were used on a patient with a highly
infectious disease, such as an Ebola infection, and the hospital's infection
control protocol requires that all devices used with these types of patients be
sterilized before being used with a different patient. Therefore, knowing the
status of the transducers before they were sent to CSP would be very helpful.
Even though there is only a small chance of learning with certainty if the
transducers were working prior to sterilization, it is still the appropriate
first question to ask. Unless you have definite confirmation that the transducers
were broken, you may have to begin the process by assuming the transducers were
functioning prior to sterilization.
If we cannot rule out that the transducers were working before being sent to CSP,
we need to investigate whether or not they were properly sterilized. Steam will
melt plastic, while a liquid sterilization technique can cause fluid to enter the
electrical connector. Most Central Sterile Processing departments will not
sterilize anything without the manufacturer's written guidelines; however,
accidents happen. And when they do, in-service training is necessary to avoid
further equipment downtime and repair cost. As everyone handling the transducers
has the responsibility to ensure their proper care, it would make sense to
provide job-specific training to the ultrasonographers, transporters, and sterile
processing personnel.
References:
[1] De Meo, M, "The Top Five Sterilization Challenges," Biomedical
Instrumentation and Technology, AAMI, Arlington, VA., Sept/Oct 2011, pages 378 -
379
[2] http://www.gehealthcare.com/usen/ultrasound/products/probe_care.html
Q480EXPL
Initially, because the complaint is vague, the best approach is to work closely
with the users in an attempt to find solutions. Of course, in order to help
diagnose problems, the Biomedical staff must be familiar with the proper
operation of the bed exit alarm in question. The rest of the answers are things
that may need to be done eventually.
In theory, a bed exit alarm that utilizes a pressure-sensitive pad on which the
patient lies sounds simplistic and foolproof. However, the use of such devices
has not been shown to be totally effective at preventing falls. For instance, bed
exit alarms tend to be unreliable for low weight (less than 100 pounds) patients
or when used with restless patients. Because different people have different bed-
exiting movements, and the pad can only be in one position, the "one size fits
all" approach seldom works. Patients can respond negatively to an audible alarm,
i.e., become agitated or attempt to move away from the noxious sound. If the
device is portable, its batteries can go dead. If the device is plugged into the
house nurse call system, cables can become disconnected.
References:
[1] http://www.rehabnurse.org/uploads/files/rnj344.pdf
[2] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2744312
Q441EXPL
A common problem with light microscopes is installation of the incorrect wattage
bulb. If the wattage is too low, the light will be dim. If too high, the bulb may
burn out prematurely.
While there is a possibility that the power supply may have a low output or that
the objective lens (the lens closest to the object under examination) is dirty,
it is far more likely that the wrong lamp was installed. Questioning a
technician's ability to properly use and maintain a piece of equipment is a risky
situation. When this becomes necessary, tact, diplomacy, and respect are always
in order.
References:
[1] Street, Laurence J., Introduction to Biomedical Engineering Technology, CRC
Press, 2008, pages 220 - 221
[2] Moore, James and Zouridakis, George, Biomedical Technology and Devices
Handbook, CRC Press, 2004, section 16-7
Q442EXPL
Due to the negative-going portion of the biphasic waveform, a device set to
measure a monophasic defibrillator output (Lown is one such traditional
waveshape) may not give an accurate energy reading. The area under the curve of
the output waveform (voltage vs. time) will be the integral over time of the
voltage squared and that area divided by the resistance of the test load.
A defibrillator analyzer checks, among other things, the energy output (in
joules) of a defibrillator. Energy delivered to the test load (50 ohms for legacy
technology monopolar devices) simulates the energy delivered to a patient.
Transthoracic impedance (the body's resistance to defibrillator current flow) has

been documented as being anywhere from 25 ohms to 180 ohms. Recognizing that
different patients have different chest impedances, manufacturers designed
biphasic defibrillators to provide the set energy level (200 J max) regardless of
the chest impedance. Analyzers that allow for different test loads are
essentially checking to ensure that the defibrillator adjusts dynamically and
automatically to provide the set energy output to different values of impedance.
The diagram below shows how power output might differ for a typical biphasic
defibrillator when different loads are used:
References:
[2] http://www.resuscitationcentral.com/defibrillation/biphasic-waveform
[3] http://www.cnrood.com/PHP/products/product/Defibrillator-+-Pacer-
Analyzers.html
Q443EXPL
The central station becoming unplugged from the UPS is the most likely answer,
with the scenario being that the central station has become inadvertently
disconnected from the uninterruptible power supply (UPS) and plugged directly
into an emergency power outlet. It reboots each time the power is transferred to
and from emergency generator power.
During the monthly transfer test, emergency power is switched from regular to
generator power (which according to NFPA 99, must occur in less than ten
seconds), then back again.
Unless the power cord from the central station computer is locked into the outlet
in the UPS, it may easily become disconnected and then be plugged into any
available outlet. This can happen unintentionally while servicing the equipment,
or the power cord can even be kicked accidentally, disconnecting it from the UPS.
(If a user sees that power has been lost to the central station – and sees a
disconnected power cord on the floor - the natural inclination is to plug it into
the closest unused outlet.)
A UPS uses its own internal battery to generate a 120-volt, 60-Hz output when its
own AC power becomes disconnected. If the batteries are not up to the task, the
UPS will not function properly. This problem could create the same symptom posed
in this question, but is less likely than the power cord being misconnected. If
the kVA rating of the UPS was too high, that would just mean that it is capable
of providing much more power than its central station load requires.
References:
[1] NFPA, Health Care Facilities Code, NFPA 99, 2012 Edition, 99:6.4.3.1
[2] King, A. and Knight, W. Uninterruptible Power Supplies, McGraw-Hill
Professional, 2002
Q444EXPL
In a sterile operating room with a patient draped on the table, there are a
limited number of things you can do as you attempt to solve the problem. The hand
control is usually not hard-wired to the table, so you can disconnect its
electrical connector and replace it with a spare hand control (which you should
keep in stock!). Hand controls are the weak link in a table system – they are
comparatively fragile and get dropped and beaten up quite a bit.
The other possible answers might cause the described problem, but are far less
likely than the hand control to be the culprit. Also, you really can not check
any of them in the clinical environment just described. The patient would have to
be moved to a different table so you could access the internal components of the
table.
References:
[1] http://www.steris.com/products/table-operating-controls
[2] http://www.skytron.us/tables_intro.htm
Q445EXPL
Obviously, there is a problem related to the batteries in the pumps. Answers A
and B are good steps to follow in order to resolve the problem. Keeping any
battery-powered device plugged in whenever possible is good practice, but is not
always done. Correcting such a practice often involves quite a bit of diplomacy
and teamwork with various departments, e.g. Nursing, Central Supply, and
Transportation.
Rechargeable batteries of the SLA (sealed lead acid) and lithium-ion types
currently used by infusion pump manufacturers have a useful life of two or more
years. Therefore, it is unlikely that the one-year-old fleet of IV pumps in
question needs its batteries replaced.
References:
Press, 2008, pages 267 - 270 and pages 241 - 243.
[2] http://www.icufaqs.org/PeripheralIVs.doc
Q446EXPL
Before any type of sterilization is performed, scope channels (lumens) must first
be mechanically cleaned with pipe-cleaner style brushes. This is true even if a
liquid-medium scope washer is used (where the scope channels are connected via
tubing to be liquid-flushed). Any items requiring sterilization of any kind must
be decontaminated and physically cleaned before the sterilization process begins,
as most sterilizing agents will not effectively kill microorganisms protected by
dried organic matter. All solid matter needs to be removed via more conventional
cleaning using detergent or a mechanical or ultrasonic scrub, followed by a
distilled or demineralized water rinse. Only then can items be effectively
sterilized.
Plasma sterilizers are slowly replacing both ETO sterilizers and scope washers
for low temperature sterilization of endoscopes.
Hydrogen peroxide is the sterilant used in plasma technology. Both rigid and
flexible scopes can be sterilized with plasma; however, lumen size and lumen
length can be limiting factors.
Plasma sterilizers are not used for sterilizing blood products; blood is
comprised of living tissue that would be destroyed by sterilization.
References:
Press, 2008, pages 98 – 106
[2] Dondelinger R, "Sterilizers. Part I: Heat Sterilization," Biomedical
Instrumentation and Technology, AAMI, Arlington, VA., Nov/Dec 2008, pages 459 -
462
[3] Dondelinger R, "Sterilizers. Part II: Chemical Sterilization in Healthcare
Facilities," Biomedical Instrumentation and Technology, AAMI, Arlington, VA.,
Jan/Feb 2009, pages 43 - 46
[4] http://www.infectioncontroltoday.com/articles/2000/06/sterilization-gas-
plasma-steam-and-washer-deconta.aspx
[5]
http://www.cdc.gov/hicpac/Disinfection_Sterilization/13_06PeraceticAcidSterilizat
ion.html
[6] http://medical-dictionary.thefreedictionary.com/transfusion
Q447EXPL
Weighing the time it will take to do this against the amount of time the
equipment can be kept out of service is the best answer, as the clinical need for
the device should be the foremost consideration. Even if you think you might be
able to fix it today, the clinical staff may be depending on it for a scheduled
case tomorrow. You may just need to call the vendor in to make the repair. Cost
should be factored into your decision in other ways as well. For instance, if a
replacement board only costs $200, yet it might take you all day to make the
repair, you have not saved the hospital any money.
Sometimes sending devices back to the manufacturer can be cost-effective, but not
always. A low fixed-price repair/exchange policy might be to your benefit if the
problems are complicated and expensive. However, if you pay as you go, costs
could exceed the value of the device!
Reference: Street, Laurence J., Introduction to Biomedical Engineering

Technology, CRC Press, 2008, pages 243 – 247
Q467EXPL
Of the entire range of the electromagnetic spectrum, only x-rays and gamma rays
are classified as ionizing radiations. Ultraviolet radiation, visible light,
infrared rays, microwaves, and radio waves are considered to be non-ionizing,
because they do not have sufficient kinetic energy to eject electrons from the
atom.
Reference: Radiation Protection in Medical Radiography, 5th edition, Sherer, MAS,
Visconti, PJ, and Ritenour, ER, Chapter 10, Elsevier Health Sciences, 2006
Q470EXPL
Film badges are a relatively low cost radiation monitoring device, typically
costing only a few dollars per unit per month. They are capable of reliably
monitoring exposure to x-radiation, gamma radiation, and all but very low energy
beta radiation.

Q487EXPL
Ethylene oxide is a gas used to sterilize a wide variety of medical products. It
offers the advantage of being able to sterilize devices at far lower temperatures
than steam sterilization requires. Compared to sterilization by radiation, the
capital equipment and controls required are far less costly for gas
sterilization. (Manufacturers processing very large volumes of devices to be
sterilized typically use radioactive sterilization.)
Gas sterilization is often used to sterilize plastics, which can not take the
high heat of steam sterilization.
However, ethylene oxide is highly toxic, and has been linked to irritation of the
eyes and respiratory tract, as well as reproductive hazards, so it does represent
a potential danger to improperly trained operators. In addition, the ethylene
oxide is absorbed by many materials, such as plastics. Before use, the gas must
be purged from the material, either by using an aeration cabinet, or a quarantine
period when the sterilized object is left on a shelf exposed to room air for a
substantial time period.
Sons, 1982, page 56
Q488EXPL
Film badges are small pieces of x-ray film contained in a plastic holder. The
film darkens in proportion to the amount of radiation exposure. By measuring the
optical density of the film after exposure to the radiation, it is possible to
determine the dosage of radiation that the wearer experienced.
Optically stimulated luminescence (OSL) measures radiation through a thin layer

of aluminum oxide. A laser light stimulates the aluminum oxide after use. This
causes it to become luminescent in proportion to the amount of radiation
exposure.
A pocket ionizing dosimeter is a pen-like device that measures the cumulative

dose of ionizing radiation received by the device. It is usually clipped to a
person's clothing and is worn to measure one's actual exposure to radiation.
Q489EXPL
Shielding of the x-ray tube helps assure that x-rays are restricted to only going
where they are intended to go, and not in directions that might be hazardous to
equipment operators, or might expose patients unnecessarily to radiation not used
to expose an x-ray film.
Filtering of the x-ray beam eliminates low energy components of the x-ray beam.
These low energy components are referred to as low quality, because they do not
have enough energy to penetrate a patient's body to expose x-ray film. Thus, they
expose the patient to radiation without providing any benefit.
Appropriate use of lead shielding and lead glass windows allows an x-ray
technician to observe the patient without risking unnecessary exposure to low-
level scattered radiation produced whenever an x-ray beam is on. An x-ray
technician will typically be involved in making many x-rays each day, and so
could risk substantial exposure to radiation if proper shielding is not employed.
Controls for x-ray equipment should always be placed in an area that forces the
operator to remain behind appropriate shielding during the operation of the x-ray
beam.
Sons, 1982, pages 122 - 123
Q502EXPL
Halothane is a non-flammable anesthetic gas.
Surgical drapes can be ignited by excessive heat, such as might be generated by

improper use of a laser.
Colonic gases contain methane, which is flammable. Laser surgery that takes place
in the presence of these gases can represent a fire hazard.
Reference: None
Q510EXPL
Ethylene oxide (EtO) is produced in large volumes and is primarily used as an
intermediate in the production of several industrial chemicals, the most notable
of which is ethylene glycol. It is also used as a fumigant in certain
agricultural products and as a sterilant for medical equipment and supplies.
Unfortunately, EtO possesses several physical and health hazards that merit
special attention. EtO is both flammable and highly reactive.
Acute exposures to EtO gas may result in respiratory irritation and lung injury,
headache, nausea, vomiting, diarrhea, shortness of breath, and cyanosis. Chronic
exposure has been associated with the occurrence of cancer, reproductive effects,
mutagenic changes, neurotoxicity, and sensitization.
Reference: http://www.osha.gov/SLTC/ethyleneoxide/index.html
Q548EXPL
Ionizing radiation is a form of radiation, which includes alpha particles, beta
particles, gamma rays, x-rays, neutrons, high-speed electrons, high-speed
protons, and other particles capable of producing ions. Compared to non-ionizing
radiation, such as radio waves or microwaves, or visible, infrared, or
ultraviolet light, ionizing radiation is considerably more energetic.
When ionizing radiation passes through material such as air, water, or living
tissue, it deposits enough energy to produce ions by breaking molecular bonds and
displacing (or removing) electrons from atoms or molecules. This electron
displacement may lead to changes in living cells.
Given this ability, ionizing radiation has a number of beneficial uses, including
treating cancer or sterilizing medical equipment. However, ionizing radiation is
potentially harmful if not used correctly, and high doses may result in severe
skin or tissue damage. It is for this reason that the Nuclear Regulatory
Commission (NRC) strictly regulates commercial and institutional uses of the
various types of ionizing radiation. Radiation, as used in 10 CFR Part 20, does
not include non-ionizing radiation.
Note: CFR stands for the Code of Federal Regulations.
Reference: http://www.nrc.gov/reading-rm/basic-ref/glossary/ionizing-
radiation.html
Q574EXPL
Pits in a defibrillator paddle can substantially increase the current density at
a specific point on the paddles, resulting in patient skin burns during
defibrillation.
Pitted paddles can be the result of improperly testing the defibrillator. To

properly test the output of a defibrillator, the paddles should be held firmly
against a test load during a test discharge. The paddle surfaces should never be
shorted together while discharging the defibrillator. Failure to follow these
precautions can result in pitted paddles.
Reference: Physio-Control Lifepak 20 Defibrillator/Monitor Operating

Instructions, http://www.physio-
control.com/uploadedFiles/products/defibrillators/product_data/operational_manual
s/LIFEPAK20_OI_3200750-018.pdf, pages 4-14, 5-8, 7-7
Q575EXPL
A centrifuge is a piece of equipment, generally driven by an electric motor (or,
in some older models, by hand), that puts an object in rotation around a fixed
axis, applying a force perpendicular to the axis. In the clinical laboratory, the
most common use for a centrifuge is to separate cells and platelets from the
liquid part of the blood. Typically, the substance to be separated into
components, such as blood, is placed in a test tube that is mounted in a swinging
mechanism such that when the centrifuge starts to spin, the bottom of the tube
will be further from the point of rotation than the top of the tube.
The centrifuge works using the sedimentation principle to separate materials on

the basis of their relative densities. The centripetal acceleration causes denser
substances to separate out along the radial direction (going towards the bottom
of the tube), while lighter components will tend to move towards the top of the
tube.
The purpose of the clinical laboratory is to analyze body fluids and tissues for
specific substances of interest and to report the results in a form which is of
value to clinicians in the diagnosis and treatment of disease.
The first step in many laboratory tests is to separate the material of interest
from other substances. This may be accomplished through extraction, filtration,
and/or centrifugation. Another step is derivatization, in which the substance of
interest is chemically altered through addition of reagents to change it into a
substance which is easily measured.
References:
[1] Wikipedia article on centrifuges, http://en.wikipedia.org/wiki/centrifuge,
retrieved June 16, 2014
[2] Christie, Barbara L., Introduction to Biomedical Instrumentation: The
Technology of Patient Care, New York, Cambridge University Press, 2009
[3] Roa, R. L., Clinical Laboratory: Separation and Spectral Methods, The
Biomedical Engineering Handbook: Second Edition, Editor: Joseph D. Bronzino, Boca
Raton, CRC Press LLC, 2000
Q576EXPL
Cells require oxygen to function. Oxygen is delivered to the cells by
transporting it through the blood as oxyhemoglobin. One byproduct of cellular
metabolism is the production of carbon dioxide (CO 2), which is transported in the
bloodstream to the lungs, where respiration removes excess carbon dioxide and
allows it to be exhaled. If carbon dioxide is not removed from the bloodstream,
it could build up to toxic levels, endangering the patient’s life.
In an anesthesia system, an absorber is used to remove carbon dioxide and excess

moisture from the patient’s exhaled breath. The absorber includes absorbent
granules, gaskets, a locking lever, and canisters. The carbon dioxide (CO 2) and
water exhaled by the patient react chemically with the absorbent granules to
reduce the levels of CO2 and moisture in the gas returned to the patient's lungs
to a safe level.
Today’s anesthesia delivery systems are composed of six major elements:

1. The primary and secondary sources of gases (O 2, air, N2O, vacuum, gas
scavenging, and possibly CO2 and helium)
2. The gas blending and vaporization system, used to vaporize a volatile
anesthetic agent
3. The breathing circuit (including methods for manual and mechanical
ventilation)
4. The excess gas scavenging system that minimizes potential pollution of the
operating room by anesthetic gases
5. Instruments and equipment to monitor the function of the anesthesia delivery
system
6. Patient monitoring instrumentation and equipment…
The concept behind an effective breathing circuit is to provide an adequate

volume of a controlled concentration of gas to the patient during inspiration,
and to carry the exhaled gases away from the patient during exhalation. Excess
gas evolves into the scavenging device, and some of the exhaled gas is rebreathed
after having the CO2 removed.
The anesthetic agent, such as desflurane or isoflurane, is vaporized and mixed

with nitrous oxide (N2O) as an adjuvant gas, along with the other gases to be
inhaled (pure oxygen and medical air), and then delivered to the patient on the
inspiration cycle. The exhaled gases pass through a one-way valve, through a CO2
absorber, and are delivered again to the patient.
References:
[1] Chatterjee, Shakti and Miller, Aubert, Biomedical Instrumentation Systems,
Delmar, Cengage Learning, 2010, p. 560
[2] Paulsen, A. W., Essentials of Anesthesia Delivery, The Biomedical Engineering
Handbook: Second Edition, Editor: Joseph D. Bronzino, Boca Raton, CRC Press LLC,
2000
[3] Aston, Richard, Principles of Biomedical Instrumentation and Measurement,
Columbus, OH, Merrill Publishing Co., 1990
Q577EXPL
A disposable cartridge is required whenever the medication to be delivered by the
infusion pump comes into direct contact with the pumping mechanism.
Piston, diaphragm, and syringe pumps all use a cartridge that has a component
that is moved by the pump and that comes into direct contact with the medication
to be delivered. These cartridges are discarded after use. While the cost of each
cartridge is typically low, the cost to the hospital over time can be
substantial. The hospital must also ensure that a sufficient inventory of spare
cartridges is on hand, otherwise the infusion pumps are rendered useless.
Peristaltic pumps (whether rotary or linear) work by occluding the tubing that
transports the medication and its carrying solution from the intravenous fluid
bag to the intravenous catheter. The pump mechanism typically pushes against the
tubing to regulate the flow rate of the medication. The tubing itself is
disposable, but the tubing used has no moving parts.
Gravity drip generally does not use a pump. Instead, a bag of medication is
attached to the patient tubing, with an external regulating (roller) clamp to
adjust the flow rate.
References:
[1] Chan, Anthony; Biomedical Device Technology; Charles C. Thomas Publisher,
LTD, 2008, pages 378-382
[2] Bronzino, Joseph D.; Medical Devices and Systems; CRC Press, 2006, pages 68-6
to 68-7
Q579EXPL
Typical hematocrit centrifuges use brushless motors and do not require the use of
a vacuum. Most centrifuges have a vibration detector that will shut down the
centrifuge. This can be caused by using inconsistent sample volumes. However,
since the samples were processed without problems in a different centrifuge,
inconsistent sample volumes are unlikely to have been the cause of the problem.
Apart from burning out the power supply or motor, usually by allowing dust to
build up inside the centrifuge, there is very little that can go wrong with a
centrifuge. Eventually, however, the bearings will wear out. This will cause
vibrations, and the vibrations will be detected and result in a shutdown.
References:
[1] Bronzino, Joseph D.; Medical Devices and Systems; CRC Press, 2006, pages 69-1
to 69-2
[2] The Operating Manual or User Manual of any typical hematocrit centrifuge
Q580EXPL
Three of these choices are, in fact, visible to the naked eye. Ruby and He-Ne
lasers are red. Argon lasers are either green or blue. Weak He-Ne lasers are, in
fact, often used as “aiming” lasers. Excimer lasers operate in the ultraviolet
region and cannot be seen by the naked eye. CO 2 lasers operate in the infrared
region and also cannot be seen by the naked eye. Both of these lasers require an
aiming system to ensure they are projecting their beams to the correct location.
Reference:
[1] Chan, Anthony; Biomedical Device Technology; Charles C. Thomas Publisher,
LTD, 2008
Q585EXPL
Anesthesia machines are used by trained anesthesia staff members
[anesthesiologists and Certified Registered Nurse Anesthetists (CRNAs)], so that
operative and diagnostic procedures can be performed without pain, the
consciousness of the patient can be suppressed, and the oxygen supply can be
guaranteed.
To ensure that anesthesia is safely delivered, both the device and the patient
must be monitored. For this purpose, all of the monitoring modes described in
this question should be used.
The parameters that are generally monitored while a patient is receiving general
anesthesia include the:
- delivered oxygen (O2) percentage
- anesthetic agent percentage
- exhaled carbon dioxide (CO2) percentage
- exhaled respiratory gas volume
- pressure in the breathing circuit
- electrocardiogram (ECG) waveform
- heart rate
- blood pressure (either invasive or noninvasive)
- oxygen saturation (blood oxygenation level)
- patient unconsciousness, degree of painlessness and level of relaxation
[measured by a peripheral nerve stimulator train of four device, and/or
electroencephalogram (EEG) monitoring through measurement of bispectral index
(BIS)]
Reference:
[1] Rüdiger Kramme, Klaus-Peter Hoffmann, Robert S. Pozos (Eds.), Springer
Handbook of Medical Technology, Springer-Verlag, Berlin, 2011, page 580
Q587EXPL
PCA stands for patient-controlled analgesia. A PCA pump is a type of infusion
pump, typically a syringe pump, used with pain medications such as opiates
(typically morphine, but sometimes other drugs such as hydromorphone, and
fentanyl). A PCA pump may be set to deliver a basal (minimum flow) rate of
medication to the patient. In addition to the basal rate, patients can push a
button to request the pump to provide additional pain medication within certain
pre-programmed timing and dosing restrictions. This not only provides pain relief
but also gives patients a sense of control over their pain management.
Syringe pumps deliver medications, usually in low doses, for anesthesia and
pediatrics. They contain alarms to indicate an occlusion condition. They can
optionally include an on-board drug library to control medication dose limits via
“soft stops” (stops that can be bypassed after a warning) or “hard stops” (stops
that cannot be bypassed because they are likely to be unsafe in almost all
circumstances.)
Hazards of PCA pumps include over-sedation and respiratory depression,

particularly if the patient is too young or too confused to understand how to use
the pump, or if family members or others are pressing the request switch. In
addition to programming safeguards, other hazards that the PCA pump’s design
attempts to alleviate include: locking mechanisms for the medication syringes to
prevent inappropriate access, concurrent respiratory status monitoring (e.g. via
CO2 monitoring), safety warnings on product labeling and staff and patient
education.
Reference:
[1] Patient Controlled Analgesia: Making it Safer for Patients: Institute for
Safe Medication Practices (ISMP)
http://www.ismp.org/profdevelopment/PCAMonograph.pdf
Q589EXPL
Syringe pumps deliver medications, usually in low doses, typically for
anesthesia, pain control or pediatric applications. They contain alarms to
indicate an occlusion condition. This is a condition where the flow of the
medication is stopped completely or partially.
Medication flow may be stopped by any condition that causes the force required to
move the syringe plunger to exceed the capability of the motor. This could be
caused by a kink in the delivery tubing or a blood clot forming at the end of the
intravenous catheter being used to deliver the medication.
While an empty syringe would also cause the motor to stall, if the pump was set
appropriately and had the appropriate alarm capabilities, the alarm generated for
this condition would not be an occlusion alarm, but either an end-of-infusion
alarm or an empty syringe alarm.
Reference: None
Q590EXPL
Pulse oximetry is a very convenient, non-invasive technology for indirectly
measuring a patient’s oxygen saturation at the measurement site, usually a
fingertip or earlobe. It uses two light sources: one infrared at 940 nm and one
visible frequency (typically red at 660 nm), and a photodetector. The changing
absorbance at each of the two wavelengths coincides with the percentage of
hemoglobin, the protein in blood that carries oxygen. Oxygenated hemoglobin
absorbs more infrared light and allows more red light to pass through.
Deoxygenated hemoglobin allows more infrared light to pass through and absorbs
more red light. The ratio of oxygenated hemoglobin to deoxygenated hemoglobin is
then used by the microprocessor to determine oxygen saturation (SpO 2).
There are very few, if any, hazards with this technology. Measurement problems
include: poor perfusion, carbon monoxide poisoning (CO binds with hemoglobin in a
similar manner to O2 binding with hemoglobin therefore resulting in erroneous
readings for a CO-poisoned patient), optical interference if the LEDs are not
properly optically shielded, and erroneous readings problems caused by finger
nail polish at the measurement site.
References:
[1] Principles of Pulse Oximetry: Anesthesia UK,
http://www.frca.co.uk/article.aspx?articleid=332
[2] Wikipedia article on pulse oximetry,
http://en.wikipedia.org/wiki/Pulse_oximetry
Q592EXPL
The circulatory system is the body’s primary pathway for both the distribution of
oxygen and other nutrients and the removal of carbon dioxide and other waste
products. Since the entire blood supply in a healthy adult completely circulates
within 60 seconds, substances introduced into the circulatory system are
distributed rapidly. Thus intravenous (IV) and intra-arterial access routes
provide an effective pathway for the delivery of fluid, blood, and medication to
a patient’s vital organs. Consequently, about 80% of hospitalized patients
receive infusion therapy.
The gravity flow/resistance regulation method is the simplest means for providing
regulated flow of IV fluids. It employs gravity as the driving force with a
roller clamp to control the resistance, and thus the flow rate. Placement of the
fluid reservoir 60-100 cm above the patient’s right atrium provides the
hydrostatic pressure gradient needed to force the IV fluid into the vein.
Typically, a nurse will watch the drip rate in a drip chamber to determine
whether the resistance is set properly, and will make adjustments to achieve the
desired drip rate.
Infusion pumps, which are pumps that combine electronics with a pumping mechanism
to generate fluid flow, are active devices that have higher performance standards
than simple gravity flow regulators. That is, an infusion pump can much more
accurately control the delivery rate, and has alarms to detect a variety of
problems, such as the end of an infusion or an occlusion of the IV catheter.
Some infusion pumps use a volumetric metering chamber to accurately deliver

fluid. These pumps typically have two chambers. Valves allow fluid to fill one
chamber from the fluid reservoir, while fluid is pumped to the patient from the
second chamber by applying pressure on a diaphragm. After a set volume is
delivered, the inlet and outlet valves reverse state, so that the first chamber
is pumping fluid while the second chamber is filling. This dual chamber
arrangement allows the pump to maintain a fairly constant flow rate to the
patient.
Other infusion pumps use a rotary peristaltic mechanism which compresses tubing
between rollers on the pumping segment and the rotor housing. With rotation, the
rollers push fluid from the container through the tubing toward the patient. At
least one of the rollers completely occludes the tubing against the housing at
all times precluding free flow from the reservoir to the patient. During a
portion of the revolution, two rollers trap fluid in the intervening pumping
segment. The captured volume between the rollers determines volumetric accuracy.
The picture below shows the operation of a rotary peristaltic pump.
(Source: http://en.wikipedia.org/wiki/Peristaltic_pump, use of image licensed

under Creative Commons Attribution-Share Alike 3.0 Unported license via Wikimedia
Commons, image author: Njmcca)
Other infusion pumps use a linear peristaltic mechanism. These mechanisms use an
array of cam-driven actuators to sequentially occlude the IV tubing starting with
the section nearest the reservoir forcing fluid toward the patient with a
sinusoidal wave action. The diagram below shows a linear peristaltic pump
mechanism.
(Source: http://en.wikipedia.org/wiki/Peristaltic_pump, use of image licensed

under Creative Commons Attribution-Share Alike 3.0 Unported license via Wikimedia
Commons, image author: Richard Schneider)
Syringe pumps employ a syringe as both the reservoir and volumetric pumping
chamber. A precision lead-screw is used to produce constant linear advancement of
the syringe plunger. These systems typically deal with relatively low volumes and
are primarily used to deliver narcotics and certain other high-potency drugs.
Syringe pumps can be preprogrammed for specific flow rates, volume limits, and
alarm settings. The diagram below shows a typical syringe pump.
(Source: http://en.wikipedia.org/wiki/Syringe_pump, use of image licensed under

Creative Commons Attribution-Share Alike 3.0 Unported license via Wikimedia
Commons, image author: ????)
Patient-controlled analgesia (PCA) pumps are a specialized syringe pump that

allow the patient to initiate a dose of medication when desired for the relief of
pain. Analgesia is most effective when it is patient-focused because each patient
and circumstances have unique features that may influence the patient’s response
to therapy. Studies have shown that patients tend to report lower levels of pain
while using less pain medication when allowed to control the amount of medication
received.
The difference between a PCA pump and a normal syringe pump is the provision for
patients to deliver a bolus dose themselves. Access by the patient to the pump
itself is prevented by a cover that can be locked after preprogramming.
Preprogrammed restraints are placed on the parameters of the boluses and, in
addition, a basal (lowest possible level) rate delivery of solution outside the
control of the patient may be provided. The picture below shows a PCA pump.
(Source: http://en.wikipedia.org/wiki/Patient-controlled_analgesia, use of image

licensed under Creative Commons Attribution-Share Alike 3.0 Unported license via
Wikimedia Commons, image author: DiverDave)
References:
Delmar, Cengage, Clifton Park, NY, 2010, pp. 292-296
[2] Street, Laurence, Introduction to Biomedical Engineering Technology, Second
Edition, CRC Press, Taylor and Francis Group, Boca Raton, 2012, pp. 144-154
[3] Parrillo, Joseph E. and Dellinger, R. Phillip, Critical Care Medicine:
Principles of Diagnosis and Management in the Adult, Fourth Edition, 2014,
Saunders, Chap. 19, pp. 255-271
[4] Wikipedia, Peristaltic pump, http://en.wikipedia.org/wiki/Peristaltic_pump,
retrieved July 16, 2014
[5] Wikipedia, Patient-controlled analgesia,
http://en.wikipedia.org/wiki/Patient-controlled_analgesia, retrieved July 16,
2014
[6] Medical Design Briefs, “Selecting Motors for Medical Pumps,”
http://www.medicaldesignbriefs.com/component/content/article/7551, retrieved July
16, 2004
Q604EXPL
In an emergency, basic first aid teaches us to stop the bleeding with a
tourniquet: a belt-and-stick device used to stop bleeding. Surgical tourniquets
stop bleeding, but they do much more. When surgery is performed on limbs, blood
flow can present a problem by obscuring the field of view and contributing to
blood loss. Surgical tourniquets are specifically designed to enable surgeons to
perform delicate surgeries in a bloodless operating field. They use compressed
gas to apply a carefully controlled amount of pressure to an air bladder on an
extremity. However, if the pressure is applied too long, tissue damage can occur.
Automatic tourniquets incorporate pumps and timing mechanisms that can be

programmed to deliver precise inflation pressures and inflation/deflation cycle
timing. They consist of a pressure display (dial gauge in older units and
electronic in newer units), the electrical pump and pressure regulator, the cuffs
that contain the inflatable air bladder, a dump valve that rapidly deflates the
cuff, and connecting tubing and connectors.
Automatic tourniquets are typically inflated using compressed gas generated by an

electric pump or delivered through a gas canister. The gas used may be nitrogen,
ambient air, or some other gas. Nitrous oxide or oxygen are not used to inflate
the tourniquet cuff because of the increased risk of fire. Chemicals, such as
tetrafluoroethane, can vaporize into a toxic gas, and so also should not be used
to inflate a tourniquet.
Some tourniquet systems utilize high-pressure gas, while other systems use low-
pressure gas. Modern hospital tourniquet systems perform self-checks of
calibration, display elapsed inflation time, and sound alarms if problems arise.
References:
[1] Street, Laurence. Introduction to Biomedical Engineering Technology, Second
Edition, CRC Press, Taylor and Francis Group, Boca Raton, 2012, p. 142
[2] McEwen, J. A., Tourniquet Overview.
http://www.tourniquets.org/tourniquet_overview.php, retrieved July 10, 2014
Q605EXPL
Automatic tourniquets incorporate pumps and timing mechanisms that can be
programmed to deliver precise inflation pressures and inflation/deflation cycle
timing. They consist of a pressure display (dial gauge in older units and
electronic in newer units), the electrical pump and pressure regulator, the cuffs
that contain the inflatable air bladder, a dump valve that rapidly deflates the
cuff, and connecting tubing and connectors.
Automatic tourniquets are typically inflated using compressed gas generated by an

electric pump or delivered through a gas canister. The gas used may be nitrogen,
ambient air, or some other gas. Nitrous oxide or oxygen are not used to inflate
the tourniquet cuff because of the increased risk of fire. Chemicals, such as
tetrafluoroethane can vaporize into a toxic gas, and so also should not be used
to inflate a tourniquet.
Some tourniquet systems utilize high-pressure gas, while other systems use low-
pressure gas. Modern hospital tourniquet systems perform self-checks of
calibration, display elapsed inflation time, and sound alarms if problems arise.
Problems can arise. Any equipment can malfunction and patients can be injured.
But other than abuse, very little goes wrong with these surgical tourniquets. The
common failure points are the connectors between the cuffs and tubing. Also the
tubing is subject to ozone damage, cracking and leaks. Replacement tubing should
be rigid enough so it does not deform when under pressure.
Other potential hazards include (1) kinked or occluded tubing connecting the cuff
to the instrument that may prevent the instrument from displaying the correct
cuff pressure, or controlling the cuff pressure correctly; (2) leaking cuffs or
leaking tubing connections may prevent the tourniquet instrument from maintaining
the set pressure in the cuff; and (3) if the power switch of some types of
electronic tourniquet instruments is inadvertently switched to an 'off' or
'standby' position while the cuff is still pressurized (due to operator error),
then the pressure will be maintained in the cuff to maintain patient safety but
the pressure display, timer and alarms of the tourniquet instruments may no
longer function and so the operator may no longer be aware of the cuff pressure
or tourniquet time.
References:
[1] Street, Laurence. Introduction to Biomedical Engineering Technology, Second
Edition, CRC Press, Taylor and Francis Group, Boca Raton, 2012, p. 142
[2] McEwen, J. A., Tourniquet Overview.
http://www.tourniquets.org/tourniquet_overview.php, retrieved July 10, 2014
Q606EXPL
A radiographic imaging system has an x-ray machine. However, it does not have
continuous image acquisition capability, a camera or a closed circuit video
system.
Computed Tomography (CT) does utilize x-rays and detectors, but does not
incorporate a camera, and it would not have a closed circuit video system. Images
are acquired based on the size of the row detector and reconstructed either
axially or multi-dimensionally.
Gamma cameras (non-SPECT/CT systems) are used by Nuclear Medicine to map portions
of the human body. These cameras use crystals with photo-multiplier tubes (PMTs)
to detect emissions from a radioactive isotope introduced into the patient's
body. Software provides the summation and averaging functions to map the emission
activity. Gamma cameras do not incorporate an X-ray machine.
A fluoroscopic imaging system uses fluoroscopy, which is an imaging technique

that uses X-rays to obtain real-time moving images of the internal structures of
a patient. In its simplest form, a fluoroscope consists of an X-ray source and
fluorescent screen between which a patient is placed. However, modern
fluoroscopes couple the screen to an X-ray image intensifier and CCD video camera
allowing the images to be recorded and played on a monitor. A fluoroscopic
imaging system is the only system that incorporates all components described; an
X-ray system (generator, X-ray tube and collimator), continuous image acquisition
capability, a camera, and a closed-circuit video system.
A PET camera is similar to the Gamma camera, mapping metabolic functions based on
isotope concentrations. There is no continuous image acquisition, camera or
closed circuit video.
Reference:
[2] Wikipedia article on Fluoroscopy, http://en.wikipedia.org/wiki/Fluoroscope,
[3] Wikipedia article on Gamma Camera, http://en.wikipedia.org/wiki/Gamma_camera,
Q607EXPL
A surgical video system allows the visualization and recording of surgical
activities during a case. To accomplish this, the system must have a video
camera, a light source, a video processor and a recorder. Most surgical video
systems will acquire their images from a camera mounted in an endoscope. In other
cases, surgical images can be mounted from a camera mounted in a surgical
microscope or some other type of surgical camera.
A video processor performs the video conversion from the camera output to a
digital video signal. It also is able to optimize the signal, and may also
perform other video-related functions.
A glide scope is a separate device that is used to assist in the placement of
endotracheal tubes. It is not part of the standard components of a SVS.
An endoscope is a device used to image inside the body. Various designs exist
based on the body area and procedure requirements.
A video camera is the image acquisition device that is typically mounted on the
endoscope or surgical microscope. It uses photosensitive chips, typically Charge
Coupled Devices (CCD) to detect the image.
A light source provides the illumination needed by the endoscope or surgical

microscope in the surgical or body area of interest. It has manual and automatic
controls for illumination.
Reference:
[1] ECRI Institute, “Surgical Video Systems Technology Overview, May 2014
Q608EXPL
Because defibrillation is an emergency procedure that must be done as quickly as
possible to reverse a potentially fatal ventricular fibrillation, the charge time
for a defibrillator should be minimized. The ECRI Institute’s defibrillator test
procedures specify that when testing defibrillators, the defibrillator should be
able to be fully charged in less than 15 seconds (10 seconds preferred), as long
as the batteries are charged to the minimum level of their specified operating
range. If the defibrillator is connected to AC power, it still should meet the
same timing requirements, regardless of the battery charge level. This timing
requirement for AC power charging also applies if the batteries are not
installed.
It would be inappropriate to allow longer charge times under any conditions, such
as less than fully-charged batteries or if the defibrillator is operating on AC
power.
References: [1] ECRI Institute, Health Devices, June 2005,

Defibrillator/Monitor/Pacemaker Evaluation/Test
Q610EXPL
PCA stands for patient-controlled analgesia. PCA pumps are designed to deliver
powerful opiates (usually) for pain therapy and can be controlled by the patient
within limits prescribed by a physician. Some PCA pumps can also be run in
continuous mode, if needed. Several different designs exist, usually
differentiated between a pole mounted design and an ambulatory design.
While most PCA pumps are a type of syringe pump, because syringe pumps generally
support low volume delivery, not all syringe pumps are PCA pumps. PCA pumps
incorporate additional safety features, such as a locking mechanism to assure
that the drug cannot be removed from the pump without authorization, and dose-
limiting software to assure that no more than the physician-prescribed amount can
be given to the patient.
A large volume infusion pump is a standard infusion pump that does not have the
capability for patient control. Its purpose is to control delivery of IV
medication over a time set by the clinicians. DERS (dose error reduction system)
is not a pump, but a software capability associated with some pumps (SMART Pumps)
designed to reduce dose errors across an enterprise by using standard drug
libraries and software verification of rates or doses entered.
Reference:
[1] ECRI Institute, Patient Controlled Analgesia Pumps, June 2011
Q611EXPL
Water baths use a heating element to raise the temperature of the water to a
desired level. Under certain conditions, such as age or exposure to excess
moisture, the insulation around the heating element could break down, providing a
path to the equipment case for the flow of leakage current. If this happens, it
can often be detected by checking the leakage current to see if it has risen
above its normal level. A simple water bath, like the one described in this
question, does not have a motor. More sophisticated shaking water baths do have
motors, and a leakage current test might identify a problem in the motor.
As for brushes, these are found in some types of motors, but not in a simple
water bath, as that would not have a motor. While a visual inspection would be
useful for identifying some other types of problems in a water bath, it could not
identify problems in a component that does not exist.
A water leak may be a problem with some types of water baths. However, leaks
generally can be detected by using a visual inspection or a simple leak test. A
pressurized test would not be required.
Reference:
[1] Atles, Les, Practicum for Biomedical Engineering & Technology Management
Issues, 2008, p. 486
Q614EXPL
X-ray fluoroscopy is a technique in which images are continuously acquired to
study, for example, the passage of an X-ray contrast agent through the GI tract
or to guide an interventional procedure. Until very recently, the traditional
detector was a digital image intensifier television system, in which the images
produced by an X-ray image intensifier were digitized using a CCD-based device.
However, this type of detector is now being replaced by flat panel solid-state
detectors, which are very similar to indirect-detection digital radiography (DR)
technology with minor modifications. For example, they include CsI (cesium
iodide) scintillator followed by a-Si (amorphous silicon) image sensor but the
thickness of the CsI scintillator is increased to increase the detection
efficiency and therefore reduce the required X-ray dose. So, modern image
intensifiers no longer use a separate fluorescent screen and have been replaced
by the more compact and efficient flat-panel detectors.
Reference:
[1] Smith, Nadine Barrie and Webb, Andrew Introduction to Medical Imaging
Physics, Engineering and Clinical Applications, Cambridge University Press, 2011,
pp. 52-53, 63-64
Q615EXPL
Solid-state digital fluoroscopy systems use very short pulses of X-rays of 5–20
ms duration depending upon the type of examination and patient size. Fluoroscopic
images are typically acquired at rates of up to 30 frames per second. The X-ray
dose per frame during fluoroscopy can be as low as one one-thousandth of that
used during serial image acquisition.
As a digital imaging system, the collection of images is not continuous but

rather happens in a discrete manner. That is, having a continuous x-ray exposure
in between the 30 times per second where image frames are collected increases
patient dose with no return in image quality.
Many modern fluoroscopy systems offer biplane imaging in order to allow better
localization of surgical instruments by collecting two images of the site at
perpendicular planes. This advantage in better visualization comes at a cost of
doubling the radiation dose to collect the two output images.
Reference:
[1] Smith, Nadine Barrie and Webb, Andrew Introduction to Medical Imaging
Physics, Engineering and Clinical Applications, Cambridge University Press, 2011,
pp. 52-53, 63-64
Q616EXPL
Pulse oximetry is a noninvasive method for continuously measuring the oxygen
saturation in the arterial blood. The parameter is not called SaO 2 but SpO2, to
signify that the oxygen saturation is determined by means of pulse oximetry and
to point towards the principal difference. The value SpO 2 from pulse oximetry is
the functional saturation, in contrast to the more accurate fractional
saturation, SaO2.
SaO2 is measured in a lab and requires acquisition of an arterial blood sample,

while SpO2 is measured non-invasively in real time.
The difference is that the functional saturation (SpO 2) is defined as the

oxyhemoglobin as a percentage of the total functional hemoglobin (i.e., only
hemoglobin that can transport oxygen), while the fractional saturation (SaO 2) is
the percentage of oxyhemoglobin of the total measured hemoglobin. The total
hemoglobin includes dysfunctional hemoglobin derivatives such as
carboxyhemoglobin or methemoglobin, in addition to the functional hemoglobin.
When significant amounts of dysfunctional hemoglobin are present, this

fundamental difference between SpO2 from pulse oximetry and SaO2 from the
laboratory analysis naturally leads to differing results.
Carboxyhemoglobin is formed in the case of smoke poisoning, and occurs when

carbon monoxide binds to hemoglobin. Pulse oximetry is not capable of
distinguishing between oxyhemoglobin and carboxyhemoglobin and so will provide
erroneously high SpO2 values.
Reference:
[1] Kramme, Rüdiger, Hoffman, Klaus-Peter and Pozos, Robert S., editors, Springer
Handbook of Medical Technology, Springer-Verlag, Berlin, 2011, p. 976
Q617EXPL
Conventional pulse oximetry is based on the assumption that only arterial blood
has a pulsatile component of light absorption, whereas tissue, venous blood and
non-pulsatile arterial blood always provide a constant DC component of the light
absorption at the measurement point.
Two LEDs transmit red and infrared (IR) light through the measurement point, and
this light undergoes absorption from all the above components. The intensities
received for both the red and infrared are registered by the detector with both
their pulsatile and constant light absorption components in each case.
The pulsatile component is normalized by the constant component in each

measurement and then a quotient of the normalized values for the red and infrared
is derived and the percentage value of the oxygen saturation SpO 2 is empirically
determined. This has the advantage that of not requiring a calibration procedure
for the pulse oximetry measurement, making the process user-friendly.
Reference:
[1] Kramme, Rüdiger, Hoffman, Klaus-Peter and Pozos, Robert S., editors, Springer
Handbook of Medical Technology, Springer-Verlag, Berlin, 2011, p. 977
Q618EXPL
Infant radiant warmers require significant time for the heater to warm up and,
subsequently, for the mattress area to warm up. Infants who are placed on these
devices are often cold-stressed from transport or cold-stressed and wet from
recent birth and cannot tolerate continued cooling while waiting for the warming
device to heat up.
A Manual mode level of heat below 10 mW/cm 2 is not sufficient for prewarming the
infant radiant warmer for these cold-stressed infants. These cold-stressed
infants cannot tolerate the time for the warmers to heat to a level appropriate
for their needs without experiencing further cold stress. The Prewarm mode allows
the infant radiant warmer to remain warmed to a level suitable for these infants
so that the infant may immediately begin warming from a cold-stressed condition
when placed on the infant radiant warmer.
The Prewarm mode is however not appropriate for care of an infant after the
infant has been placed on the infant radiant warmer and either the Manual or the
Baby-controlled modes are subsequently used.
Reference:
[1] ANSI/AAMI/IEC 60601-2-21:2009, "Medical Electrical Equipment — Part 2-21:
Particular requirements for the basic safety and essential performance of infant
radiant warmers," subclause 201.3.207
Q619EXPL
From a medical perspective, the patient data desired is the percentage of oxygen
contained within the hemoglobin of (usually) arterial blood (SaO2) or (less often)
venous blood (SvO2). Unfortunately, this data requires that a blood sample be
taken and analyzed with a co-oximeter. This laboratory analysis takes time.
A pulse oximeter, on the other hand, is a noninvasive device that offers nearly
instantaneous, continuous data that correlates with the percent oxygen saturation
of hemoglobin in arterial blood. While this method may be slightly less accurate
than a co-oximeter, and therefore is distinguished from it by calling the results
SpO2 versus SaO2, the benefit of real-time patient data has outweighed the
relatively small inaccuracy. This is particularly true in anesthesiology, where a
patient's condition must be continuously and aggressively monitored in order to
prevent hypoxia.
Modern pulse oximeters use digital signal processing techniques to analyze the
signals and reduce errors. The accuracy of these modern devices is usually within
1% of the "true" (SaO2) values.
Reference:
[1] Chan, Anthony, Biomedical Device Technology, Charles C. Thomas Publisher,
2008, Chapter 31
Q620EXPL
Pulse oximeters determine the percentage of oxyhemoglobin in the blood by
comparing the transmission of light produced by LEDs at two frequencies (red and
infrared light) during the pulse. By comparing the minimum and maximum light
intensities for each frequency, the oxygen saturation of the blood can be
empirically determined. Anything that interferes with the transmission of either
of these two light frequencies can cause the pulse oximeter reading to be be
inaccurate.
Bright ambient light that that impinges on the pulse oximeter sensor because of
poor positioning of the sensor can result in a low reading. Patient movement
(shivering, for example) can cause errors between the maximum and minimum pulse
intensities. Since the SpO2 reading depends upon the ratio of these max/min peaks,
patient movement, weak pulses, or vasocontriction can result in abnormally low
readings. Nail polish can sometimes block the light from reaching the detector
entirely, and will tend to result in the pulse oximeter failing to provide any
reading at all.
Pulse oximeters are designed to detect oxygen molecules that are attached to
blood hemoglobin. Carbon monoxide (but not carbon dioxide) can also attach to
hemoglobin. Unfortunately, most pulse oximeters cannot distinguish between oxygen
and carbon monoxide. Patients suffering from carbon monoxide poisoning can
exhibit signs of cyanosis, yet have perfectly normal pulse oximeter readings of
greater than 95%.
Reference:
[1] World Health Organization, Patient Safety: Using the Pulse Oximeter
http://www.who.int/patientsafety/safesurgery/pulse_oximetry/who_ps_pulse_oxymetry
_tutorial2_advanced_en.pdf
Q627EXPL
X-Ray Image Intensifier Televisions Systems are commonly used components of a
modern fluoroscopy system and are used as an indirect method of viewing real-time
moving images of what is happening inside a patient’s body. Flat-panel x-ray
detectors (FPD) for fluoroscopy are an alternative to the image intensifier/TV
(II/TV) digital system that came into use in the 1980s to allow visualization of
x-ray images.
Direct fluoroscopy produces a greenish image on a fluorescent screen when exposed

to x-rays, and was the system used prior to the instroduction of image
intensifier/TV systems. The image produced is faint and the radiologist must
adapt to the dark for 20-30 minutes before viewing the image. Therefore, direct
fluoroscopy using a fluorescent screen is no longer commonly used.
An ion chamber does not display radiation but rather detects the presence of
radiation and its intensity. DICOM (Digital Imaging and Communications in
Medicine) is a radiologic image communication standard. Ion detectors are
commonly used in laboratory analyzers for gas chromatography.
References:
[1] Seibert, Anthony J., Flat-panel detectors: how much better are they?,
Pediatric Radiology, September 2006; 36(Suppl 2): 173–181, available online at
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2663651/
[2] Khandpur, R.S., Biomedical Instrumentation, Technology and Applications,
McGraw Hill, 2005, pages 306, 385, 509, 525-527, 552, 567, 580
Q628EXPL
Of the three factors cited, only ambient light and motion may affect the
measurement made by the pulse oximeter. Since the high intensity exam lights are
shining on the patient's hands, these lights may be influencing the reading.
Also, the patient is reported to be shivering, which could cause motion of the
probe.
The one factor that would not affect the oxygen saturation reading is skin
thickness. While the patient is reported to be obese, oximeters work by comparing
light transmission associated with oxyhemoglobin and comparing it to the light
transmission associated with deoxygenated hemoglobin. That ratio is not affected
by skin thickness.
Reference:
McGraw Hill, 2005, page 322
Q629EXPL
Controlled hyperthermia is elevated temperature in the range of 42–45°C or
higher. A machine that elevates patient temperature is a hyperthermia machine.
These machines generally work by either blowing warmed air on a patient or by
circulating warmed fluid through a blanket that is in contact with the patient.
By contrast, a hypothermia machine reduces patient temperature, generally by
circulating cooled fluid through a blanket that is in contact with the patient.
Liquid crystal thermometry is a temperature measurement device.
An SCD pump is a device providing sequential compression. It generally is used

with a sleeve around the patient’s legs that is inflated and deflated one or more
times per minute. This therapy is intended to prevent the formation of blood
clots in the patient’s legs, which could lead to a pulmonary embolism.
A PCA pump is a patient-controlled analgesia infusion pump that allows a patient

to periodically dispense an opiate pain medication based on the patient's own
desires. Studies have shown that patients tend to report lower levels of pain
while using less pain medication when allowed to control the amount of medication
received.
Reference:
Q630EXPL
A defibrillator analyzer measures the energy output of a defibrillator discharge
pulse in joules or watt-seconds.
Reference:
Q631EXPL
Electrical safety analyzers are meters designed to perform basic electrical tests
on AC-powered medical devices. Specifically, these analyzers measure enclosure
leakage current, patient leakage current and ground continuity.
A defibrillator analyzer tests the output energy of the defibrillator in joules

or watt-seconds.
An electrosurgical analyzer tests the output of an electrosurgical unit in watts

or HF (high-frequency) current.
A portable oscilloscope is used to analyze and plot two-dimensional waveforms of

electrical signals.
A phototherapy radiometer measures the output light of a phototherapy device.
Reference:
Q632EXPL
All of the diagnostic imaging procedures which are potential answers for this
question use fluoroscopy. Fluoroscopy is an x-ray technique which provides
continuous viewing of real time, active processes in the body. Fluoroscopy uses
x-rays with a very low energy in the range of 25-30 keV. Fluoroscopy includes a
number of variations including general purpose fluoroscopy for gastrointestinal
and urological studies, portable applications using C-arms for surgery such as
orthopedic or vascular procedures, specialized angiographic units related to
interventional radiology where aneurysms can be repaired and aortic valves
replaced (TAVR) using minimally invasive techniques, and heart procedures
performed in the cardiac catheterization lab such as balloon angioplasty, excimer
laser angioplasty and coronary artery stenting.
Angiography is a technique that injects a contrast material into blood vessels to

allow visualization of distal blood vessels. The contrast agent blocks the
transmission of the X-rays, so that the condition of the internal lumen of those
blood vessels can be observed under the fluoroscope.
Cardiac catheterization is done to observe the flow of blood through the heart.
It is typically used to identify the condition of the patient’s heart, as well as
the coronary arteries that supply blood to the heart muscle. It is not used
during orthopedic surgical cases, where the need would be for the surgeon to
visualize the condition of bones.
A C-arm is generally a portable radiographic fluoroscopic unit. These are

generally used to provide real-time imaging of medical procedures such as
orthopedic, vascular, angiography, or pacemaker lead insertion. In all of those
cases, it is important for the physician to be able to track the position of
something that has been inserted into the patient’s body as it is manipulated
during the procedure being done. A chest X-ray typically would be done to produce
a static image or images to identify the presence of fluid in the lungs or a lung
tumor. It does not require real-time information to be available to the
physician, so a C-arm would not be used.
A barium study generally would be used to track the flow of material through the
gastrointestinal (GI) system. A patient would be asked to swallow (for an upper
GI examination) a liquid that contains barium sulfate, which blocks X-rays.
Alternately, for a lower GI examination, the patient can be given an enema with a
solution that contains barium sulfate.
Balloon angioplasty is a technique used to widen a blood vessel with an

obstruction in it. This would typically be done to widen a coronary artery, for
example, to increase blood flow to heart muscle. Balloon angioplasty is not done
as part of a GI examination.
References:
[1] Heritage Education, Medical Methods and Uses for X-Rays: Fluoroscopy,
http://www.heritage-
education.com/article_medicalmethodsandusesforxraysfluoroscopy.htm, retrieved
August 2, 2014
[2] World Health Organization, WHO Diagnostic Imaging,
http://www.who.int/diagnostic_imaging/imaging_modalities/en/, retrieved August 2,
2014
[3] Wikipedia, Fluoroscopy, http://en.wikipedia.org/wiki/Fluoroscopy, retrieved
August 2, 2014
[4] Street, Laurence J., Clinical Procedures for Medical Technology Specialists,
CRC Press, 2011, Angiography, pages 46-48
Q633EXPL
Patient-controlled analgesia pumps allow patients to give themselves a dose of
pain medication (typically, an opiate) at the push of a button. The application
of the PCA technique is very broad including post-surgical, oncology, and other
patients where pain is an issue. As the pain medication can have deadly effects
at high doses, there is a limit to the amount infused per unit time. These pumps
also have a programming option to deliver doses at intervals. Bolus capability is
common in PCA pumps to stop acute pain through a patient-administered dose of the
pain medication.
Nutrition is provided by enteral feeding pumps. Antibiotics are typically

administered by syringe pumps. Large volume bags are not used with PCA pumps.
References:
[1] EBME Infusion Devices Training Tutorial
http://www.ebme.co.uk/articles/clinical-engineering/46-infusion-devices-training-
tutorial, retrieved August 2, 2014
[2] Wikipedia, Patient Controlled Analgesia,
http://en.wikipedia.org/wiki/Patient-controlled_analgesia, retrieved August 2,
2014
Q634EXPL
A pulse oximeter is a device that provides a noninvasive and continuous
measurement of the percent of oxygenated hemoglobin. The basis for pulse oximetry
is the Beer-Lambert Law of optical absorption which states that the concentration
of a substance can be determined by its absorption of light. In pulse oximetry, a
differential measurement of absorption is used based on the absorption curves of
oxygenated hemoglobin (HbO2) and un-oxygenated hemoglobin (Hb) at different
wavelengths of light. Two wavelengths of light generated by light-emitting diodes
(LED) are used in conjunction with a photo-detector to make the measurement
across a vascular bed - typically the finger. An LED emitting in the 660-nm (red)
range is a wavelength highly absorbed by un-oxygenated hemoglobin whereas a
second LED emitting 920-nm (infrared) light is highly absorbed by oxygenated
hemoglobin. The LEDs are sequentially pulsed on and off, and the photo-detector
is synchronized to make simultaneous reading for the red and infrared light
transmission.
If the non-invasive blood pressure cuff is on the same arm as the finger that is
being used to measure oxygen saturation, the cuff will stop the blood flow to the
finger resulting in the loss of the waveform and reading. The other choices (nail
polish, carbon monoxide poisoning, or bright light) would cause a continuous
inaccuracy in the reading and/or a complete loss of signal.
References:
[1] WHO Using the Pulse Oximeter - Advanced
_tutorial2_advanced_en.pdf
[2] How Equipment Works,
http://www.howequipmentworks.com/physics/respi_measurements/oxygen/oximeter/pulse
_oximeter.html#problems, retrieved August 2, 2014
[3] World Health Organization, WHO Pulse Oximetry Training Material,
http://www.who.int/patientsafety/safesurgery/pulse_oximetry/tr_material/en/,
retrieved August 2, 2014
Q635EXPL
The intra-aortic balloon pump (IABP) and catheter system has been used since the
late 1960s to support patients in cardiogenic shock. A hot dog shaped inert
balloon at the distal end of a catheter is placed in the femoral artery and then
moved up into the aorta just below the origin of the left subclavian artery. The
IABP uses low-density helium gas to rapidly inflate the balloon at the onset of
diastole when the aortic valve closes. The balloon is deflated just prior to the
opening of the aortic valve and systole. This effect reduces the ventricular
afterload (impedance) and increases stroke output.
Unlike the cardio-pulmonary bypass machine, the IAPB technique does not provide
any additional oxygenation of the blood. The complication rate for IAPB is high,
with reports of 10-50% of patients reporting an unintended complication in their
condition. The IABP increases the diastolic pressure.
References:
[1] Marino, Paul L., The ICU Book, Lippincott Williams and Wilkins, 2007, pages
269-271
[2] Wikipedia, IABP, http://en.wikipedia.org/wiki/Intra-aortic_balloon_pump,
retrieved August 2, 2014
[3] Maquet, Intra-Aortic Balloon Counterpulsation Therapy: interactive online
training, http://ca.maquet.com/file_assets/e-
learning/theory_program/theory_program.html
[4] IAPB Anesthesia Tutorial, http://www.frca.co.uk/Documents/220%20Intra-
aortic%20Balloon%20Pump%20Counterpulsation.pdf
Q636EXPL
Water baths are used for various testing protocols in the laboratory. Generally
they use water but some baths use oil depending upon the application. Most baths
provide moderate liquid temperature stability over a range extending from room
temperature to as high as 60 degrees C, but some will go higher. The tanks for
the liquid (water or oil) have electric heaters with thermostat control to allow
the liquid to be properly heated and maintained at the desired temperature.
Unlike hyper/hypothermia equipment, water baths lack a circulation pump for

continuous flow. They may have an agitator to keep the bath temperature constant
throughout the tank.
References:
[1] World Health Organization, WHO Maintenance Manual for Laboratory Equipment,
http://apps.who.int/iris/bitstream/10665/43835/1/9789241596350_chapters1-
9_eng.pdf?ua=1, pages 31-34
[2] Microeguide, Laboratory Equipment: Water Bath Description,
http://www.microeguide.com/equipment/water_bath.asp, retrieve August 2, 2014
[3] J. Ochei & A Kolhatkar, Medical Laboratory Science: Theory and Practice, Tata
McGraw-Hill, 2000, page 23
Q637EXPL
A defibrillator tester is an instrument capable of measuring the energy output
from a cardiac defibrillator while generating a simulated ECG output to the
defibrillator to test its response and correct application of shock to life-
threatening rhythms only.
The energy storage device is the component of the defibrillator (for example, a
capacitor) that is charged with the energy necessary to deliver an electrical
defibrillation pulse to the patient. There is no need for this device in the
tester.
Reference:
[1] ANSI/AAMI DF80:2003, Medical electrical equipment — Part 2-4: Particular
requirements for the safety of cardiac defibrillators (including automated
external defibrillators), Section One: 2 Terminology and Definitions.
Q638EXPL
Fetal monitoring is a common practice in hospitals. Changes in fetal heart rate
during contractions are an important measure of potential problems such as fetal
hypoxia. Fetal monitors record contraction events and strength, and monitor the
fetus’ heart rate during contractions to determine fetal response to the stress
of labor. The measurements of contraction intensity and frequency during labor
can help assess the progression of labor, the effect of medications including
those which induce labor, and detect abnormal contraction efforts. Patterns of
heart rate variability called accelerations and decelerations seen before, during
and after contractions, are monitored and analyzed to determine if medical
interventions are required. Fetal monitors measure fetal and maternal ECG, fetal
heart rate via ultrasound, and contraction strength and timing through the use of
external toco transducers or internal fluid-filled catheters connected to a
pressure transducer. A toco transducer, which is short for tocodynamometer
transducer, is a pressure-sensitive transducer that detects the presence of
uterine contractions when held in place against a woman’s abdomen.
After rupture of the membranes, a spiral electrode is commonly used to record

fetal ECG through direct connection to the fetal scalp or other presenting part
of the fetus. The spiral electrode typically consists of a “corkscrew” active
electrode and reference electrode all part of an assembly inserted into the
vagina. A third connection is made with an indifferent electrode strapped to the
mother’s leg. If the spiral electrode is not making good contact, the recordings
will be poor and the electrode will have to be repositioned or replaced.
Answers A, B, and C are all related to recording the fetal heart rate using the
ultrasound technique, where the ultrasound transducer must have a coupling
solution applied, is attached via a belt and has to be positioned toward the
fetal heart. While all of these techniques detect fetal heart rate, recording the
fetal ECG requires a direct electrical connection, which only the spiral
electrode can provide.
References:
[1] R.S.Khandpur, Biomedical Instrumentation: Technology & Applications, McGraw-
Hill, 2005, Pages 276-279
[2] Electronic Fetal Monitoring Tutorial, Center for Experiential Learning, East
Tennessee State University, http://www.utilis.net/fhm/2625.htm, retrieved
8/24/2014
Q639EXPL
External defibrillators produce an electrical discharge of about 20 milliseconds
with a voltage of 2,000 to 4,000 peak volts. Large area paddles or pads are
applied to the patient’s thorax to transfer the defibrillator energy, which may
be as high as 320 joules. A conductive electrolyte gel is used to transfer the
electrical energy from the electrodes to the patient through their skin. Skin
burns can occur if there is a concentration of energy over a small area or if the
resistance to current flow is high. Increased resistance can be caused by the
electrolyte on the pad being dried out. This may occur if clinical staff use a
pad that is past the expiration date indicated on the package or if the package
has been opened.
Staff should not physically contact patients during defibrillation, but such
contact will not have any effect on the possibility of the patient getting skin
burns. Burns are less likely with external pacemakers due to the low energy
output. Monopolar defibrillators have not been shown to be more likely to cause
skin burns compared to the newer biphasic defibrillators.
References:
[1] Laurence J. Street, Clinical Procedures for Medical Technology Specialists,
CRC Press, 2011, Defibrillation, Pages 120-124
[2] Paul Marino, The ICU Book, Lippincott, Williams and Wilkins, 2007, pages 280-
283
[3] R.S.Khandpur, Biomedical Instrumentation: Technology & Applications, McGraw-
Hill, 2005, Chapter 26
[4] Defibrillation: What you should know, Physio-Control Corp., 1996, pages 15-
18, available at http://www.cenetec.salud.gob.mx/descargas/cursos-
talleres_IngClinica_2012/estimulacion-cardiaca/Desfibrilacixn_Booklet.pdf,
retrieved 9/10/2014
Q640EXPL
To troubleshoot problems with medical devices, a rational approach should be
used. Knowing the device application, operation, and technical aspects make
finding device problems more successful. If you are not familiar with a device,
use logical troubleshooting techniques and common sense.
Logical troubleshooting starts at the system level - the device, all of its
connections, operation, and the environment, and then works down to a specific
focus area - control, cable, module or component. Common sense is critical in
successfully resolving problems.
Clinical staff is the first line of problem solving for devices. Clinical users
of devices are responsible for proper operation of the device, correct assembly
and application of disposable and consumable components, and, for some devices,
simple maintenance, such as battery replacement in a telemetry transmitter.
Clinical staff should be able to solve most cable, lead wire and electrode
problems, unless they are atypical or involve multiple causes.
The ECG monitor records the millivolt voltages from the electrodes attached to
the patient, conducted via lead wires and cables to amplifiers which drive the
monitor display. Any discontinuity in the circuit can lead to no ECG displayed on
the monitor. Electrical power from the AC outlet typically powers the devices
with an on-off switch used to activate the equipment. A microprocessor is the
likely “brain” of the unit controlling the operation of the monitor with
functional and self-test programs part of the software system.
Since the question makes clear that the device does turn on, the equipment must
be been plugged in and the power button must be working. The microprocessor is a
primary device being checked during the internal self-check. Since the self-check
passed, we can assume the microprocessor is working properly. The only correct
option listed is that the cable from the device to the patient is defective.
References:
[1] Khandpur, R.S., Biomedical Instrumentation: Technology & Applications,
McGraw-Hill, 2005
[2] Biomedical Equipment Troubleshooting, King Saud University, Slide 15,
http://faculty.ksu.edu.sa/Monif/Documents/Medical%20equipment%20troubleshooting.p
df, retrieved 9/10/2014
[3] Taking the Trouble Out of Troubleshooting, 24x7 Magazine Digital Edition,
Allied Media, August, pages 24-31 http://edition.pagesuite-
professional.co.uk/launch.aspx?referral=other&pnum=0&refresh=fL0213AgM0q9&EID=dc9
d285d-e22b-4fe1-afce-34f62e5e64dc&skip=&p=0, retrieved 9/10/2014
Q641EXPL
An ultrasound therapy unit provides some types of physical therapy treatment. The
unit consists of an applicator or transducer applied to the patient with a gel
interface to the patient’s body. The transducer has a piezoelectric crystal which
converts the electrical energy from a radio frequency transmitter to vibration-
producing ultrasound waves. The ultrasound enters the body and produces primarily
a thermal treatment effect.
Moisture in the transducer head can heat producing a burning effect. A cracked
crystal will have hot points at the crack creating heat and potential burns.
Newer ultrasound therapy systems have a head warming feature to lessen the
feeling of a cold transducer head on the body. Some patients will perceive the
head to be hot. Since all three causes would account for the symptom described,
in the absence of any additional information, the best answer in this case is
“all of the above.”
References:
[1] Therapeutic Ultrasound, Wikipedia,
http://en.wikipedia.org/wiki/Therapeutic_ultrasound, retrieved 9/9/2014
[2] Overview of Ultrasound Therapeutic Applications and Safety Considerations,
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3810427/, retrieved 9/9/2014
[3] Therapeutic Ultrasound, EBME, http://www.ebme.co.uk/articles/clinical-
engineering/93-therapeutic-ultrasound, retrieved 9/10/2014
[4] Intelect Transport, Vectra Genisys service manual,
http://www.djoglobal.com/sites/default/files/Service%20Manual%20-
%202782%20Transport%20Ultrasound.pdf, retrieved 9/9/2014
[5] Mettler Electronics, Sonicator 740 Instruction Manual,
http://www.mettlerelectronics.com/images/products/therapeutic_ultra/740_manual.pd
f, retrieved 9/9/2014
[6] FDA MAUDE Adverse Event Report,
http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=1
006096, retrieved 9/9/2014
Q642EXPL
The microplate reader is a type of spectrophotometer designed to read results of
the ELISA test, a technique used to determine the presence of antibodies or
specific antigens in samples. The reaction between antigens or antibodies
interacting on a solid surface with labeled antibodies is read by the
spectrophotometer. The acronym ELISA stands for "enzyme-linked immunosorbent
assay." The wavelength for operation is typically between 400 nm and 750 nm
(nanometers). A fiber-optic connection to the microplate well is used to transmit
the light through the sample. The detection system determines the sample’s
absorbance. The microplate reader may have many wells to read via a
microcontroller-driven sensor going from well to well. The optical results are
converted into a diagnostic value.
Cleaning the sensors, lenses and light emitters is a daily task for device users.
The light system is very sensitive and a dirty sensor can cause inaccuracies
varying from row to row.
The user training should focus on the procedures to be completed every day. The
user should make sure that the optical sensors for each channel are clean. If
dirt is detected, the surface of the windows of the light emitters and the
sensors should be cleaned with a small brush. Also, users should confirm that the
lighting system is clean.
If the illumination lamp is not on, you would get no readings. There is no
chamber in a microplate reader, thus no chamber gasket. Zeroing the device is
automatic. An error in the zero state would cause a non-varying inaccuracy across
each row, not a row-to-row variation in accuracy.
References:
[1] World Health Organization, Maintenance Manual for Laboratory Equipment,
Chapter 1, http://whqlibdoc.who.int/publications/2008/9789241596350_chapters1-
9_eng.pdf, retrieved 9/9/2014
[2] Bisen, Prakas and Sharma, Anjana, Introduction to Instrumentation in Life
Sciences, CRC press, 2013, Chapter 3, Spectroscopy, pages 115-127
Q645EXPL
The laser, which stands for "light amplification stimulated emission of
radiation," was invented in 1961 by Theodore "Ted" Maiman. It only took
four years for it to be first applied to medicine. There are three
elements required for a laser to work:
1. Laser medium - promotes population inversion when excited. It can be a
gas, solid, or liquid.
2. Optical cavity with resonating circuit - one 100% reflective mirror and
one partially transmissive mirror.
3. Source of energy - electrical or light; this may be called excitation
or "pumping."
The characteristics of a laser include a monochromatic or single

wavelength, and coherence, which means that the electromagnetic waves
produced by the laser are all at the same frequency and phase. Lasers have
a mode or shape of the output which is called the transverse
electromagnetic field - TEM. The mode generally used for medical
applications is referred to as TEM00 which concentrates energy at the
center of the output beam. The output can be continuous, pulsed, Q-
switched (microsecond pulses), or mode-locked (picosecond pulses). The
wavelength of a laser can be from far infrared into the ultraviolet range.
A number of laser types are used in medicine. The chart below shows some
of them and their characteristics:
Laser Type Wavelength Laser Medium Pumping
10.6 um; far Gas, 5% CO2 + 10% N2

CO2 Electrical
infrared +85% He
Nd:YAG 1.06 um; infrared Nd-doped YAG crystal Optical
Argon 488 nm; blue Argon gas Electrical
Excimer 193 nm; ultraviolet Fluoride gas Electrical
Diode 810 nm or 980 nm Solid state Electrical
Ho:YAG (Holmium:yttrium-aluminum-
2100 nm Crystal Optical
garnet)
Lasers that do not have a visible light laser beam require an aiming beam.
This is typically a helium neon laser with an output in the red spectrum.
This low power aiming light may have to be directed through a microscope
or other delivery apparatus. The CO2 (carbon dioxide) laser beam is
absorbed by all tissue and H2O (water). This laser emits in the infrared
electromagnetic radiation range, and the beam produced will be absorbed by
optical fibers. If the beam passes through an optical fiber, the fiber
will heat and burn. Thus the CO2 laser beam should not be transmitted
through an optical fiber. Typically an articulated arm employing precisely
aligned mirrors is used to transmit the beam to the tissue via a
handpiece, a micro-manipulator with a joy stick attached to a surgical
microscope, or hollow endoscope.
As indicated in this question, connecting a CO2 laser to a fiber-optic

cable should never be done. While these lasers are designed to prevent
this connection from being made, there have been reports of surgeons
attempting to do this (inappropriately) to make it easier to deliver the
laser's energy to certain surgical sites. This invariably leads to damage
to the fiber-optic cable.
The other laser types can be transmitted through a fiber-optic cable.
References:
[1] Fanning, James, Are Your CO2 Lasers Precise?, Biomedical
Instrumentation & Technology, May/June 2006, pages 231-232
[2] Laser, Wikipedia, http://en.wikipedia.org/wiki/Laser, retrieved
September 14, 2014
McGraw-Hill, 2005, pages 755-758
Q646EXPL
late 1960s to support patients in cardiogenic shock. A 2- to 5-inch balloon is
located at the distal end of a catheter placed in the femoral artery and fed up
into the aorta just below the origin of the left subclavian artery. The IABP uses
low density helium gas to rapidly inflate the balloon at the onset of diastole
when the aortic valve closes. The balloon is then deflated just prior to the
The balloon pump has at least two trigger sources – ECG and arterial blood
pressure (ABP) waveforms. If the ECG signal is noisy due to external
interference, the trigger can be changed to the ABP if the signal is solid as it
is reported to be in this case. This should lead to reliable triggering. When the
patient trembling decreases or ends, the signal should be switched back to ECG as
ECG is the preferred trigger source.
Changing the drive gas is not recommended. Helium is the standard drive gas due
to its low atomic number and viscosity. Also, it has a low risk of causing an
embolism should the balloon rupture. Kinks in the catheter do not affect the
triggering. Shortening the balloon inflation cycle has no effect on the trigger
reliability.
References:
[1] Abbreviated operators Guide CS 100, Maquet, page 3, available at
http://ca.maquet.com/file_assets/abbreviated-operators-guides/en/CS100-IABP-AOG-
EN.pdf, retrieved September 10, 2014
[2] Intra-aortic Balloon Pump, Wikipedia, http://en.wikipedia.org/wiki/Intra-
aortic_balloon_pump, retrieved September 10, 2014
[3] Intra-Aortic Balloon Counterpulsation Therapy: interactive online training,
http://ca.maquet.com/file_assets/e-learning/theory_program/theory_program.html,
Q690EXPL
For proper hemodialysis to occur, a hemodialysis system relies on having a
dialysate that has the correct concentration and the correct acid-base balance
(ionic composition). The dialysate’s conductivity is measured to determine its
concentration, while the dialysate’s pH is measured to determine that it has the
correct ionic composition. Both the pH and conductivity must be within acceptable
limits before initiating dialysis.
The dialysate composition and concentration are adjusted by adding in both an

acid concentrate and a bicarbonate concentrate in carefully controlled
quantities. The hemodialysis machine generally uses a servo-controlled mechanism
to continuously adjust the acid and bicarbonate amounts added to stay within
required limits.
If the acid and bicarbonate inputs are reversed, the servo loops may make a
solution of acceptable ionic strength (correct conductivity) but with an
incorrect ionic composition (out of range pH value).
The presence of air bubbles in the dialysate circuit is known to cause false
conductivity alarms but does not cause the value of the pH to change. When one of
the input concentrates run out, the mixing process cannot produce the desired
conductivity from one concentrate only. Therefore, this condition will result in
both the conductivity and pH being out of range.
Reference:
[1] Nissenson, Allen R. and Fine, Richard N., Handbook of Dialysis Therapy, 4th
edition, Saunders, 2007, pages 193-194
Q693EXPL
A ventilator assists a patient’s breathing by forcefully pushing air into the
lungs. Different breathing modes can be used to assist the patient depending upon
the patient’s particular needs, and the patient’s ability to generate spontaneous
breaths.
Continuous positive airway pressure (CPAP) is the use of constant positive

pressure in the airway of a spontaneously breathing patient. In this mode, the
patient must initiate all of his/her breaths. The ventilator will not cycle, but
does maintain a continuous pressure to help force air into the lungs
continuously, rather than just on a breath-by-breath basis.
In the triggered mode of breathing, the ventilator detects and uses the
initiation of a spontaneous inspiratory effort to start its ventilation cycle.
On the other hand, in the mandatory breathing mode, the rate of mechanical
ventilation is high enough to suppress any spontaneous breathing and therefore,
the number of breaths per minute is fixed and independent of spontaneous
breathing.
The synchronized mandatory breathing mode is a hybrid of these two modes where a
spontaneous inspiratory effort that occurs sufficiently close to the time that a
mandatory breath is due will cause the mandatory breath to be initiated. This is
useful when the rate of mandatory breathing is low, allowing the possibility of a
spontaneous breathing effort in between mandatory breaths. In all these modes
(triggered, mandatory, and synchronized mandatory), the ventilator plays a role
in assisting or performing the cycle of breathing, which is not the case in CPAP
treatment.
References:
[1] Mackenzie, Iain, Core Topics in Mechanical Ventilation, Cambridge University
Press, 2008, pages 92
[2] Continuous positive airway pressure, Wikipedia,
http://en.wikipedia.org/wiki/Continuous_positive_airway_pressure, retrieved
October 1, 2014
Q694EXPL
Ventilation modes do not presently have any internationally agreed upon
terminology. As a result, commercial ventilator manufacturers may use the same or
similar names for modes that operate in quite different ways. Also, different
manufacturers use their own unique names for modes that operate in very similar
ways. Broadly speaking, modes fall into four categories: mandatory, triggered,
spontaneous and hybrid modes. Assisted spontaneous breathing mode would fall
under the category of a triggered mode.
In triggered mode, there are several parameters that can be inspected to properly
compare modes with different commercial names. These parameters include the
control type, target or limit, and expiratory cycling variables used. Matching
those parameters between modes with different commercial names allows the
inclusion of more potential ventilators in the selection process.
Rejecting all offers but the one that included the exact terminology would be
incorrect without inspecting what each of them is actually doing. The example
given in this question is for commercial modes that are all synonymous based on
their technical evaluation and illustrates clearly how many good offers can be
rejected if we were to only consider the name.
Asking Purchasing to rewrite the Request for Proposal based on only one company
meeting its criteria would also be an inappropriate action based solely upon the
difference in ventilation mode names. It is important to evaluate the responses
of the vendors to determine if their assertion of equivalence is or is not valid,
before taking such a drastic action as rewriting an RFP.
References:
[1] Mackenzie, Iain, Core Topics in Mechanical Ventilation, Cambridge University
Press, 2008, pages 103-112
[2] Mireles-Cabodevila, E. et al., "Alternative modes of mechanical ventilation:
A review for the hospitalist," Cleveland Clinic Journal of Medicine, July 2009,
volume 76, number 7, pages 417-430, http://www.ccjm.org/content/76/7/417.long
Q699EXPL
To produce x-rays, an x-ray tube causes a stream of electrons to hit an anode.
Because this process can cause intense heat at a single spot on the anode, most
x-ray tubes use a rotating anode so that the electrons hit other spots on the
anode, reducing the likelihood of heat damage.
When the anode surface exhibits any form of irregularity such as wear or
cracking, the focal spot wobbles as the anode rotates. This causes poor x-ray
resolution because the x-ray beam will be non-uniform over the exposure time.
The filament in an x-ray tube heats a cathode, which serves as the source of the
electrons that hit the anode. Having an open-circuit filament will cause the
cathode to remain cold, so that no x-rays are generated from the tube, resulting
in a blank (not just poor resolution) image.
When a filament has a partial short circuit, the filament will not heat the
cathode to the proper operating temperature. A partial short circuit typically
happens if a section of the filament touches the cathode focus cup, causing it to
weld itself to the cup. The result is that the filament effectively becomes
shorter. When this happens, the mA selected by the user will not be the actual mA
level, and the film will be underexposed, although its resolution will still be
fine. As the user tries to recalibrate the x-ray to achieve the desired exposure,
the user will find it is very difficult to properly adjust the mA level.
Reference:
[1] McClelland, Ian R., X-ray Equipment Maintenance and Repairs Workbook for
Radiographers & Radiological Technologists, pp. 104-105, , World Health
Organization, 2004, pages 104-105,
http://whqlibdoc.who.int/publications/2004/9241591633_part3.3.pdf; see also
http://whqlibdoc.who.int/publications/2004 for the entire 9241591633 document,
which is available in 16 parts
Q700EXPL
The simplest way to check for an open-circuit condition in an x-ray tube filament
is to use a multimeter set to a low resistance ohmmeter setting and measure the
resistance between any two pins in the cathode receptacle of the tube (hence
checking both the fine and broad focus filaments). If the filaments are all
intact, there will be a low resistance between any two pins. However, if there is
an open circuit with one of the filaments, then there will be a very high
resistance in the case of one or more pairs of the pins.
Even though it is also possible to check for open circuit condition by visual
inspection of the heated filament with the generator turned on such that the
preheat circuit is on, it is rather cumbersome and time consuming to remove the
collimator and filter and then reassemble everything once the test is finished.
This can still be an alternative when the anode is to be inspected or when a
filament partial short circuit is suspected. If you are only trying to test for a
filament open-circuit condition, using a multimeter will be a much quicker way to
determine this condition.
A common cause of x-ray tube instability is gas in the tube (i.e., a "gassy
tube"), which causes very high current to flow during an exposure. The presence
of gas is usually corrected by using a procedure called "seasoning." This
condition is not related in any way to a filament open-circuit condition,
therefore observing such high current flow does not help detect that condition.
High-tension cable arcing is also not related to the condition of the filament.
The high tension cable provides a high voltage to the anode to force electrons to
collide with the anode at a high speed, generating x-rays. The voltage on the
filament is a much lower voltage that heats the filament, which then heats the
cathode causing thermionic emission of electrons from the heated cathode. These
electrons are then accelerated towards the anode by the high voltage.
Reference:
[1] McClelland, Ian R., X-ray Equipment Maintenance and Repairs Workbook for
Radiographers & Radiological Technologists, World Health Organization, 2004,
pages 104-105, http://whqlibdoc.who.int/publications/2004/9241591633_part3.3.pdf;
see also http://whqlibdoc.who.int/publications/2004 for the entire 9241591633
document, which is available in 16 parts
Q701EXPL
Fetal monitors detect fetal heart rate externally using an ultrasound transducer
to continuously transmit and receive ultrasonic waves. The frequency shift (that
is, Doppler shift) of the reflected signal is proportional to the velocity of the
reflecting structure, which is the fetal heart in this application.
The output of such systems usually includes an audio output of the detected
Doppler shift as well as a computed heart rate based on analysis of this Doppler
shift over time.
The key issue in detecting the correct fetal heart signal is that the transducer
must be positioned so that the active field area of the probe (defined as the
intersection of transmit and receive elements’ field patterns) includes the fetal
heart. That way, movement of the fetal heart as it beats is detected as a
frequency shift between the transmitted and received ultrasound signal.
If the transducer’s position is not correct, the result will be a meaningless,
noisy audio signal and an erratic computed estimate of the fetal heart rate. Even
if the transducer positon is correct at one point in time, so that there is a
good audio signal and fetal heart rate estimate, any movement of the fetus can
move the fetal heart away from the active field area of the probe causing the
problem described in this question and requiring an adjustment of the probe to a
new position that restores the signal integrity so that the fetal heart rate is
properly detected.
When a fuse in the power entry module opens, it disconnects the mains from the
device and the device will have no power. Without power, the fetal monitor will
not have the noisy audio signal or erratic rate display described in this
question. Instead, it will have no audio and no rate display.
In a Doppler ultrasound-based fetal monitor, maternal heart rate never interferes

with the fetal heart rate due to the selectivity of the probe active field area.
This field area is so small that it will never include both the fetal heart and
the maternal heart at the same time. Maternal heart rate interference can be a
problem with devices measuring the fetal ECG using surface electrodes, which are
likely to pick up the electrical activity of the bigger maternal heart.
While it is possible that the ultrasound transducer broke, it is far more likely
that the fetus moved, so that the fetus' heart is now outside the active field
area.
Reference:
[1] Philips Medical Systems, Addendum: Additional Information Regarding
Ultrasound Fetal Monitoring, 2009, page 3,
https://www.swissmedic.ch/recalllists_dl/02848/Vk_20091223_05-e2.pdf, retrieved
October 1, 2014
Q749EXPL
DICOM identifies a standard methodology for exchanging medical images.
DICOM (Digital Imaging and Communications in Medicine) is the predominant

standard for handling, storing, printing, and transmitting medical imaging
information. It includes a file format definition and a network communications
protocol. DICOM enables the integration of medical imaging devices (x-ray
machines, CT scanners, MRI machines, ultrasound machines, etc.), servers,
workstations, printers, and network hardware from multiple manufacturers into a
unified picture archiving and communication system (PACS). PACS is the actual
system that moves, stores and allows retrieval of the images, while DICOM defines
the methods used to get the image data from the device that generates the image
into the PACS.
DICOM has been widely adopted by hospitals and is now moving into areas such as
dentists' and physicians' offices.
MDDS describes a medical device data system, which is software and/or hardware
that allows a medical device to send and/or receive information to and from
another system, such as an electronic medical record system.
RIS is an acronym for a radiology information system, which is the general

terminology associated with the computer system used to run a radiology
department, rather than the system specifically used to store image data.
References:
[1] DICOM, Wikipedia, http://en.wikipedia.org/wiki/DICOM, retrieved September 5,
2014
[2] Horii, Steven C., DICOM: A Nontechnical Introduction to DICOM, University of
Iowa,
http://www.uiowa.edu/hri/courses/medicalImagingInformatics/dicom/Horii_nontechnic
alIntroduction.pdf, retrieved September 7, 2014
Delmar Cengage Publishing, Clifton Park, NY, 2010, pages 616-619
[4] Advanced Data Systems Corp., What Are The Differences Between PACS, RIS, CIS,
and DICOM?, http://healthcare.adsc.com/blog/what-are-the-differences-between-
pacs-ris-cis-and-dicom, retrieved October 24, 2014
Q750EXPL
PACS (picture archive and communication system) is a system that stores medical
information, including 2D images and 3D medical images, such as x-rays, CT and
MRI scans. PACS allows the medical professional to store, send, search for and
retrieve the large data files used in paperless radiology. It generally consists
of multiple networked computers and servers.
All modern PACS use the DICOM (Digital Imaging and Communications in Medicine)
standard to move information from the device generating the image into the PACS.
DICOM describes the protocol used to transmit medical image data across a
network.
MDDS describes a dedical device data system, which is software and/or hardware
that allows a medical device to send and/or receive information to and from
another system, such as an electronic medical record system.
RIS is an acronym for a radiology information system, which is the general

terminology associated with the computer system used to run a radiology
department, rather than the system specifically used to store image data.
References:
[1] Advanced Data Systems Corp., What Are The Differences Between PACS, RIS, CIS,
and DICOM?, http://healthcare.adsc.com/blog/what-are-the-differences-between-
pacs-ris-cis-and-dicom, retrieved October 24, 2014
Q755EXPL
Photomultiplier Tubes (PMTs) are optical detectors utilizing the external
photoelectric effect. They are vacuum tubes with a glass envelope and an internal
structure that consists of a photoemissive cathode (photocathode), an electron
multiplier stage (several dynodes) and an electron collector (anode) inside the
vacuum tube. Light passes through the vacuum tube's input window and hits the
photocathode.
When light photons strike a photocathode, electrons in the valence band absorb
photon energy and become excited. These excited electrons are then released by
the photocathode.
These electrons then are accelerated towards the first dynode in the
photomultiplier section. The dynode is an electrode that is capable of emitting
secondary electrons. This secondary emission is repeated at each of the
successive dynodes (typically 10 stages of dynodes), significantly multiplying
the number of electrons released at each stage. The total number of secondary
electrons emitted are collected by the anode and output to an external circuit as
an electrical signal.
References:
[1] Hamamatsu Editorial Board, Photomultiplier Tubes, Basics and Applications,
3rd edition, Hamamatsu Photonics, 2006,
http://www.hamamatsu.com/resources/pdf/etd/PMT_handbook_v3aE.pdf, retrieved
September 5, 2014
[2] Brown, Robert G. W. and Dakin, John P., Handbook of Optoelectronics, Volume
1, Taylor and Francis Group, CRC Press, Boca Raton, 2006, pages 414–416
Q756EXPL
Light is an electromagnetic wave that can be characterized by its speed,
wavelength, phase, and intensity. The human eye is receptive to visible light in
the range of approximately 400 to 700 nanometers (nm).
Perceived color is determined by the wavelength of the light. Monochromatic light

is light of a single color (only one frequency or wavelength). Monochromatic
light is said to be coherent when essentially all of the electromagnetic waves
are in phase with each other.
A laser is a coherent, monochromatic light source that operates by stimulated

emission.
Reference:
[1] Scott, David M., Industrial Process Sensors, Taylor and Francis Group, CRC
Press, Boca Raton, 2007, pages 36-45
Q757EXPL
Lasers are typically constructed of three elements: an active medium, a pumping
source, and a resonant cavity. The active medium is the lasing material that
releases electromagnetic radiation (generally, coherent visible light, although
some materials produce radiation outside the visible light spectrum) when
properly stimulated. The active medium can be in any of the four states of
matter: solid, liquid, gas, or plasma. The wavelengths of the emitted light are
determined by the specific transitions between the energy levels in the lasing
material.
Typical active media used in medical lasers include CO 2 (carbon dioxide), argon,
and Nd:YAG (neodymium-doped yttrium aluminum garnet). The different types of
lasers penetrate tissue to different depths and are absorbed differently by
different colored tissues. As a result, different types of lasers are preferred
for different types of surgeries.
References:
[1] Al-Azzawi, Abdul, Physical Optics Principles and Practices, Taylor and
Francis Group, CRC Press, Boca Raton, 2006, pages 103–172
[2] Laser, Wikipedia, http://en.wikipedia.org/wiki/Laser, retrieved October 24,
2014
[3] Laser surgery, Wikipedia, http://en.wikipedia.org/wiki/Laser_surgery,
Q759EXPL
In a laser, photons are amplified, leading to the use of the acronym laser for
the descriptive title “Light Amplification by Stimulated Emission of Radiation.”
The optical amplification occurs when photons bounce back and forth within an
optical cavity (optical resonator). Energy is added to the active material by
“pumping” it with energy from electricity, light, or a chemical reaction.
Photons make repeated passes through the active material so that the intensity of
the optical field builds up. One end of the resonator has an optical mirror that
is perfectly reflective, while the other end is partially reflective. The
partially reflecting mirror allows a constant fraction of laser beam to escape.
Eventually a steady state will be achieved in which the optical gain is balanced
by the losses from the mirror, causing the release of intense, monochromatic
light.
References:
[1] Sands, D., Diode Lasers, Taylor & Francis Group, CRC Press, Boca Raton, 2004,
chapter 3
[2] Ulaby, F., Michielssen, E., and Ravaioli, U., Fundamentals of Applied
Electromagnetics, 6th edition, Pearson—Pentice Hall, Upper Saddle River, 2010,
page 365
[3] Laser, Wikipedia, http://en.wikipedia.org/wiki/Laser, retrieved October 24,
2014
Q760EXPL
A vacuum tube consists of a negative cathode and a positive anode. A
photomultiplier consists of a photocathode that emits electrons when struck by
light (photons), and a positively charged anode. In between the cathode and
anode, there are multiple amplifying stages called dynodes.
When electrons are released by the photocathode, they accelerate towards the
first dynode, releasing several electrons for each electron that hits the dynode.
This amplification process is repeated at each dynode stage, so that the overall
output current is proportional to the intensity of the light entering the
photomultiplier tube (PMT), and is multiplied many times compared to the original
current flowing from the photocathode. The typical gain of a PMT is on the order
of 100,000 (105), but may go as high as 10,000,000 (107).
Reference:
[1] Photomultiplier Tubes: Basics and Applications, Third Edition (Edition 3a),
Hamamatsu Photonics Corporation, 2007, pages 13-19, 47, available at
October 27, 2014
Q761EXPL
Photomultiplier tubes are sensitive to external magnetic fields found in the
environment. For this reason, a photomultiplier tube will have a magnetic shield
to help protect the tube against magnetic fields. However, if the field is strong
enough, the shielding may not be effective, causing a variation in the tube’s
operation. Also, it is possible that the magnetic shielding could be damaged or
deformed, causing it to be less effective. This would only be evident in the
presence of an interfering magnetic field. If the spectrophotometer had been
working correctly earlier, it would be appropriate to check for the presence of a
new device that could produce a significant magnetic field in the immediate
vicinity of the spectrophotometer. Examples of those types of devices include a
new refrigerator or box fan, which have motors that can produce a magnetic field
that can affect the tube’s operation.
If the photomultiplier tube had degraded, the problem would have been present
when you tested the spectrophotometer in your shop. While it is possible that
your testing was not done correctly, this seems unlikely if you followed the
guidelines specified by the manufacturer.
If the sample door did not seal properly, this also would have been apparent when
you tested the spectrophotometer.
If the line voltage being supplied to the lab was not within specifications, it
is very likely that other equipment in the lab would not be operating properly.
Therefore, it seems most appropriate to check the operating environment to see if

any new devices were recently placed near the spectrophotometer.
Reference:
Hamamatsu Photonics Corporation, 2007, pages 26, 120-121, available at
October 27, 2014
Q762EXPL
A photomultiplier tube (PMT) converts light intensity into an electric current.
It cannot distinguish between light at different wavelengths or frequencies. It
can only detect intensity.
Reference:
Hamamatsu Photonics Corporation, 2007, pages 13-19, available at
October 27, 2014
Q781EXPL
As the electron beam hits the phosphor on the CRT screen, the phosphor
illuminates, creating light that is visible to the observer. This is called
phosphorescence. Once the electron beam moves to a different spot on the CRT, the
phosphorescence starts to decay. Depending upon the characteristics of the
phosphor, this decay can happen as quickly as a few microseconds, up to a few
seconds. This continued illumination is known as persistence.
The refresh rate is the number of times per second that the CRT screen is
redrawn.
The blanking period is the time when the CRT’s electron beam is turned off. For a
raster scan, where the screen is redrawn from top to bottom several times per
second, the blanking period allows the beam to transition from the point where
one frame of the CRT image is completed (generally at the lower right of the
screen), up to the point where the next frame begins (generally at the upper left
of the screen), without illuminating any portion of the screen during the
transition.
The raster rate is not a term used in conjunction with CRTs.
Reference:
[1] Cathode Ray Tube, Wikipedia, http://en.wikipedia.org/wiki/Cathode_ray_tube,
[2] Persistence, The Free Dictionary website,
http://encyclopedia2.thefreedictionary.com/persistence, retrieved October 28,
2014
[3] How Computer Monitors Work: CRT Monitors, How Stuff Works website,
http://computer.howstuffworks.com/monitor7.htm, retrieved October 28, 2014
Q782EXPL
Pitting of an x-ray tube anode is generally caused by excessive heat that is not
properly dissipated. In most x-ray tubes, the anode rotates so that the electron
beam hits different spots on the anode, preventing heat from building up in any
one spot. If the anode is spinning too slowly, or the mA setting for the cathode
current is too high, or the kV setting for the voltage difference between the
cathode and the anode is too high, excess heat can build up in spots, causing
pitting.
A loss of vacuum would result in a burned-out cathode.
If the anode were rotating too quickly, this would help counteract any potential
heat buildup, so this would not cause pitting.
Since the anode is sealed inside a vacuum tube, it cannot be cleaned (or
touched). Therefore, it is not subject to damage by cleaning agents.
Reference:
[1] Sprawls, Perry, X-Ray Tube Heating and Cooling, Sprawls Educational
Foundation website, http://www.sprawls.org/ppmi2/XRAYHEAT/, retrieved October 29,
2014
Q783EXPL
In an x-ray tube, the heated cathode produces electrons by thermionic emission.
The high voltage between the anode and cathode accelerates the electrons towards
the anode. When the high energy electrons strike the anode, x-rays are produced.
The constant stream of electrons colliding with the anode tends to heat the
anode. Because that heat can damage the anode, measures must be taken to
dissipate the heat. The most common approach in modern x-ray tubes is to use a
rotating anode, so that the heat generated is dissipated over a much wider area.
The glass wall of the tube is specially constructed to allow for electromagnetic
induction, allowing the anode to spin without any moving parts protruding through
the tube.
The anode is enclosed by a vacuum tube, so direct coupling is impossible.
The other options indicated, utilizing thermal currents or the force of electron
collisions, are not used in modern x-ray tubes.
Reference:
[1] Sprawls, Perry, X-Ray Tube Heating and Cooling, Sprawls Educational
Foundation website, http://www.sprawls.org/ppmi2/XRAYHEAT/, retrieved October 29,
2014
Q787EXPL
If the secondary voltage remains constant and the secondary resistance (load)
increases, then by Ohm's law, the secondary current must decrease, since I = V /
R. If the secondary current decreases, the primary current will also decrease in
line with the turns ratio of the transformer.
Reference:
Q802EXPL
All of the items listed are likely pulse oximetry alarms except >100% for a high
SpO2 alarm, because it is impossible for a patient to have an SpO 2 greater than
100%.
SpO2 measurements can appear to change even when the patient’s actual oxygen
saturation levels remain constant. For example, movement can fool the sensor into
reporting an erroneous low reading, generating a low SpO 2 alarm that is often a
nuisance alarm.
A pulse oximeter uses a probe placed on the tip of a finger (typically) that
transmits two wavelengths of light (visible and infrared) through the fingertip.
The relative transmission of light at different wavelengths is measured to help
determine the oxygen saturation level of the blood in the finger. (Other types of
sensors are also available, such as for the foot or ear, but the finger sensor is
the most common.)
A bad sensor, or bad sensor connection, is a possible cause for the inability to
obtain a signal, causing an alarm condition. The sensor on an oximeter is often
subjected to substantial abuse, and breakage of the sensor's connector is a
common problem. Another common problem with pulse oximeters are battery problems
generating alarms as they discharge, although these kinds of alarms are not
necessarily nuisance alarms.
References:
[1] 2015 Hospital National Patient Safety Goals, The Joint Commission,
http://www.jointcommission.org/assets/1/6/2015_NPSG_HAP.pdf, retrieved May 30,
2015
[2] Welch, James, An Evidence-Based Approach to Reduce Nuisance Alarms and Alarm
Fatigue, Horizons, AAMI, Spring 2011, http://www.visimobile.com/wp-
content/uploads/2013/02/Horizons_Alarms-Article_Welch_Spring-2011.pdf, retrieved
October 31, 2014
Q805EXPL
Differences between a non-invasive blood pressure (NIBP) monitor and other
methods of taking blood pressure measurements are not unusual. To some extent,
the values recorded by a nurse taking a stethoscope-based (auscultatory)
measurement will vary depending on the skill and experience of the person taking
the measurement. For properly trained individuals, the ausculatory readings often
are reasonably repeatable by that individual, but different nurses may get
different readings, depending upon their ability to hear and interpret the
Korotkoff sounds associated with blood pressure measurement.
Variations can also be caused by the patient’s anatomy/physiology. For example, a

patient may show a different blood pressure when the left and right arms are
compared.
Leaky tubing is also a very common problem with NIBP measurement.
Reference:
[1] Noninvasive Blood Pressure Measurement, AACN Application Note,
http://www.aacn.org/wd/practice/docs/practicealerts/non-invasive-bp-
monitoring.pdf, retrieved October 31, 2014
[2] About Non-Invasive Blood Pressure: Application Note, Philips Healthcare,
http://www.healthcare.philips.com/pwc_hc/main/shared/Assets/Documents/Resuscitati
on/heartstart/About-Non-Invasive-Blood-Pressure.pdf, retrieved October 31, 2014
Q806EXPL
Occlusion alarms are caused when tubing is partially or completely blocked so
that fluid cannot flow. As a result, pressure builds up, and is sensed by the
infusion pump. When the pressure reaches a certain value, an occlusion alarm
occurs.
By definition, downstream means between the pump and the patient. A kink in the
tubing between the fluid bag and the patient could generate an upstream occlusion
alarm, but not a downstream occlusion alarm. An empty IV fluid bag would probably
generate an empty bag alarm, but would not generate a downstream occlusion alarm.
Reference:
[1] Monitoring and detection of IV line occlusions, Carefusion,
http://www.carefusion.com/pdf/Infusion/clinical_documentation/white_papers/IF2282
-Alaris_SE_Pump_Monitoring_IV_whitepaper.pdf
Q808EXPL
Heated ventilator circuits are used for all of the reasons listed.
If a patient's lungs are exposed to dry air, they may be damaged, so moisture is
added to the air that the ventilator is sending into the patient. But if that
moisture gets into the ventilator’s transducers, condensation can cause
"rainout." This can result in a wet ventilator transducer, which may cause the
transducer to fail.
Excessive moisture can create an environment that contributes to the growth of
microbes that may cause ventilator-associated pneumonias.
By heating and humidifying the air, the patient's lungs are protected. And by
heating the air, it is much less likely that moisture will condense on the
transducers, or that there will be a location in the ventilator circuit where
water can pool, creating a favorable environment for the growth of microbes.
Therefore, all of the above is the correct answer.
References:
[1] Humidification during invasive and noninvasive mechanical ventilation: 2012,
National Guideline Clearinghouse, Agency for Healthcare Research and Quality,
http://www.guideline.gov/content.aspx?id=36911, retrieved October 31, 2014
[2] Rain-Out: Condensation in oxygen tubing; causes and solutions, Caire Medical
website, http://www.cairemedical.com/getattachment/351587f7-8146-4de7-a73d-
33a1bd3c351a/.aspx, retrieved October 31, 2014
[3] Heated Wires Can Melt Disposable Breathing Circuits, ECRI Institute,
http://www.mdsr.ecri.org/summary/detail.aspx?doc_id=8086, retrieved October 31,
2014
Q812EXPL
A general-purpose syringe pump is used for delivering a small amount of medicine
contained in various sizes of syringes directly into a vein. Syringe pumps are
not controlled by the patient, except in the case of a small subset of specialty
syringe pumps known as Patient-Controlled Analgesia (PCA) pumps.
A large volume pump (LVP) delivers large volumes of fluids and medicines into the
vein and is not controlled by the patient.
An epidural pump is a pump that has been configured for epidural delivery. It is
designed to deliver a small amount of medicine into the epidural space near the
bottom of the spine. It is not patient-controlled.
A PCA pump is used to deliver very powerful and addictive pain medications (such
as morphine) upon patient demand. Most modern PCA pumps use a syringe locked
behind a door on the pump to hold the medication and prevent tampering. PCA pumps
generally offer the advantage of greater pain control at a lower dose of
medication.
An intrathecal pump delivers a small amount of medicine directly into the spine.
References:
[1] Epidurals for Pain Relief After Surgery, Patient website,
http://www.patient.co.uk/health/epidurals-for-pain-relief-after-surgery,
[2] Wladis, Claire, Introduction to IVs,
http://www.cwladis.com/math104/lecture6.php, retrieved October 16, 2014
[3] Intrathecal drug pump, Mayfield Clinic website,
http://www.mayfieldclinic.com/PE-PUMP.htm#.VEACYPPD_cs, retrieved October 16,
2014
Q814EXPL
Fetal monitors detect fetal heart rate (FHR) using an ultrasound transducer. A
potential issue is the presentation of the maternal heart rate (MHR) as the FHR
rate because of incorrect positioning of the ultrasound transducer. This can
happen if the fetal heart is located in an unexpected position.
In this case, the reported FHR is close to what is expected of the MHR. Since the
heart rate is within a reasonable range, it is not likely to be a defective
ultrasound transducer, so there is no reason to switch out the ultrasound
transducer.
The best course of action is to obtain the MHR using an external device, such as
an oximeter, and confirm that the mother's heart rate is substantially different
from the FHR being displayed on the fetal monitor. If the MHR determined using
the external device is within a few beats of the reported FHR, the clinician
should suspect that the fetal monitor is picking up the mother's heart beat,
rather than the intended fetal heart beat.
It would not help to reposition the toco transducer because it measures uterine
contractions and not FHR. It would not help to reposition the mother’s ECG
electrodes because normally the ECG is not measured on a woman in labor. Even if
it were, the fetal ECG cannot be recorded using ECG electrodes placed on the
mother's skin.
References:
[1] Core Medical Equipment, World Health Organization, 2012,
http://whqlibdoc.who.int/hq/2011/WHO_HSS_EHT_DIM_11.03_eng.pdf, page 21,
[2] Emereuwaonu, Ikechukwu, Fetal Heart Rate Misrepresented by Maternal Heart
Rate: A Case of Signal Ambiguity, American Journal of Clinical Medicine, Winter
2012, 9(1), 52-57. http://www.aapsus.org/userfiles/files/ajcm12.pdf. retrieved
October 29, 2014
Q815EXPL
A CO2 laser produces an invisible infrared treatment beam that is active when the
laser is fired. Before firing, a visible, low power, aiming beam (also known as a
guide or pilot beam) is produced by the laser to allow the surgeon to properly
direct the laser’s position to the appropriate target in the surgical site. This
aiming beam is not the same beam as the invisible CO 2 beam.
These two beams need to be aligned so that the aiming beam is exactly focused on
the firing beam. If the beams are not aligned, then the treatment beam will not
coincide with the aiming beam, and the CO 2 beam may hit an unintended location,
causing a patient injury.
Most laser issues are related to alignment and cleaning of optics rather than
component failure.
If the laser power is out of calibration, then it would result in either

insufficient or excessive power to the treatment site.
If there is no firing at all, then the power supply may be a problem.

If the grounding is an issue, then that could result in a shock hazard for the
operators, but it would not cause a firing issue.
References:
[3] Absten, Gregory, The Fundamentals of Laser Technology, Biomedical
Instrumentation & Technology, May/June 2002, pages 203-207,
https://www.lasertraining.org/Administrative/Library/AAMILaserFundamentalsArticle
0602.pdf, retrieved October 29, 2014
[4] Goldwasser, Samuel, SS Laser Testing, Adjustment, Repair.
http://www.repairfaq.org/sam/laserstr.htm, retrieved October 29, 2014
Q816EXPL
The quickest way to isolate the problem the user experienced with the pump is to
review the device history file maintained inside the pump. This file contains
alarm and other performance information that may be used to perform a root cause
analysis and find out what happened, why it happened, and what to do to prevent
it from happening again.
Performing a preventive maintenance inspection or a simulated run of the pump may

help to isolate the problem, but it is certainly a slower way of identifying the
problem because there is no information available to help narrow the field of
potential problems.
The computerized maintenance management system (CMMS) may list a history of the
issues that have occurred in the past with this pump, but there is no way of
determining whether the historical data relates to the current complaint without
more information than has been provided so far.
The alarm threshold and sensitivity may need to be adjusted, but this should
never be done without getting clinician input and following the required
procedures in your hospital to get the approvals required to make a change.
Making this kind of change should never be done arbitrarily. The cause of the
alarm needs to be determined before any adjustments are considered.
References:
[1] Clinical Alarms: 2011 Summit, AAMI,
http://www.aami.org/htsi/alarms/pdfs/2011_Alarms_Summit_publication.pdf,
[2] Pain management portfolio: Alaris PCA and EtCO2 modules FAQs, Carefusion,
http://www.carefusion.com/pdf/Infusion/clinical_documentation/faq_tip_sheets/alar
is-pain-management-faqs.pdf, retrieved October 29, 2014
[3] Safety Issues With Patient-Controlled Analgesia (Part 1), Institute for Safe
Medication Practices,
http://www.ismp.org/Newsletters/acutecare/articles/20030710.asp, retrieved
October 29, 2014
[4] Infusion Patients Safely: Priority Issues from the AAMI/FDA Infusion Device
Summit, AAMI,
http://www.aami.org/htsi/infusion/summit/AAMI_FDA_Summit_Report.pdf, retrieved
October 29, 2014
Q817EXPL
Improper electrode application will cause a distorted EEG waveform and can result
in the inability to properly analyze the EEG signal.
A hard drive in need of defragmentation might slow down the system, but it would
not distort the EEG recordings.
Most EEG recordings are done while a patient is awake, although a sleep lab might
do EEG recordings on a patient who is asleep to determine when the patient is
awake or asleep.
A poor network connection would result in the unit being unable to connect to the
network. This would not lead to signal distortion.
A defective UPS would result in the device not being able to be used in the event
of power failure.
Reference:
Q818EXPL
The most likely cause is a leak in either in the hoses, fittings, O-rings, or
manifold, any one of which could prevent the pump from reaching the target
pressure.
A low battery condition would be indicated by a power related alarm or a complete

failure of the tourniquet to operate.
If a valve was stuck either open or closed, then the possible symptoms might
include the cuff not inflating or deflating, or a valve failure alarm might be
generated. Most tourniquets have several valves, and the symptoms would depend on
which valve was not operating properly.
If a unit is out of calibration that would not cause a pump to continuously run,
but instead it would probably inflate to a wrong pressure.
If the inflation switch was stuck, the pump would not continuously inflate, but
would stop inflating once the pump pressure set point had been reached.
Reference:
[1] Operator & Service Manual A.T.S. 2000 Tourniquet System,
http://www.frankshospitalworkshop.com/equipment/documents/various_equipment/servi
ce_manuals/various/Zimmer%20ATS-2000%20Tourniquet%20System%20-
%20Service%20manual.pdf, retrieved May 24, 2015
Q819EXPL
Poor skin contact can cause poor temperature control.
A broken temperature probe would result in the failure to detect any temperature.
For most warmers, this would generate an alarm condition.
Since most warmers are not connected to the hospital’s computer network, it is
extremely unlikely that a virus could have infected the warmer’s software.
Heater elements do not typically degrade. They either operate or do not operate.
The clinician would be the best person to diagnose a patient problem and should
recognize additional symptoms indicating a distressed patient. An infant warmer
is not a diagnostic device used for assessing the health of a patient; instead,
it is a therapeutic device providing a medical intervention needed by the
patient.
References:
[1] Infant Radiant Warmers Can Burn: Use with Care, ECRI Institute,
http://www.mdsr.ecri.org/summary/detail.aspx?doc_id=8263, retrieved October 29,
2014
Q821EXPL
Hypothermia is the name given to the condition that occurs when the body’s core
temperature is too low. A normal body temperature is considered to be about 37o C.
Hypothermia is generally considered to occur when the temperature drops below 35 o
C, although some define the start of hypothermia as a temperature below 36 o C.
Hyperthermia is the opposite condition, when the body’s core temperature is above
the normal range. This is generally considered to be any temperature above 37.5 o
C.
Homeostasis is the property of keeping internal conditions in the body relatively

constant. For example, when it comes to core body temperature, the body’s
regulatory mechanisms try to maintain temperature within a relatively narrow
range of about 36.5o C to 37.5o C
References:
[1] Wolfe, Glen L., Troubleshooting Hypo/Hyperthermia Units, Biomedical
Instrumentation & Technology, September 2008, Volume 42, Number 5, pages 369-370
[2] Hypothermia, Wikipedia, http://en.wikipedia.org/wiki/Hypothermia, retrieved
November 3, 2014
[3] Hyperthermia, Wikipedia, http://en.wikipedia.org/wiki/Hyperthermia, retrieved
November 3, 2014
[4] Homeostasis, Wikipedia, http://en.wikipedia.org/wiki/Homeostasis, retrieved
November 3, 2014
Q825EXPL
Hypothermia occurs when the body’s temperature is too low, hyperthermia occurs
when the body’s temperature is too high. A clinician will try to restore the
patient’s body temperature to a normal level using either a heating (to treat
hypothermia) or cooling (to treat hyperthermia) device.
Most body warming devices use a forced-air or water-circulation method. Forced-

air systems work by blowing warm air through a blanket perforated with thousands
of tiny holes.
Homeostasis is the property of a system in which variables are regulated so that

internal conditions remain stable and relatively constant. Examples of
homeostasis include the regulation of temperature and the balance between acidity
and alkalinity (pH). It is a process that maintains the stability of the human
body's internal environment in response to changes in external conditions, so
that, for example, the body's temperature or blood pH level stay at fairly
constant values. A patient that is in homeostasis would not need to be either
warmed or cooled.
References:
[2] Hypothermia, Wikipedia, http://en.wikipedia.org/wiki/Hypothermia, retrieved
November 3, 2014
[3] Hyperthermia, Wikipedia, http://en.wikipedia.org/wiki/Hyperthermia, retrieved
November 3, 2014
[4] Homeostasis, Wikipedia, http://en.wikipedia.org/wiki/Homeostasis, retrieved
March 10, 2015
Q826EXPL
Most body warming devices use a forced air or water circulation method. Forced
air systems work by forcing heated air through a blanket with thousands of tiny
holes. This blanket is either placed over or under the patient to be warmed.
If the high temperature alarm has been triggered, then the device has determined
that the temperature of the air at the end of the hose going into the blanket is
higher than is safe.
A faulty fan motor, clogged air filter, or missing fan blades would all decrease
the air flow, but would not affect the setting of the unit’s primary thermostat,
which determines the delivered temperature. Therefore, none of these problems
would account for a high temperature alarm being triggered.
If the high temperature thermostat was improperly adjusted, or was defective,

then it might detect a normal temperature as being too high, and so generate an
alarm. Therefore, this is a possible cause of the problem described.
References:
[1] 3M Bair Hugger Model 505 Warming Unit Service Manual, 3M Company,
http://multimedia.3m.com/mws/media/798399O/service-manual-
english.pdf?&fn=200597.pdf, pages 14, 21, retrieved November 6, 2014
Q827EXPL
Most body warming devices use a forced air or water circulation method. Forced
air systems work by forcing heated air through a blanket with thousands of tiny
holes. This blanket is either placed over or under the patient to be warmed.
A faulty fan motor, clogged air filter, or missing fan blades would all decrease
the air flow, which could result in the patient not being warmed as quickly as
the clinician expects.
References:
[1] 3M Bair Hugger Model 505 Warming Unit Service Manual, 3M Company,
http://multimedia.3m.com/mws/media/798399O/service-manual-
english.pdf?&fn=200597.pdf, pages 14, 21, retrieved November 6, 2014 [2] Wolfe,
Glen L., Troubleshooting Hypo/Hyperthermia Units, Biomedical Instrumentation &
Technology, September 2008, Volume 42, Number 5, pages 369-370
Q830EXPL
Infant warmers are used to provide an unobstructed work environment for the care
of critically ill infants and newborns, while keeping them warm. The infant
warmer uses a heating element that produces invisible infrared (IR) light with a
wavelength greater than 3 microns (3 × 10 -6 m) to heat the infant without causing
damage to the infant’s eyes. This light shines down on the infant from above.
The primary system used to control the warmer is a proportionally controlled

servo system consisting of a thermistor probe applied to the infant's abdomen or
other exposed body area to detect the infant's temperature and then provide
feedback to an electronic control system that adjusts the level of IR radiation
either by cycling the heating element on and off or by changing its power level
in order to maintain the appropriate body temperature. An alternate control
system uses a timer to turn on the heating element for a specified time. This
second system is generally used only on a short-term basis because of the hazard
it presents that an infant’s temperature might not be properly controlled because
of the lack of feedback.
The IR heating element, the servo controls, a reflector that maximizes downward
radiation, and often a work light with slots to vent heat are contained in the
canopy above the work surface. Most permanently attached infant warmers have a
flat working surface with three fold-down panels to keep the patient from falling
off the working surface.
Reference:
[1] Dondelinger, Robert M., Infant Warmers, Biomedical Instrumentation &
Technology, November/December 2010, Volume 44, Number 6, pages 485-487
Q831EXPL
The technology associated with the infant warmer is relatively simple, and
maintenance is straightforward. The main diagnostic instrument is an electronic
thermometer to check that the temperature produced by the warmer corresponds to
the temperature settings.
A very common problem associated with infant warmers is caused by blocking the
vents in the canopy by placing objects on top of the canopy. The IR heating
element, servo controls, a reflector that maximizes downward radiation, and often
a work light with slots to vent heat are contained in the canopy above the work
surface. Blocking the vents can cause the canopy temperature to rise and
sometimes there will be enough heat to melt some of the warmer’s plastic parts.
Blocking the vents can also reduce the life of the infrared heating element.
Reference:
[1] Dondelinger, Robert M., Infant Warmers, Biomedical Instrumentation &
Technology, November/December 2010, Volume 44, Number 6, pages 485-487
Q833EXPL
Half of the blood’s volume consists of plasma, which is a fluid that contains
water with dissolved salts and proteins such as albumin, antibodies, and clotting
proteins. There are also a number of hormones, electrolytes, sugars, fats,
minerals, and vitamins included in plasma. The remaining blood volume consists of
the cellular components, which are, in order of volume:
Red blood cells (RBC- erythrocytes)
White blood cells (WBC - granulocytes, lymphocytes, and monocytes)
Platelets (thrombocytes)
Hematology analysis is used to determine the types and numbers of cells (RBC,
WBC, and platelets) that make up the patient’s blood. This analysis can be
performed manually, or by semi-automated, or fully automated equipment. Fully
automated systems count the cellular components, perform some mathematics, and
present the results for interpretation.
Fully automated hematology analyzers utilize either the volumetric impedance

method or the less common light scattering method to determine cell types and
volumes. Each takes advantage of the fact that cellular components of blood have
different sizes. These differences in cell size produce different conductivities
(for the volumetric impedance method) or disperse light at different intensities
(for the light scattering method) as they pass through an aperture.
The electronics of each system closely monitor the performance of the analyzer to
assure it remains operational and that measurements stay within specification.
A common technical problem with both automatic methods concerns the sample feed
circuit, which can experience minute vacuum leaks in the maze of plastic tubing
used to deliver blood samples to the measurement aperture. This tubing should be
replaced by either the laboratory technician or the BMET on a routine basis as
part of scheduled maintenance. Light-scattering analyzers can suffer from
misalignment of the laser or light beam, debris in the sample stream, and
electronic noise. These problems are normally corrected by the lab technician as
part of routine daily performance checks conducted by the user.
Reference:
[1] Dondelinger, Robert M., Hematology Analyzers, Biomedical Instrumentation &
Technology, July 2009, Volume 43, Number 4, pages 300-304
Q835EXPL
Ultrasound is used to measure the speed of blood. Sound is reflected by the red
blood cells, and a Doppler shift takes place that changes the frequency of the
returned ultrasound beam because the red blood cells are moving. Thus, the blood
speed can be determined by the frequency shift. This principle is generally used
by Doppler ultrasound pulse detectors to detect the changes in the speed of blood
flow during different parts of the cardiac cycle, and then translate those
changes into a pulse rate.
References:
[1] Tuszunski, J.A. and Dixon, J.M. Dixon, Biomedical Applications of
Introductory Physics, John Wiley & Sons, Hoboken, 2002, pages 198-199
[2] Deane, Colin, Doppler ultrasound: principles and practice, Sonoworld website,
http://www.sonoworld.com/Client/Fetus/html/doppler/capitulos-html/chapter_01.htm,
Q836EXPL
The fundamental principle of diagnostic ultrasound is relatively simple. A high
frequency sound wave ranging from 2 MHz to 50 MHz is transmitted through the body
using an ultrasonic (piezoelectric) probe. Every time the sound wave encounters a
discontinuity (a change in acoustic resistance), part of the wave is reflected
back and part of the wave continues deeper into the body. The time of travel
corresponds to the distance from the probe.
The electronics are divided into two sections, the front end used to control
transmission and reception of the ultrasound signal, and the signal processing
electronics that calculate the distances, amplitudes, and time delays that are
used to provide a display on a video monitor or generate a digital output that
represents the internal structure of the body.
The most problematic part of any ultrasound scanner is the probe. The probe
contains precisely-shaped crystals that are highly susceptible to mechanical
shocks such as being dropped on the floor or falling out of the probe caddy and
hitting a solid object. Such probe mistreatment can degrade the image or
eliminate the image completely. An additional problem associated with the probe
is the numerous wires in the cable that connects the probe to the scanner. This
cable is often bent or pulled on as part of a routine ultrasound examination,
causing wires to break over time. Another problem is the probe connection.
Plugging and unplugging different probes can bend or break the connecting pins.
While the most common electronic problem is the power supply, problems here are
generally detected as part of the scanner’s self-check that is routinely done
when the scanner is turned on. This self-check would also detect problems in the
frequency generator. While it is possible that the display is damaged, this is
not likely. All of these problems are far less common than a problem with the
probe because of the mechanical abuse that probes tend to suffer.
Reference:
[1] Dondelinger, Robert, Diagnostic Ultrasound, Biomedical Instrumentation &
Technology, January 2006, Volume 40, Number. 1, pages 39-44
Q837EXPL
The most common ECG cable and wire problems reported are incorrect electrode
placement, poor connectivity between the electrodes and patients, broken lead
wires, and dry or old electrodes.
Most experienced clinical users can often easily detect most of these problems.
Most often this is simply accomplished by replacing the faulty surface
electrodes, ECG cable, or lead wire with a new one.
Typically, an ECG cable or ECG lead wires are tested with an ohmmeter. If the
ohmmeter shows continuity, by displaying a very low resistance reading, between
the connector end of the cable and the head of the cable for each wire, despite
flexing the cable to check for intermittent breaks in the wire, you can conclude
that the cable is good. Many ohmmeters incorporate a continuity checker feature
that provides an audible indication when connected at each end of an intact cable
or wire.
None of the other types of meters would be used to check whether a cable is good
or not. A wattmeter is used to measure the power in a circuit. A voltmeter
measures the voltage across two points in a circuit. An ammeter measures the
amount of current flowing through an electrical component.
Reference:
[1] Turkmen, Ahmet and Pantiskas, Carl, Management of ECG Cables and Leadwires,
Biomedical Instrumentation & Technology, March/April 2011, Volume 45, Number 2,
pages 130-133
Q838EXPL
Electrocardiogram (ECG) and electroencephalogram (EEG) recordings are made by
placing electrodes at specified locations on the body. Reliable, noise-free
measurements require that the electrodes make good (low-resistance) contact with
the skin. Unfortunately, the skin’s natural electrical resistance is high due to
the presence of dead skin cells, oil and grime. In order to reduce the tissue-
electrode interface resistance, skin preparation may consist of shaving the hair
at the measurement site, cleaning the skin with an alcohol pad or other cleaning
agent, and rubbing the skin as part of the preparation process.
Reference:
pages 130-133
Q858EXPL
Magnetic resonance imaging relies on an accurate mapping of the correlation
between spatial location and the magnetic field produced by the MRI magnet to
correctly reconstruct images. When this mapping becomes distorted, the images
will no longer be accurate.
An MRI uses a very strong magnet to form a static field that aligns the nuclei of
hydrogen atoms (found in water) in the area to be imaged. On top of this, the MRI
applies a smaller oscillating electromagnetic field to excite the aligned
hydrogen atoms. The excited hydrogen atoms emit characteristic radio frequency
signals as they try to realign with the static field. This allows the hydrogen
atoms to be spatially located, allowing the MRI image to be created.
The stronger the magnet producing the static field, the better the signal-to-
noise ratio (SNR), allowing images to be acquired more quickly. For example, a 3T
MRI system has a better SNR than that of a 1.5T system.
The static field must be uniform in the imaged region to allow the accurate
spatial mapping of MRI signal strength to be done. If the static field changes in
any way, then the linear mapping done during calibration will no longer be
accurate, and the reconstructed images appear distorted.
The magnetic field characteristics can be affected by the presence of large

ferromagnetic objects in the vicinity of the magnet. It is important to remember
that the magnet’s vicinity is three-dimensional, meaning that the floors above
and below the magnet also affect the MRI, not just objects on the same floor.
Since construction work usually involves heavy machinery with motors, it seems
logical that construction work in the vicinity of the magnet (right above it –
keeping in mind the three-dimensional definition of vicinity) could indeed cause
a distortion to the static magnetic field that might explain the distorted
images.
Patient positioning should not cause any distortion in an MRI image. The MRI
image obtained should be accurate, as long as there is no patient movement during
the image acquisition period. So, this should not be an issue related to the
distortion seen in this problem.
Problems in the electrical supply to the reconstruction computer may cause

hardware damage to the computer, but this is extremely unlikely to cause a
miscalculation or failure in the reconstruction software. So, this is not a
reasonable cause for the problem.
References: [1] Bushong, Stuart, Magnetic Resonance Imaging: Physical and

Biological Principles, 3rd Edition, Mosby, 2003, chapter 13
[2] VA design Guide: Magnetic Resonance Imaging, Department of Veterans Affairs,
2008, pages 2-14, 2-15, https://www.wbdg.org/ccb/VA/VADEGUID/mri.pdf, retrieved
November 10, 2014
Q860EXPL
The use of bicarbonate-containing dialysate causes chemical deposits such as
calcium and magnesium carbonate to accumulate in the dialysate circuit. Such
deposits can interfere with conductivity-based monitoring of dialysate
composition and therefore, hemodialysis machines must be cleaned regularly to
prevent the buildup of chemical deposits in the dialysate circuit. This is done
through a simple cleaning cycle with acetic or citric acid when no patient is
connected to the machine. This is an effective way to remove such deposits.
Therefore, the difference seen between the calibrated conductivity monitor and
the machine’s own is probably because of the presence of chemical deposits on the
machine’s conductivity sensor contacts after a long period of operation without
cleaning.
As a standard safety precaution, a hemodialysis machine has at least two internal

conductivity cells to provide redundancy for this very important conductivity
measurement. The dialysis machine's control circuitry will constantly compare the
readings of the two conductivity cells to detect a possible failure, so that the
operator can immediately take appropriate actions to provide for patient safety
if a failure is suspected. Since the hemodialysis machine has not detected a
failure of either conductivity cell, it is very unlikely that this is the source
of the reported problem.
The presence of water quality issues may cause the conductivity measurements made
by both the machine's internal sensors and the portable calibrated meter to be
incorrect, but both would register the same reading, assuming that the machine's
internal conductivity cells were correctly calibrated. So a water quality issue
would not explain the difference between the two measurements.
Reference:
[1] Nissenson, Allen R. and Fine, Richard, Handbook of Dialysis Therapy, 4th
Edition, Saunders, 2007, pages 166, 197
Q862EXPL
Infant radiant warmers are electrically-powered devices that use an infrared
radiant heat source to maintain an infant's body temperature at a desired level.
In the baby-controlled mode of operation, the amount of radiated energy is
controlled by measuring the infant's skin temperature, and using this to provide
feedback to the control circuitry. The control circuit then modulates the power
to the heating element.
On the other hand, the manual mode does not utilize feedback. This mode allows
the radiated energy output to be set manually by the user. The pre-warm mode
keeps the warmer heated, so that it is ready to receive an infant without having
to expose the infant to an initial period of cold after the warmer is first
turned on.
When the skin temperature sensor is faulty, the baby-controlled mode does not
have the correct temperature feedback required for proper operation. Therefore, a
faulty skin temperature sensor would indeed cause problems in the operation of
this particular mode, while not having any effect on the manual or pre-warm
modes.
Given that the warmer appears to work properly in the manual and pre-warm modes,
there should be no problems with heating element.
The infant warmer works by using radiant heat. It does not have a fan, so there
is no air filter. It also does not have a chamber. The infant is kept on an open
platform which allows the clinicians to have unobstructed access to treat a
critically ill infant. Since there is no chamber, there is no chamber sensor.
Reference:
[1] IW900 Infant Warmer Technical Manual, Fisher & Paykel Healthcare, IW900
Infant Warmer Technical Manual, 2006, pages 33-34,
http://www.frankshospitalworkshop.com/equipment/documents/infant_incubators/servi
ce_manuals/Fisher&Paykel_IW900_Infant_Warmer_-_Technical_manual.pdf
[2] Medical Electrical Equipment — Part 2-21: Particular requirements for the
basic safety and essential performance of infant radiant warmers, ANSI/AAMI/IEC
60601-2-21:2009, AAMI, Subclause 201.3 Terms and Definitions, pp. 33-35
Q864EXPL
EEG recording is extremely sensitive to interference because of the very low
signal levels that are being measured. Here, the EEG system appears to work well
for all channels except one. This narrows the search down to the components in
the path of this channel. It also rules out the influence of global interference
sources because they would affect all channels, not just one. Therefore, noise
from the power supply is unlikely to be the source of this problem.
Since the calibration signal input to the EEG system works well, then the signal
conditioning path inside the EEG system is working properly. In other words, this
rules out the presence of a malfunction in the differential amplifier circuit for
this channel.
Also, given that the same electrode for this channel produced a good trace when
connected to a different electrode lead for a different channel, this means that
it has a proper connection to the patient’s scalp and therefore, this cannot be
the cause of the problem.
Between the working electrode and the working signal conditioning signal path,
the two components that are left as possible problems are the EEG cable and the
electrode lead that connects to the electrode. Since the leads tend to be flexed
quite often, they do break after a while, which would explain the artifact seen
on the one channel. Any loss of connection or faulty shielding will cause the EEG
signal in this lead to pick up interference from surrounding sources much more
than the other good leads and therefore this is the likely cause for this
problem.
Reference:
[1] Electroencephalograph EEG-9100/9200 Service Manual, Nihon-Kohden, pages 3.3-
3.6,
ce_manuals/eeg/Nihon_Kohden_EEG-9100-9200_-_Service_manual.pdf, retrieved
November 12, 2014
Q865EXPL
A holmium surgical laser system has two laser sources: a low power visible laser
for the aiming beam and another high power source for the surgical laser beam.
Because the holmium laser produces a beam in the infrared range, it cannot be
seen, so a visible aiming beam is used by the surgeon to aim the laser at the
appropriate surgical target. A holmium laser, like a Nd:YAG laser, sends its
laser beam through an optical fiber.
The output from both sources is directed into the optical fiber delivery system
by mirrors. In between the mirrors and the optical fiber, the debris shield
protects the internal optical components of the laser from damage by a faulty or
misused delivery device. A problem with either the delivery fiber optics or the
debris shield would cause the symptoms described in this problem, since they
affect both the aiming and surgical beams very much the same way.
If the laser overheated, either because of continuous use over too long a period,
or because there was inadequate cooling of the laser, due to restricted air flow
or to use in a room with too high a temperature, an overheating alarm would be
generated, but this would not affect the intensity of the laser beams.
Reference:
[1] VersaPulse PowerSuite Holmium and Dual Wavelength Surgical Lasers Operator
Manual, Revision E, Lumenis, 2004, pages 68-69,
http://www.bostonscientific.com/templatedata/imports/collateral/Urology/dfu_holmi
um_01_ur_us.pdf, retrieved November 12, 2014
Q866EXPL
Fetal monitors use continuous wave Doppler ultrasound to detect the fetal heart
rate (FHR) externally by detecting the movement of the fetal heart. The frequency
(or Doppler) shift of the reflected signal is proportional to the velocity of the
reflecting structure, which will indicate the rate at which the fetal heart
beats. The output of fetal Doppler systems usually includes an audio output of
the detected Doppler shift to enable the clinicians to monitor the fetal heart
rate without looking at the monitor’s display. The FHR is also shown on the
monitor’s digital display, as well as continuously recorded on a paper strip that
becomes part of the permanent medical record.
As with any audio device, when there is a problem in the audio circuit (faulty
amplifier, bad connection in signal path, etc.), the audio output will disappear.
Therefore, this is a possible cause for the present problem.
Since the FHR appears to be correctly reported on the digital display and the
strip, the electronics responsible for the transmission, reception, and
processing of the ultrasound signal should all be working properly. The
ultrasound transducer should also be working properly because a damaged probe
will not allow the FHR to be detected correctly. The toco transducer detects the
intensity of maternal uterine contractions, which is a different parameter than
the FHR. Also, it does not produce an audio signal. Therefore, these are not
possible causes of the reported problem.
Reference:
[1] PFM1 Fetal Monitor Operating Manual, Ultrasound Technologies, page 12,
http://www.frankshospitalworkshop.com/equipment/documents/ultrasonographs/user_ma
nuals/Ultrasound%20Technologies%20PFM1%20Fetal%20Monitor%20-%20User%20manual.pdf,
Q867EXPL
A hypothermia/hyperthermia unit provides a means of regulating patient
temperature by supplying temperature-controlled water through a connector hose to
a water blanket that then helps to heat or cool the patient. A patient probe
senses the patient’s temperature, and the unit then adjusts the cooling or
heating of the water as required to regulate the patient temperature.
The hypothermia/hyperthermia machine does not control the temperature in the

room. That is the function of the room’s thermostat. It also does not control a
water bath. While the unit does have a reservoir that contains water that is
heated or cooled, that tank is not considered a water bath, which is a piece of
equipment typically found in a clinical lab. A water bath would be an open
container of heated water that typically is used to maintain clinical laboratory
samples at a desired temperature.
Local application of heating via ultrasonic probes is generally used to provide

localized heating, typically for a physiotherapy treatment. This local treatment,
however, is not used to to control the body temperature of a patient. Moreover,
such ultrasound applicators can only be used to provide heating, and not cooling.
References:
[1] Hico-Variotherm 550 Hypothermia/Hyperthermia Unit Operating Instructions,
Hirtz & Co., 2009, page 10, http://www.hico.de/files/bda_vt_550__5-
0909_en_ng.pdf, retrieved November 12, 2014
[2] MTA6900 Medi-Therm III Hyper/Hypothermia Machine Operator’s Manual, Gaymar
Industries, 2000, page 2, http://www.meql.com/Manuals/Gaymar-Meditherm-MTA-6900-
Operators-Manual.pdf, retrieved November 12, 2014
Q868EXPL
during uterine contractions are an important indicator of potential problems such
as fetal hypoxia. Fetal monitors record contraction events and strength, and
monitor the fetus’s heart rate during contractions to determine fetal response to
the stress of labor.
The measurements of contraction intensity and frequency during labor can help
assess the progression of labor, the effect of medications including those that
induce labor, and detect abnormal contraction efforts. Patterns of heart rate
variability, called accelerations and decelerations, seen before, during and
after contractions, are monitored and analyzed to determine if medical
interventions are required.
Fetal monitors can be used to measure the following:

- fetal ECG, using a scalp electrode affixed to the fetus’s scalp, while the
fetus is still in the womb
- maternal ECG, using externally applied ECG electrodes
- fetal heart rate, using an ultrasound transducer or a scalp electrode
- contraction strength and timing, using an external toco transducer or an
internal intrauterine pressure catheter connected to a pressure transducer
The toco transducer measures the frequency and duration of uterine contractions
through the use of a pressure-sensing transducer placed on the patient’s fundus,
the top portion of the uterus. The transducer is held in place by an belt that
encircles the patient’s abdomen. The amplitude of the transducer signal depends
on various factors, such as the position of the transducer, the belt tension and
the size of the patient.
A problem related to recording a heart rate, whether maternal or fetal, would not
be influenced by the transducer responsible for recording contractions. If the
fetal scalp electrode is improperly applied, or if the ultrasound transducer is
positioned so it is picking up maternal blood vessel activity rather than
contractions of the fetal heart, then either the maternal heart rate would
replace the fetal rate on the monitor, or there would not be a reliable fetal
heart rate indicated.
In addition, an active fetus would not decrease the strength of the signal
associated with contractions. If anything, it might account for an increase in
the activity recorded by the toco transducer.
If the belt holding the toco transducer was loose or if the belt stretched, this
would reduce the pressure that is holding the toco transducer against the
patient, which in turn could reduce the signal strength, and so account for a
deteriorating signal level.
References:
McGraw-Hill, 2005, Pages 276-279
[2] Electronic Fetal Monitoring Tutorial, Center for Experiential Learning, East
Tennessee State University, http://www.ob-efm.com, EFM Basics, Equipment Used for
EFM/Equipment, page 4, retrieved November 20, 2014
Q869EXPL
The most common technique for manually measuring blood pressure is the
auscultatory technique. This is the technique used by a clinician who wraps a
cuff around the patient’s arm, inflates it and then listens for the Korotkoff
sounds that start when the cuff is deflated to the systolic pressure, and stop
when the cuff reaches the diastolic pressure.
For automated blood pressure measurements, the oscillometric technique is more

commonly used due to its noise immunity and the fact that cuff placement is not
as critical.
The difference between the auscultatory and oscillometric methods is that while
the auscultatory method relies on listening for sounds, the oscillometric
technique looks for small changes in the pressure in the cuff/tubing system
caused by turbulent blood flow in the brachial artery as the cuff is deflated
between the systolic and diastolic pressures. These oscillations start out small
when the cuff reaches the patient’s systolic pressure. As the cuff pressure
continues to decrease, the oscillation pressure increases, reaching maximum
amplitude when the mean arterial pressure is reached. As the cuff continues to
deflate, the oscillations decrease. The diastolic value does not have a distinct
event associated with this value. The most common computer algorithms used by
NIBP manufacturers identify this event as a sudden decrease in the slope of the
pressure oscillation envelope.
The NIBP operating cycle is as follows:

- After the cuff is inflated to a value above the patient's systolic pressure,
the cuff is slowly deflated.
- Oscillations in the cuff pressure start to occur when the cuff pressure falls
below the systolic pressure. These oscillations are due to vibrations in the
walls of the artery caused by turbulent flow.
- The first occurrence of pressure oscillations signifies the systolic pressure
value. As the cuff pressure continues to decrease, the oscillations of the artery
walls cause ever-increasing pressure oscillation amplitude.
- The oscillation pressure will be at maximum amplitude when the cuff pressure
equals the mean arterial blood pressure.
- As the cuff pressure continues to decrease, the oscillations also decrease.
To determine blood pressure, an oscillometric NIBP unit uses a "lookup table"

stored in its memory, along with appropriate algorithms that compare the
oscillations seen at various cuff pressures against comparison testing done
during validation of the unit against known blood pressures. As the NIBP device
utilizes empirical data to prove accuracy, each individual manufacturer utilizes
their proprietary algorithm for identification of systolic and diastolic events.
The ANSI/AAMI SP 10 standard for Manual, electronic or automated

sphygmomanometers, section 4.4.5.1.1.B specifies the required accuracy of NIBPs
as "the mean difference of the 255 individual paired measurements of the test
system and the comparison system shall be +/- 5 mmHg or less with a standard
deviation of 8 mmHg or less." Therefore, the permitted tolerance is greater than
+/- 3 mmHg. Repeatability of measurements is an important measure of the NIBP
quality.
References:
McGraw-Hill, 2005, Pages 223-229
[2] ANSI/AAMI SP 10:2002/(R)2008 Manual, electronic or automated
sphygmomanometers, section 4.4.5.1.1.B
[3] Fluke Biomedical, Education and Training, Frequently Asked Questions,
Simulators, ProSim FAQ - NIBP,
http://www.flukebiomedical.com/biomedical/usen/advantagetraining/frequently_asked
_questions.html, retrieved November 20, 2014
Q870EXPL
late 1960s to support patients in cardiogenic shock. A 2- to 5-inch balloon is
located at the distal end of a catheter placed in the femoral artery and fed up
into the aorta just below the origin of the left subclavian artery. The IABP uses
low density helium gas to rapidly inflate the balloon at the onset of diastole
when the aortic valve closes. The balloon is then deflated just prior to the
The balloon pump has at least two trigger sources – ECG and arterial blood
pressure (ABP) waveforms. If the ECG signal is noisy due to external
interference, the trigger can be changed to the ABP, if that is a good quality
signal. This should lead to reliable triggering. Generally, the ECG is the
preferred trigger source, although it may not be possible to use if the ECG
signal has substantial artifact, such as might be caused by a patient trembling.
Helium is the standard drive gas due to its low atomic number and low viscosity,
which allow it to rapidly fill the balloon. Also, it has a low risk of causing an
embolism should the balloon rupture and the helium escape into the bloodstream.
Your observations allow you to eliminate a problem with the balloon catheter
inside the patient for two reasons. One, if the balloon was ruptured or there was
another leak in the balloon catheter system, blood would flow back through the
catheter and be visible in the clear portion of the tubing connecting the IABP to
the catheter. Secondly, by clamping the tubing proximal to the catheter/tubing
connection, you are eliminating the catheter side of the system. Since the leak
is still there, the leak is not related to the catheter. All of the other answers
identify locations that are proximal to the location of the tubing clamp, and so
these could be sources of the leak.
References:
[1] Troubleshooting Beyond the Basics, Arrow Intra-aortic Balloon Pump, Section
9, Possible Problems with Helium Delivery, page 54-55,
http://www.arrowintl.com/documents/pdf/education/ttb-tg0999.pdf, retrieved
November 20, 2014
[2] Intra-aortic balloon pump, Wikipedia, http://en.wikipedia.org/wiki/Intra-
aortic_balloon_pump, retrieved November 20, 2014
[3] Intra-Aortic Balloon Counterpulsation Therapy: interactive online training,
Maquet, http://ca.maquet.com/file_assets/e-
learning/theory_program/theory_program.html, retrieved November 20, 2014
Q871EXPL
The electrocardiograph (ECG) records the electrical activity of the heart over
time. Voltage changes associated with the cardiac excitation cycle can be
recorded by placing electrodes on the surface of the body, typically, on the
chest or limbs.
ECG monitors can display heart rate, as well as establishing alarms for heart
rate, arrhythmias, and waveform abnormalities. The monitor allows the ECG to be
displayed, recorded and sent remotely to other devices and computers.
For monitoring applications, the ECG signal’s bandwidth is filtered to reduce

interference from patient movement and electrical interference. If the patient
has a pacemaker, this signal must be identified so as not to interfere with
interpretation.
The specific arrhythmia alarm, Ventricular Tachycardia (Vtach), is a ventricular

rhythm of more than 100 beats per minute, with at least three irregular
heartbeats in a row. Since Vtach can lead to fatal ventricular fibrillation,
clinicians want to quickly identify when Vtach is taking place so that
appropriate interventions can be initiated.
The question tells us that this patient is having their heart rhythm established
by a pacemaker. If the monitor’s Pacer mode has not been activated, then the
periods of ventricular pacing will not be properly detected by the arrhythmia
monitor’s algorithm, resulting in the algorithm possibly seeing the pacemaker
pulses as extra QRS complexes. These "extra" QRS complexes would translate to the
higher apparent heart rate shown on the digital display, and would also appear to
be irregular heart beats to the arrhythmia detection algorithm, resulting in
triggering the Vtach alarm.
Most arrhythmia monitoring systems insert a visible pacer spike if the monitor
has been put in Pacer mode.
None of the other options noted in the question (ECG electrodes not making proper
contact, the alarms set in Neonatal mode, or excessive patient movement) would
cause a Vtach alarm. Poor contact would generate a Leads Off, Poor Signal or
Noisy Signal alarm. While using Neonatal mode would not be appropriate for an
adult, this mode uses a much higher heart rate than 100 bpm as its default
condition for triggering a Vtach alarm. For example, Philips monitors use 150 bpm
as the default neonatal heart rate to trigger a Vtach alarm. Excessive patient
movement would show up as artifact on the ECG and would generally be detected as
a Poor Signal or Noisy Signal alarm, not as a Vtach alarm.
References:
[2] Ventricular Tachycardia, Wikipedia,
http://en.wikipedia.org/wiki/Ventricular_tachycardia ,
[3] Arrhythmia Monitoring for the Paced Patient, Arrhythmia Monitoring Algorithm,
Philips Medical Systems, pages 11-15,
http://incenter.medical.philips.com/doclib/enc/fetch/2000/4504/577242/577243/5772
45/577817/577869/Arrhythmia_Monitoring_Algorithm_Application_Note_(ENG).pdf%3fnod
eid%3d578137%26vernum%3d3
[4] Drew, Barbara J., et al., Insights into the Problem of Alarm Fatigue with
Physiologic Monitor Devices: A Comprehensive Observational Study of Consecutive
Intensive Care Unit Patients, PLOS One, Figure 13,
http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0110274
[5] IntelliVue Patient Monitor Instructions for Use, Philips, 2008,
http://www.mc.vanderbilt.edu/documents/nursingeducationresources/files/MP20-
MP90%20Instructions%20for%20Use%20Manual%20Rev_G_0%20%20English%20M8000-
9001K.pdf, page 461, retrieved November 20, 2014
Q872EXPL
The laser, which stands for "light amplification by stimulated emission of
radiation," was invented in 1961 by Theodore "Ted" Maiman. It only took
four years for it to be first applied to medicine. There are three
elements required for a laser to work:
1. Laser medium - promotes population inversion when excited. It can be a
gas, solid, or liquid.
2. Optical cavity with resonating circuit - one 100% reflective mirror and
one partially transmissive mirror
3. Source of energy - electrical or light; this may be called excitation
or "pumping"
The characteristics of a laser include a monochromatic or single

wavelength, and coherence, which means that the electromagnetic waves
produced by the laser are all at the same frequency and phase. Lasers have
a mode or shape of the output which is called the transverse
electromagnetic field - TEM. The mode generally used for medical
applications is referred to as TEM00 which concentrates energy at the
center of the output beam. The output can be continuous, pulsed, Q-
switched (microsecond pulses), or mode-locked (picosecond pulses). The
wavelength of a laser can be from far infrared into the ultraviolet range.
A number of laser types are used in medicine. The chart below shows some
of them and their characteristics:
Laser Type Wavelength Laser Medium Pumping
10.6 um; far Gas, 5% CO2 + 10% N2 +

CO2 Electrical
infrared 85% He
Nd:YAG 1.06 um; infrared Nd-doped YAG crystal Optical
Argon 488 nm; blue Argon gas Electrical
Excimer 193 nm; ultraviolet Fluoride gas Electrical
Diode 810 nm or 980 nm Solid state Electrical
Ho:YAG (Holmium:yttrium-aluminum-
2100 nm Crystal Optical
garnet)
The CO2 laser utilizes a mixture of carbon dioxide, nitrogen, and helium as
the active, energy emitting gas. The gases are mixed and go into the laser
tube. The gas flows down the end of the tube where it is discharged via a
pump. A high voltage is placed between each end of the tube as the
excitation source. The tube has a fully reflective mirror at one end and a
partially transmitting mirror on the other. When properly excited, this
laser will radiate energy in the far infrared region, at 10.6 microns.
If the tanks supplying the gas are empty or turned off, the gas needed by
the laser to operate correctly will not be available, and the laser’s
output power will be significantly reduced, or even eliminated entirely,
depending upon the residual gas in the tube.
The CO2 laser does not use optical pumping, such as a flash lamp would
produce. Also the active medium is not a crystal or laser diode.
References:
[1] Fanning, James, Are Your CO2 Lasers Precise?, Biomedical
Instrumentation & Technology, May/June 2006, pages 231-232
[2] Laser, Wikipedia, http://en.wikipedia.org/wiki/Laser, retrieved
September 14, 2014
[4] Whitehouse, David R., Understanding CO2 Lasers,
http://www.laserk.com/newsletters/whiteCO.html, retrieved November 20,
2014
Q874EXPL
Electrosurgery was successfully developed in the 1920s by Dr. Harvey Cushing, a
noted neurosurgeon from Harvard Medical School, and William Bovie, who originally
developed RF generators for cancer studies. Dr. Cushing was looking to solve a
significant problem with bleeding during brain surgery and had read about the
coagulating effects of radio frequency energy. Mr. Bovie applied a radiofrequency
technique using high voltage spark gaps to produce a device that would both
coagulate blood and cut tissue.
The actions of the RF energy applied to tissue are described by the two primary
modes of operation of the electrosurgical unit (ESU). Tissue cutting is
accomplished by using a pure sine wave output. This continuous energy explodes
the cells by rapidly turning the cellular fluid into steam. The coagulation
output is a burst or pulse of higher voltage energy which dries out the cells
forming a coagulum and producing homeostasis.
Electrosurgery configurations include monopolar output devices in which a point

source, active electrode is used at the application site and the RF electricity
is returned to the generator through a large surface area return or dispersive
electrode pad.
Electrosurgical burns at the dispersive electrode site are due to poor electrical
contact at this location. This could be due to any of the stated factors –
placement over a bony protrusion, body hair not shaved at the site or other
factors that prevent the electrode surface from making full contact with the
patient. These other factors could include improper placement of the electrode
under the patient, placement at a location relatively far from surgical site, an
electrode with dried gel creating a high resistance, or not cleaning the
electrode site prior to placement. The burn is caused by the high electrical
energy density at the contact points under the pad, generating excessive heat.
Also, arcing of the RF energy between the pad and the patient can lead to burns.
Burns can be prevented through the use of return electrode impedance monitoring
systems, e.g. REM, combined with placement of the return electrode on a flat,
muscular area such as the thigh, cleaning, shaving and drying the electrode site
before application, smoothing the electrode for uniform skin contact after
placement, and taking action to check the pad if the surgeon asks for more power,
but the tissue effect is limited.
References:
[2] KLS Martin Group,
http://www.klsmartin.com/fileadmin/Inhalte/Downloads_Prospekte/HF-Geraete/90-604-
02-04_09_06_Handbuch_HF.pdf, retrieved November 18, 2014
[3] Covidien Force FX Electrosurgical Generator C User’s Guide,
http://surgical.covidien.com/content/dam/covidien/Websites/covidien/com/surgical/
biomed-connect/force-fx-electrosurgical-generator-c-users-guide.pdf, retrieved
November 18, 2014
[4] ECRI Institute, Medical Device Safety Reports, ESU Burns from Poor Dispersive
Electrode Site Preparation,
http://www.mdsr.ecri.org/summary/detail.aspx?doc_id=8204, retrieved November 18,
2014
Q875EXPL
Defibrillation is a resuscitation technique used to stop ventricular fibrillation
through a high-current depolarization of the heart. Optimally, the heart then
regains its normal sinus rhythm. Defibrillators are also used to halt atrial
fibrillation in a technique termed synchronized cardioversion.
Defibrillation techniques have changed over time from the original use of 60
Hertz alternating current, to monopolar DC pulses, to the current biphasic DC
pulse defibrillator. Less energy is required to defibrillate a patient with a
biphasic pulse as compared to a monopolar pulse. This reduces device power
consumption, burns, and myocardial damage - a possible consequence of the large
energy pulse.
Synchronized cardioversion is a lower energy shock synchronized with the peak of

the QRS complex. Synchronization avoids the delivery of a shock during the T-
wave. If the shock occurs during cardiac repolarization, which happens during the
T-wave period, there is the potential that the shock could cause ventricular
fibrillation. Synchronized cardioversion is applied for medication-resistant
unstable atrial fibrillation, atrial flutter, atrial tachycardia, and
supraventricular tachycardias. If the defibrillator is in cardioversion mode, it
will only fire when it detects a QRS complex. A patient in ventricular
fibrillation will not have a QRS complex, so the defibrillator would not fire in
this mode.
The other choices are also possibilities. As a safety feature, modern
defibrillators discharge internally if the shock buttons are depressed before the
charge level has been reached or if the energy selector was changed during the
charge cycle. Therefore, all three choices identified in this question could
explain why the defibrillator failed to fire.
References:
Delmar Cengage Learning, 2010, pages 244-269
[2] Zoll R Series Plus, R Series BLS Operator’s Guide, Zoll Medical Corporation,
2013, Chapter 14, pages 155-162,
http://www.zoll.com/WorkArea/DownloadAsset.aspx?id=23784, retrieved November 18,
2014
[3] Synchronized vs. Unsynchronized Cardioversion, ACLS-ALGORITHMS.com website,
https://acls-algorithms.com/synchronized-and-unsynchronized-cardioversion,
Q876EXPL
measurement of the percentage of oxygenated hemoglobin in the blood. The basis
for pulse oximetry is the Beer-Lambert Law of optical absorption which states
that the concentration of a substance can be determined by its absorption of
light. In pulse oximetry, a differential measurement of absorption is used based
on the absorption curves of oxygenated hemoglobin (HbO 2) and deoxygenated
hemoglobin (Hb) at different wavelengths of light.
Typically, a pulse oximeter sensor is placed at the tip of a finger. The sensor
has two light emitting diodes (LEDs) on one side of the finger, and a
photodetector on the other side of the finger. The photodetector detects changes
in the intensity of light produced by the LEDs as that light is transmitted
through the finger. (Alternate locations are sometimes used for sensor placement,
such as an earlobe or toe.)
One LED emits light in the 660 nm (visible red light) range, while the other LED
emits light in the 920 nm (invisible infrared) range.
Oxygenated hemoglobin highly absorbs light in the 920 nm infrared light, while
not absorbing the 660 nm red light. Conversely, deoxygenated hemoglobin absorbs
the visible red light, but does not absorb the infrared light.
To make its measurements, the oximeter sequentially pulses the two LEDs on and
off, and the photo-detector is synchronized to read the red and infrared light
transmission when the appropriate LED is turned on.
As the oxygen saturation level of the blood rises, the amount of oxygenated
hemoglobin in the blood rises, resulting in decreased transmission of infrared
light through the finger into the photodetector.
A change in the oxyhemoglobin percentage would not change the intensity of red
light transmission through the finger, so the choice related to that possibility
is incorrect. In addition, an oximeter does not use blue light to detect oxygen
saturation levels, so that choice is also incorrect.
References:
[1] Problems with Pulse Oximeter, How Equipment Works website,
_oximeter.html#problems, retrieved November 18, 2014
[2] WHO Pulse Oximetry Training Material, World Health Organization,
http://www.who.int/patientsafety/safesurgery/pulse_oximetry/tr_material/en/,
McGraw-Hill, 2005, pages 318-322, retrieved November 18, 2014
Q877EXPL
The definition of apnea is the cessation of breathing. Apnea is a significant
concern for infants especially preterm babies, neonates and infants in their
first month of life, as their respiratory system may not be fully developed.
Apnea monitors were developed in an effort to rapidly alert caregivers of apnea
situations so resuscitation efforts can begin quickly. The most common technology
associated with apnea monitors uses the technique of impedance pneumography. This
device measures the small changes in the impedance or electrical resistance of
the thorax as the patient breaths.
The measurement technique employs a small high frequency current (in the 20,000 –
200,000 Hz range) injected into electrodes placed on the chest. This high
frequency current does not stimulate the nerve or muscle cells, and does not
raise electrical safety issues.
When the patient takes air into their lungs, the resistance of the thorax, as
measured by two electrodes placed on the upper thorax, increases. This is due to
both the increasing resistance of the air-filled lung tissues and the increased
separation of the electrodes. Most of the current travels through the surface
layers of the thorax, thus the change in lung resistance related to air volume
accounts for only a very small amount of the change in impedance between the two
electrodes.
Since the current injected into the electrodes remains constant throughout the
respiration cycle, the changes in impedance are detected as changes in voltage.
These changes are transformed into a waveform representative of the time and
amplitude relationship of the breathing effort and expansion of the upper thorax.
The peaks of the waveforms are detected as breaths, after additional signal
processing to reduce artifacts.
After each breath is detected, a timer restarts. After a time selected by the
equipment operator, generally in the range of 10 to 60 seconds, if no subsequent
breath has taken place, an alarm sounds to alert the operator that apnea has been
detected, and that intervention is required.
The impedance pneumograph primarily measures changes in the circumference of the

chest related to breathing effort. Thus the device does not directly measure
patient ventilation. In addition, the electrodes do not have the ability to
detect changes in oxygen levels or sounds of any type, so the choices related to
those factors are not correct.
References:
[2] Smart2 Monitor - Parents' Guide, Apria Healthcare,
http://www.apria.com/wps/wcm/connect/f7ef6cf7-980b-4828-8bbd-
58af9082d4b0/Respiratory_Apnea+Monitors_SmartMonitor2_%234003.pdf?MOD=AJPERES,
[3] David, Yadin, et al., editors, Clinical Engineering (Principles and
Applications in Engineering), CRC press, 2003, pages 285-295
Q879EXPL
The most common problem associated with ventilator circuits is leaks. Ventilator
circuits are made up of plastic tubing with multiple joints, and it is very
possible for one or more joint to loosen over time.
If constant flow is being delivered, then the pressure should continue to

increase throughout the time of inspiration. In the case of a leak, some of the
gas intended to be delivered to the patient will not get to the patient as it
escapes through the leak. If that is happening, you could see the pressure
plateau described in this question.
An appropriate first response is to ask the respiratory therapist to look for

leaks in the circuit by temporarily occluding the patient tubing at various
points in the circuit to isolate the source of the leak.
Since the display on the screen appears to be accurate and the respiratory
therapist is able to control the ventilator, it is very unlikely that this is an
electrical problem, which is what performing an electrical safety check or
replacing the flow rate transducer would imply. Nor would altering the FiO 2 ratio
have any effect, since changing the oxygen percentage delivered to the patient
would not affect the pressure in the patient circuit.
References:
[1] Cairo, Jimmy M. and Pilbeam, Susan P., Mosby's Repiratory Care Equipment, 7th
Edition, Mosby Elsevier, 2004
[2] Kherallah, Mazen, Basic Modes of Mechanical Ventilation,
http://www.slideshare.net/subodhchaturvedi1/basic-ventilatory-modes?related=2,
[3] Chatburn, Robert L., Fundamentals of Mechanical Ventilation: A short course
on the theory and application of mechanical ventilators, Mandu Press Ltd., 2003,
https://my.clevelandclinic.org/ccf/media/Files/Pulmonary/Fundamentals%20of%20Mech
anical%20Ventilation.pdf
Q888EXPL
These types of problems are simple if you utilize unit analysis. First, calculate
the volume of oxygen (in liters) in the cylinder, using the conversion of 3.14
liters per psi.
Volume = (2200 psi)(3.14 L/psi)

Volume = 6908 L
Next we can determine how long this much oxygen will last, given the flow rate
set on the ventilator of 12 liters per minute.
Time = (6908 L)/(12 L/min)
Time = 576 min
Converting this to hours yields:

Time = (576 min)/(60 min/hour)
Time = 9.6 hours
So this cylinder, when full, should be expect to supply gas for about 9.6 hours.
If it is emptying well before that, you should ask the respiratory therapist to
carefully check the patient circuit for a leak. If none is found, then it would
be appropriate to check for internal leaks in the ventilator.
References:
[1] Tutorial on calculation of O2 tank duration, Kingswood College Respiratory
Care Program, http://wwwappskc.lonestar.edu/programs/respcare/duration.html,
[2] Oxygen Cylinder and O2 Tank Duration Calculation, Medfixation website,
http://www.medfixation.com/oxygen-cylinder-tank-calculation, retrieved November
30, 2014
Q893EXPL
The quality of an ECG signal is highly dependent upon a stable electrode system.
Even tiny changes in the electrical resistance between the electrode and the
patient’s skin can lead to small changes in the DC voltage seen by the electrode.
This small, slow change in the DC voltage at the electrode site can cause the
wandering baseline (or baseline drift) seen in this ECG waveform.
There can be several different causes for this change in resistance at the
electrode site, including respiration, muscle contraction, and poor electrode
application. All of these can cause tiny movements of the electrode which result
in baseline drift.
Better electrode site preparation technique and replacing the electrodes can
often solve a baseline drift problem. In more extreme cases, the electrodes may
need to be taped down to minimize the movement that can lead to impedance changes
and the resulting baseline drift.
References:
[1] ECG Wave and Screen Examples, Nasiff Associates, Inc. website,
https://nasiff.com/help/fig13.htm, retrieved November 26, 2014
[2] ECG Artifacts, Mauvila ECG Tutorial,
http://www.mauvila.com/ECG/ecg_artifact.htm, retrieved November 26, 2014
[3] Dhanaraj, T. and Reddy, G. Umamaheswara, Removal of Baseline Wandering in ECG
Signals Using Singular Value Decomposition, International Journal of Engineering
Research and Applications, Volume 2, Issue 1, Jan-Feb 2012, pages 379-382,
http://www.ijera.com/papers/Vol2_issue1/BH021379382.pdf, retrieved November 26,
2014
Q898EXPL
Anesthesia machines receive medical gases (oxygen, medical air, and nitrous
oxide) from high-pressure gas supply lines or standalone gas cylinders. The
machine then controls the gas flow and reduces the pressure in the breathing
circuit to a safe level for the patient. The anesthesia machine also mixes
volatile anesthetics into the final gas mixture, and delivers the resulting
mixture to a breathing circuit connected to the patient’s airway. Because an
anesthesia machine is a life support device, several safety features are included
to allow the anesthesiologist to monitor its safe operation and detect any
deviation before it causes harm to the patient.
Among those features is the visible bellows that can be observed to detect any
problems early on. During inspiration, fresh gas input pushes down on the
bellows, forcing the gas in the bellows into the patient's lungs. During
exhalation, gas flows from the patient into the bellows, causing them to expand.
The exhaled gases are then sent through the CO 2 absorber, which removes carbon
dioxide from the gas that is recirculated back into the patient's lungs, and to
the scavenging system designed to prevent the release of the anesthestic agent
into the room air breathed by the medical personnel in the patient vicinity.
Bellows that fail to expand or tend to collapse during ventilation can be the
result of several possibilities.
The first of these is a problem in fresh gas flow into the breathing circuit.
When there is no fresh gas flow, the volume in the breathing circuit will slowly
fall because of the constant uptake of oxygen by the patient and absorption of
expired CO2 in the absorber. Since the oxygen pressure gauge reading shows that
the oxygen being delivered from the wall connection is within its normal range,
this is unlikely to be the source of the problem identified in this question.
A more likely explanation is a gas leak that exceeds the rate of fresh gas flow.
Leaks are particularly important in closed-circuit anesthesia and therefore
should be quickly located and corrected. Low peak inspiratory alarms may be the
result of a leak or partial breathing-circuit disconnection.
In case of a bellows retention problem, the bellows would either be seen slipping
off of their mounting base, or the bellows would appear to be abnormally
distended (i.e., greater than normal size), rather than failing to fully expand,
as described in this question.
When the O2 flush valve is activated, fresh oxygen is introduced into the patient
circuit, and this tends to drive the pressure higher in the circuit. However, the
question here states that the low peak inspiratory alarm is being activated,
which is not consistent with high pressure in the circuit.
References:
[1] Aespire 7900 Anesthesia Machine Technical Reference Manual, Datex-Ohmeda
Inc., Page 7-42,
http://www.frankshospitalworkshop.com/equipment/documents/anaesthesia/service_man
uals/Datex_Ohmeda_Aespire_7900_-_Technical_reference.pdf, retrieved December 2,
2014
[2] Butterworth, John F. IV, Mackey, David C., and Wasnick, John D., Morgan and
Mikhail’s Clinical Anesthesiology, McGraw Hill, 2013, pages 85-86
Q899EXPL
Anesthesia machines receive medical gases (oxygen, medical air, and nitrous
oxide) from high-pressure gas supply lines or standalone gas cylinders. The
machine then controls the gas flow and reduces the pressure in the breathing
circuit to a safe level for the patient. The anesthesia machine also mixes
volatile anesthetics into the final gas mixture, and delivers the resulting
mixture to a breathing circuit connected to the patient’s airway. Because an
anesthesia machine is a life support device, several safety features are included
to allow the anesthesiologist to monitor its safe operation and detect any
deviation before it causes harm to the patient.
The basic idea in detecting a leak is to consider all connections in the machine
as potential sources of the leak and then check each location. A large leak can
be easily detected by an audible sound near the loose connection. For smaller
leaks, applying a soap solution to suspect connections and looking for bubble
formation is often a good way to identify the location of a leak. Also, when
servicing the machine, the oxygen flush button can be used to fill the circuit
using high pressure O2 and then observe how the pressure falls in different parts
of the system. This can help detect more subtle leaks. Therefore all of the
methods listed as choices in this question are appropriate ways to identify the
source of a leak.
References:
[1] Butterworth, John F. IV, Mackey, David C., and Wasnick, John D., Morgan and
Mikhail’s Clinical Anesthesiology, McGraw Hill, 2013, page 86
[2] Anesthesia Apparatus Checkout Recommendations, 1993, Nurse Anesthetist
website,
http://nurseanesthetist.org/documents/Anesthesia%20Apparatus%20Checkout%20Recomme
ndations,%201993.pdf, retrieved December 2, 2014
[3] Aespire 7900 Anesthesia Machine Technical Reference Manual, Datex-Ohmeda
Inc., page 7-5 to 7-6,
http://www.frankshospitalworkshop.com/equipment/documents/anaesthesia/service_man
uals/Datex_Ohmeda_Aespire_7900_-_Technical_reference.pdf, retrieved December 2,
2014
Q900EXPL
Fetal monitors use ultrasound Doppler technology to externally monitor the fetal
heart rate during pregnancy. The ultrasound transducer sends an ultrasound beam
into the mother’s body and listens for the reflected beam. When the fetal heart
is within the ultrasound beam produced by the transducer, the movement of the
heart’s walls generate a periodic Doppler shift waveform that allows the
estimation of the fetal heart rate (FHR).
Since all tissues moving under the transducer can generate Doppler echoes, the
output signal may also be affected by unwanted influences, such as fetal
movements, fetal breathing or hiccups, maternal movements such as breathing or
position changes, and pulsating maternal arteries. On occasion, some parts of the
fetal heart, such as parts of the wall or valves, may be moving in a way that
create extra reflections that are seen by the fetal monitor as extra heart beats,
with the result that a higher than actual heart rate is computed.
Also, the algorithms used by fetal monitors to automatically estimate FHR have
well-known limitations that may result in incorrect estimation of half or double
the correct rate. Depending upon transducer positioning and anatomical
variability, a fetal monitor may inappropriately switch to following the maternal
heart rate (MHR) instead of the FHR. (This problem is called maternal insertion).
Because fetal monitors can only display a number that indicates the computed
heart rate, the clinicians using the monitor are not able to definitively
identify if the transducer is correctly picking up the heart rate or not. If
there is reason to question whether the heart rate on the fetal monitor is the
actual FHR, a different technology should be used to verify that the correct
heart rate is being computed.
While repositioning the ultrasound transducer may cause it to be placed so that

it properly picks up the fetal heart, rather than another source of movement, it
is inappropriate to conclude that this is a way to determine the correct FHR,
because it is still using the same technology as before, rather than an
independent method of verification. Similarly, bringing in a different fetal
monitor is not a solution, because again, it uses the same ultrasound transducer
technology as the first monitor, so it is not able to provide independent
information.
Since the FHR in this problem is suspiciously high and given that the MHR is
usually lower than normal FHR, it is unlikely that the problem source here is due
to maternal insertion. (A maternal heart rate will generally remain below 100
bpm, although it can be higher in some women. Fetal heart rates will generally
range from 110 to 160 bpm.) Therefore, the comparison between the mother’s pulse
(which corresponds to the MHR) to the audio output of the fetal monitor (which
corresponds to the suspiciously high FHR) will not provide any new information.
The use of ultrasound imaging to locate and study the heart of the fetus will
provide a reliable estimate of the fetal heart rate that does not have the same
limitations as the fetal monitor. With an ultrasound image, the clinician has a
visual indication of the actual heart beat, and so can independently confirm the
validity of the computed heart rate. Hence, the estimate obtained from ultrasound
imaging should be considered to provide a reliable independent estimate of the
FHR that can be compared to the fetal monitor’s reading.
Reference:
[1] Addendum: Additional Information Regarding Ultrasound Fetal Monitoring,
Philips Avalon FM20 / FM30 / FM40 / FM50 Fetal Monitors, 2009, pages 1-2, 7, 14,
https://www.swissmedic.ch/recalllists_dl/02848/Vk_20091223_05-e2.pdf, retrieved
December 2, 2014
Q901EXPL
The ultrasound transducer used with a fetal monitor sends an ultrasound wave into
the mother’s body, and then listens for a return pulse generated by the
reflection of the ultrasound signal from internal structures. If properly
positioned, the transducer will receive its reflections from the fetal heart. The
movement of the heart will generate a Doppler shift in the return signal. By
properly processing the signal, the fetal heart rate can be estimated.
The ultrasound transducer contains a piezoelectric crystal which can be damaged

either mechanically or electrically. In order to verify that the transducer is
working, it can be tested by aiming it at a user’s hand. By holding the
transducer in one hand, and moving the other hand repeatedly towards and then
away from the surface of the transducer (without using gel), the fetal monitor
should generate a corresponding variable audio output that allows the
verification of the correct operation of the transducer. Failure to hear an audio
output that corresponds to this motion confirms damage to the transducer.
Visual inspection of the transducer during operation does not provide much
insight because while this may identify external damage, it does not identify an
internal defect. So, this is not sufficient to confirm a problem.
Measuring the waveforms to and from the transducer is usually cumbersome to

perform and the measured signals, especially the received signal, are difficult
to interpret. So, this is not a practical test.
It is also not possible to use the standing waves in a water tank to detect
problems with the probe since such this would only look at the transmission side
of the probe. This procedure would not verify that the probe is capable of
receiving the reflected wave, so, this is not a correct choice.
Reference:
[1] Philips Avalon Fetal Monitor FM20 / FM30 / FM40 / FM50 Instructions for Use,
Philips Healthcare, page 75, http://www.medimac.com.au/wp-
content/uploads/2012/12/Avalon-FM20_FM30_FM40_FM50-Rev_F.0-
Instructions_for_Use.pdf, retrieved December 2, 2014
Q902EXPL
A syringe pump is a programmable infusion pump used to continuously administer
small amounts of fluid or medication to a patient at a precise flow rate without
pulsation.
Syringe pumps employ a precision lead-screw driven by a stepper motor to slowly

push the syringe plunger at a constant rate in order to deliver the prescribed
rate of infusion. The device estimates the infused volume by measuring the linear
distance traveled by the syringe plunger and multiplies that by the cross-
sectional area of the syringe used. In order for this estimate to be correct, it
is necessary to correctly identify the type of syringe being used.
If the syringe in use has a different volume or cross-sectional area than the one
that the pump expects to be in use, the pump could deliver an inappropriate
volume or deliver fluid at an unintended rate. This could happen if the clinician
substituted a different brand of syringe or different size of syringe. If this
happens, no alarms will be triggered, because this type of pump generally does
not have an independent way to verify the type of syringe in use.
Having a low battery, occlusion, or a displaced syringe might all contribute to

malfunction of the syringe pump that could slow or even stop its operation. None
of these would account for an infusion that ended early. In addition, all of
these conditions would trigger device alarms.
References:
[1] McKinley T34 Syringe Pump Guidelines for use in Adult Palliative Care
Patients, NHS Greater Glasgow and Clyde, pages 28, 31,
http://www.palliativecareggc.org.uk/uploads/file/guidelines/11956_McKinley_Pump_G
uidelines_Feb_09.pdf, retrieved December 2, 2014
[2] Syringe Driver, Wikipedia, http://en.wikipedia.org/wiki/Syringe_driver,
Q903EXPL
A hemodialysis machine circulates a patient’s blood through a dialyzer that
removes waste products from the blood. This is done when a patient’s kidneys are
no longer able to function properly.
A dialysis machine has two circuits: one for the dialysate, the solution that
will absorb the waste products in the blood, and one for the patient's blood.
Those two circuits meet at the dialyzer membrane, where osmotic pressure allows
waste products to flow from the blood into the dialysate. The remaining blood is
then returned to the patient.
The presence of air bubbles trapped on the dialyzer membrane reduces the
effective surface area of the dialyzer, reducing its overall efficiency. In order
to keep this from happening, a hemodialysis machine has a deaeration (degassing)
system in the dialysate circuit that removes dissolved gases by exposing water to
sub-atmospheric pressures generated by a vacuum pump. If those dissolved gases
are not adequately removed from the dialysate, the resulting problems can include
false blood-leak and conductivity alarms, in addition to decreased dialysis
efficiency.
Having air bubbles in the blood circuit would be detected by the ultrasonic air-
foam detector in the blood circuit. Under those conditions, a blood leak alarm in
the blood circuit, but not in the dialysate circuit, would be triggered and the
venous clamp would be energized. This condition would not trigger a conductivity
alarm.
Having the dialysate temperature outside the safe range would trigger a
temperature alarm, but would not cause either a blood-leak or conductivity alarm
to be generated.
When the dialyzer ruptures, the blood leaks from the blood circuit to the
dialysate circuit causing a true and persistent blood-leak alarm. This condition
does not trigger the dialysate conductivity alarm.
Reference:
[1] Nissenson, Allen R. and Fine, Richard N., Handbook of Dialysis Therapy, 4th
edition, Saunders, 2007, pages 193-194
Q904EXPL
The basic operation of a defibrillator involves charging a large capacitor using
the power available from the mains or a built-in rechargeable battery. When the
device is using battery power, the charging speed depends on the condition of the
battery. If the battery is not adequately charged, because the battery has
reached its end-of-life, or there is a problem in the charge circuit preventing
the battery from fully charging, or the battery has been depleted and needs to be
recharged, then the time required to charge the capacitor may be longer than it
should be.
In order to maximize battery life, batteries must be maintained properly. They

can be damaged by repeated deep discharge, repeated shallow charging, or improper
storage.
Since the capacitor is a passive component, it is unlikely to change in a way

that would cause increased charging time. The capacitor used in a defibrillator
is an electrolytic capacitor, which could leak, leading to decreased capacitance.
Since the indicated charge level is based on the voltage measured across the
capacitor’s terminals, if the capacitance decreased, the indicated charge would
be reached more quickly. (The actual charge would be lower than indicated,
because the energy stored by the capacitor is directly proportional to the
capacitance times the square of the voltage on the capacitor, so if the
capacitance is lower than specified, for a given voltage, the energy stored will
be lower. The charge indicator circuitry assumes that the capacitor’s value is
constant, so that the voltage across the capacitor is a valid indication of its
charge level.)
Pitted paddles may cause patient burns, but they would have no effect on charging
time.
If the charge button were broken, the defibrillator would not charge at all,
because it would not get the signal necessary to initiate the charge cycle. By
itself, a defective button would not cause a problem with charge time.
Reference:
[1] Lifepak 12 Defibrillator/Monitor Operating Instructions, Physio-Control,
2008, pages 4-17, 8-8 through 8-11, http://www.physio-
control.com/uploadedfiles/products/defibrillators/product_data/operational_manual
s/lifepak12_operatinginstructions_3207254-008.pdf, retrieved December 2, 2014
Q906EXPL
Infant radiant warmers use an infrared radiant heating source to maintain the
temperature of an infant. In the baby-controlled mode of operation, the amount of
radiated energy delivered to the infant is controlled by measuring the skin
temperature and then using this value to provide feedback to modulate the
warmer’s output, with the goal of maintaining the infant’s temperature at a
desired level.
On the other hand, the manual mode does not utilize this feedback and allows the
radiated energy to be maintained at a constant level selected by the user. So,
when the device is operating in the manual mode, the output will not be
controlled by the skin temperature. Therefore, it can be a possible cause for the
problem described here.
When operating in the baby-controlled mode, the heat path between the heater
element and the baby’s skin should be unobstructed to allow the control process
to work properly. Any obstruction could result in variations in the amount of
heat reaching the baby’s skin that are not accounted for in the control loop, and
so can potentially cause the kind of instability observed in this question.
The preferred location for the skin temperature sensor is a soft muscle area,
such as the abdomen. The probe should not be placed on the extremities or on a
bony area, as these may give inaccurate temperature readings, and could lead to
the possibility of overheating the infant, because the temperature in those
locations would not properly reflect the baby’s core temperature. However, the
warmer would still show stable control of infant’s temperature, which is not
consistent with the problem identified in this question.
The probe should not be placed underneath the infant, as the local pressure of
the probe could lead to the formation of blisters and damage to the infant's
skin.
References:
[1] Fisher & Paykel 900 Series Infant Warmer Operating Manual, Fisher & Paykel
Healthcare, page 6-1,
http://www.frankshospitalworkshop.com/equipment/documents/infant_incubators/user_
manuals/Fisher&Paykal_900_-_User_manual.pdf, retrieved December 2, 2014
[2] Woo, Eileen K., Infant Skin Temperature Probes: Follow These Tips for Use,
FDA website,
http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/TipsandArticlesonDevice
Safety/ucm230220.htm, retrieved December 2, 2014
Q911EXPL
The electrosurgical generator delivers electrical power in the radiofrequency
(RF) range at high voltage to perform a desired surgical function, such as
cutting and coagulation. To do this, it contains components that are responsible
for generating the RF, supplying the high voltage, and controlling the proper
operation of the system. The application of this electrical power is controlled
via foot or hand switches connected to the surgical instrument (or handle)
operated by the surgeon. When the generator is powered on and the proper surgical
instrument is attached and activated, the output power should be delivered to the
surgical location. If this does not happen, then this may be caused by a
malfunction in one or more of the generator’s functional blocks. So, all the
answers above can cause this problem.
Reference:
[1] Valleylab Force FX™-8C Electrosurgical Generator Service Manual, Valleylab,
pages 6-7, http://photos.medwrench.com/equipmentManuals/1123-3307.pdf, retrieved
December 2, 2014
Q912EXPL
The healthcare technology management (HTM) professional is uniquely qualified to
provide input on safety and technology issues related to medical devices.
Therefore, The Joint Commission requires hospitals to solicit input from
individuals who operate and service equipment when selecting and acquiring
medical equipment. Appropriate input would include a technology evaluation and
comparison of available devices. A comparison may include the technical
comparison of battery life. The evaluation should include a contextual comparison
of whether it is compatible and safe to operate in the current environment.
A tourniquet normally does not need any special utilities, and space constraints
are usually not a problem, but, there may be existing supplies, like cuffs, that
involve compatibility issues. That is, are the supplies needed for the proposed
tourniquet the same as ones the hospital already stocks for its existing devices?
If the hospital is able to standardize on a single cuff, it may offer the
opportunity to reduce overall costs and minimize any special training
requirements.
The safe use and management of any medical device in the hospital environment may
include how that device is associated with issues such as alarm management and
other applicable National Patient Safety Goals.
References:
[1] Comprehensive Accreditation Manual for Hospitals, effective July 1, 2015, The
Joint Commission, EC.02.04.01, EP 1
[2] 2015 Hospital National Patient Safety Goals, The Joint Commission,
http://www.jointcommission.org/assets/1/6/2015_NPSG_HAP.pdf, retrieved May 30,
2015
[3] Logan, Mary, and Anthony J. Montagnolo, Executive Insights on Healthcare
Technology Safety, Association for the Advancement of Medical Instrumentation,
2014, http://www.aami.org/aami-ecri/Tech Trends 2014.pdf, retrieved December 10,
2014
[4] Procurement Process Resource Guide, WHO Medical Device Technical Series,
World Health Organization, 2014,
http://whqlibdoc.who.int/publications/2011/9789241501378_eng.pdf?ua=1, retrieved
December 10, 2014
Q915EXPL
Of the choices given, a defective power supply could be a likely explanation for
the unit's failure to power up at all. For all of the other problems indicated: a
calibration problem, a defective fan, or a defective applicator, the unit would
continue to power up, even if it did not perform as expected.
If the unit is out of calibration then it may not deliver an output that is
consistent with the selected settings. This might be indicated by the lack of the
expected physiological effect. Alternately, some machines are capable of self-
diagnosing an out-of-calibration condition, and would display an error code if
that happened. A calibration failure might also be diagnosed by testing with an
ultrasound power meter, and finding that the output is out of specification.
If the fan is defective, then the fan will not blow and the unit may get
insufficient cooling. But in all likelihood, the unit would still turn on,
although it may shut down spontaneously after some time period because it
overheated.
If the applicator is defective then the treatment may not be delivered.

Generally, this type of failure would be indicated by an error message displayed
on the console. A bad applicator could be caused by a broken cord, or by damage
to the applicator head.
Reference:
[1] Ultrasound Therapy System Service Manual for Intelect Transport and Vectra
Genisys, Chattanooga Group, 2008,
http://www.djoglobal.com/sites/default/files/Service Manual - 2782 Transport
Ultrasound.pdf, retrieved December 11, 2014
Q916EXPL
Endoscopic surgery relies on the introduction of a fiber optic system into the
surgical location to allow the surgeon to visualize the area where the operation
is being performed through small incisions and using surgical instruments
introduced into the surgical area through a rigid tube or flexible manipulator.
The fiber optic system transmits light into the surgical field, so that a camera
introduced into the surgical area has the light needed to allow the surgeon to
see what is being done. If the fibers in a fiber optic cable are damaged, less
light will get into the surgical field, and the result will be a dark image.
Poor grounding or loose connections on the cables may result in interference that
is indicated by "snow" on the image. If the settings on the video monitor are
incorrect, then the picture may be dull and lack contrast. A bad camera would
likely cause poor picture quality, but would not necessarily produce a dark
image.
Reference:
[1] Diiulio, Renee, Understanding Video Components, Service Solutions, 24x7,
2009, http://www.24x7mag.com/2009/10/understanding-video-components, retrieved
December 9, 2014
Q917EXPL
If the footswitch is dirty, then the ESU may only work intermittently.
If the REM (return electrode monitoring system) is out of calibration, then

either the ESU will not work or the ground pad connection may be poor and cause a
dispersive electrode burn on the patient at the grounding pad site.
A grounding problem with the ESU or the video monitor can cause interference from
the ESU on the video monitor.
The wireless network access points are designed to receive Wi-Fi signals. Neither
the video monitor nor the ESU will be connected to the Wi-Fi network, and the
access points will not attenuate either the ESU signal or the video signal, so
improper attenuation would not cause the problem described.
References:
[1] Diiulio, Renee, Managing Electrosurgical Equipment, 24x7, 2007,
http://www.24x7mag.com/2007/11/managing-electrosurgical-equipment, retrieved
December 10, 2014
[2] Wu, Ming-Ping, et al., Complications and recommended practices for
electrosurgery in laparoscopy, The American Journal of Surgery, 179.1 (2000),
pages 67-73
[3] 2012 Perioperative Standards and Recommended Practices: Recommended Practices
for Electrosurgery, Association of Perioperative Registered Nurses, 2012,
https://www.medline.com/media/mkt/pdf/research/or-safety-lean/AORN-
electrosurgery-guidelines.pdf, retrieved December 10, 2014
[4] Erwine, Mike, 5th Generation ESU Technology Presentation June 2009, BC Group,
2009, http://www.slideshare.net/merwine/5th-generation-esu-technology-june-2009,
Q918EXPL
A venous alarm could be caused by a problem related to the venous blood tubing
between the dialyzer and patient. This could be caused by clotting inside the
tubing or kinking of the tubing that brings venous blood to the dialyzer.
A high arterial pressure alarm would be generated in the case of kinking or

clotting in the arterial line tubing between patient and blood pump.
A dirty blood leak sensor might cause a blood leak alarm.
Air in the blood tubing would be indicated by an "air" alarm.
References:
[1] Pearson, Cheri, How to Troubleshoot a Dialysis Machine, eHow website,
http://www.ehow.com/how_5805134_troubleshoot-dialysis-machine.html, retrieved
December 10, 2014
[2] Young, Bessie, ASN Advisory Group: ASN Dialysis Curriculum, American Society
of Nephrology, https://www.asn-
online.org/education/distancelearning/curricula/dialysis/HemodialysisMachinesYoun
g.pdf, retrieved December 10, 2014
Q919EXPL
Anesthesia machines are designed to deliver a minimum proportion of 25% oxygen in
the ventilation gas sent to a patient. This is done using a fail-safe system that
maintains a minimum 1:3 ratio of oxygen to nitrous oxide in the gas mixture.
For Ohmeda anesthesia machines, this minimum ratio is maintained by a mechanical

system known as Link-25. North American Dräger's anesthesia machines use a
similar system called the ORMC (oxygen ratio monitor controller).
If the proportioning system is out of adjustment, the problem described in this

question could occur.
None of the other conditions described would affect the delivered gas ratio. If
the high pressure regulator was out of adjustment, then the low pressure
regulator would maintain a preset delivery of oxygen and the high pressure relief
valve would release excess pressure.
A leak in the CO2 absorber would affect the amount of gas that provides the
patient ventilation, but not the ratio of gases.
A leak in the scavenger system would not affect the ratio of gas delivery, but
would result in the waste gas from the patient getting into the operating room
suite, potentially exposing the surgical personnel to unintended anesthetic
gases.
References:
[1] Lynch, Patrick K, Service Solutions: A Brief History of Anesthesia Machines,
24x7, Allied Media LLC, 2007, http://www.24x7mag.com/2007/01/service-solutions-a-
brief-history-of-anesthesia-machines, retrieved December 10, 2014
[2] Andrews, J. Jeff, Troubleshooting the Anesthesia Machine, Winterlude
Symposium 1994, Department of Anesthesia, The University of Texas Medical Branch,
Galveston, 1994, http://www.anesthesia.org/winterlude/wl94/wl94_1.html, retrieved
December 10, 2014
[3] Simplified Diagram of Anesthesia Machine, Mosby Inc.,
https://classconnection.s3.amazonaws.com/925/flashcards/1578925/jpg/0040081337828
455179.jpg, retrieved December 10, 2014
Q920EXPL
A "Too Long In Charge" alarm will occur if a steam sterilizer's chamber does not
reach the set temperature within the allotted time.
A steam sterilizer depends upon getting an adequate amount of steam to raise the
temperature inside its chamber to a high enough level and to maintain that
elevated temperature for a long enough period to kill all organisms. If the
sterilizer chamber does not get the full supply of steam, then the sterilizer may
not reach or maintain the temperature for the required time.
If there is a loss of steam or if the steam inlet valve does not open or is only
partially open, then the sterilizer would not receive the full supply of steam
and may not fully pressurize the chamber.
If the steam trap is defective, then not enough steam may get into the
sterilizer, which could result in a "Too Long In Charge" alarm.
Similarly, if the exhaust valve is stuck open, then the sterilizer would not be
able to adequately pressurize and reach the set temperature, which could also
cause the "Too Long In Charge" alarm condition.
The function of the air inlet valve is to release the vacuum inside the chamber
after a vacuum cycle, allowing air to enter the chamber. If this valve fails,
then the vacuum would be maintained in the chamber for longer than intended. The
air inlet valve is only active at the end of the sterilization cycle, so its
failure would not affect the time required to charge the chamber, so this could
not account for the alarm condition described in this question.
References:
[1] Jackson, Rocky, Heidebrecht, John and Nowak, Christopher, A Commonsense
Approach to Steam Sterilizers, 24x7, Allied Media LLC, 2007,
http://www.24x7mag.com/2007/08/a-commonsense-approach-to-steam-sterilizers,
[2] Operator Manual: Amsco Century Medium Steam Sterilizers, Steris Corporation,
2004,
http://rwjms.rutgers.edu/research/core_facilities/ses/documents/CenturyMedium26x3
7.5OperatorManualP129373-461.pdf, retrieved December 10, 2014
[3] A Guide to Steam Trap Testing, TLV Co., LTD,
http://www.tlv.com/global/TI/steam-theory/steam-trap-test.html, retrieved
December 10, 2014
Q925EXPL
Chlorine and its combined form, chloramine, are high-level oxidative chemicals.
They are added to municipal water systems to kill bacteria, but they also destroy
red blood cells. For this reason they must be removed from water used for
dialysis. Reverse osmosis (R/O) systems that are used to purify water used for
dialysis are not very effective at removing chlorine and chloramines. Therefore,
chlorine is removed from the incoming water by running it through tanks filled
with granulated carbon, which absorbs chlorine.
The carbon tanks are placed before the reverse osmosis system, so there is no
reason to troubleshoot "downstream" from the carbon tanks. Therefore, running
either the self-test or cleaning process of the dialysis machine would not
resolve the problem. The dialysis machine itself has no way to remove chlorine.
It relies on receiving water that already has had chlorine removed before getting
into the machine. Similarly, chlorine does not become trapped in tubing. It is
dissolved in the water, and the presence of kinks in the tubing would not affect
the chlorine level.
Finally, the role of the carbon tanks is to remove chlorine from the incoming
city water, regardless of the level in the incoming water. Therefore, it is not
appropriate to test the level of chlorine in the incoming water.
Reference:
[1] Monitoring Your Dialysis Water Treatment System, Northwest Renal Network,
2005, page 6, http://www.nwrenalnetwork.org/watermanual.pdf, retrieved December
13, 2014
Q927EXPL
It is unlikely that the dialysis machine itself is measuring heart rate.
Dialysis machines have a number of alarms, including the following:
Temperature - Dialysis machines include heaters to make sure the blood returning
to the body is at body temperature, rather than either too high or too low.
Blood pressure - Since dialysis machines are pumping blood outside the body, it
is very important that blood pressure and blood leaks are closely monitored and
alarms generated if there are problems. The blood pressure is carefully monitored
at various points in the circuit to assure that the correct pressure gradients
are maintained, and to assure that the patient's own blood pressure does not go
outside the desired range.
TMP (Trans-membrane pressure) - The pressure across the dialysis membrane has to
be measured in order to make sure the membrane is still functioning properly. If
the TMP is outside the desired range, the appropriate compounds will not flow out
of and into the blood at appropriate rates.
Air in line - Air emboli are very dangerous and air bubbles in the blood must be
eliminated prior to the blood returning to the body.
References:
[1] How Does a Dialysis Machine Work?, DaVita website,
http://www.davita.com/treatment-options/hemodialysis/in-center-hemodialysis/how-
does-a-dialysis-machine-work?/t/5596, retrieved December 14, 2014
[2] Introduction to Dialysis Machines, Maxim Integrated,
http://pdfserv.maximintegrated.com/en/an/AN4698.pdf, retrieved December 14, 2014
Q928EXPL
All of the utilities listed (electrical power, water quality, and drain capacity)
are critical to hemodialysis and are more prone to problems in the home than in
the hospital or dialysis clinic environment. In addition, in order to monitor for
blood leaks and other critical problems, it is often recommended that a person on
home hemodialysis have a caregiver or care assistant of some kind (e.g. competent
family member or friend) on site while the patient is on dialysis. In general,
the chemicals associated with home dialysis do not need to be kept refrigerated,
so there is no need to be concerned about the refrigeration capacity available in
a patient's home.
References:
[1] Home Hemodialysis, National Kidney Foundation website,
https://www.kidney.org/atoz/content/homehemo, retrieved December 14, 2014
[2] Cost Associated With Home Dialysis, American Association of Kidney Patients
website, https://www.aakp.org/education/resourcelibrary/dialysis-
resources/item/cost-associated-with-home-dialysis.html, retrieved December 14,
2014
Q929EXPL
When an infant warmer has both a primary and backup thermostat, usually the only
way to test the backup thermostat is to bypass the primary thermostat. Of course,
read the service manual and look at the schematic before conducting such a test
to make sure it makes sense for the specific model being tested.
Bypassing both thermostats could be very dangerous and could cause the entire
system to overheat. Heating the warmer without bypassing the primary thermostat
would not test the backup thermostat, because in a properly operating warmer, the
primary thermostat would always shut off before the backup thermostat.
Reference:
None
Q930EXPL
The aim in troubleshooting is to quickly isolate the problem. With a complex
system, one technique for performing that isolation is to "half-split," which
involves bisecting the system to try to determine which portion of the system is
the origin of the problem. In addition, when troubleshooting, it is generally
beneficial to try things that can be accomplished fairly quickly with a minimal
expenditure of effort to narrow down the source of the problem. One other
technique frequently used in troubleshooting is to introduce a known good signal
into various points in the system to see where a breakdown might be occurring.
In this case, we might suspect that there is a problem either in the monitor or
the video router. We can rule out a problem with the monitor itself if when a
known good signal is put into the monitor, the monitor produces the expected
display.
Similarly, since the video router has at least three outputs, we can put a known
good signal into the cabling leading to the suspect monitor by connecting that
cable to one of the known good outputs that is currently connected to a monitor
that works. In most cases, both of those techniques could be accomplished fairly
easily, so both are appropriate troubleshooting methods to employ here.
While putting a known good signal directly into the monitor, bypassing all of the
cabling, would be the best way to rule out a problem with the monitor itself, it
may be that this will take more time to accomplish than simply switching the
outputs of the video router, because of the requirement to find an independent
video source and bring it to the OR.
Reference:
[1] Troubleshooting, Wikipedia,
http://en.wikipedia.org/wiki/Troubleshooting#Half-splitting, retrieved December
14, 2014
Q937EXPL
The intra-aortic balloon pump (IABP) is a heart assist device that decreases the
load on the heart by increasing cardiac output and increasing the perfusion of
oxygen in the myocardium. The IABP connects to a catheter which is placed so that
its end is in the aorta. There is a balloon at the end of the catheter. By
inflating the balloon at the onset of diastole, when the heart muscle is relaxed,
and deflating the balloon at the onset of systole, when the ventricles fully
contract, the IABP performs counterpulsation, which is beneficial to the heart.
The balloon is inflated and deflated using helium gas. Helium has a low
viscosity, which allows it to quickly inflate and deflate the balloon. In
addition, if the balloon were to rupture, helium is easily dissolved in the
blood, making it unlikely to cause an embolism.
Reference:
[1] Noblitt, John, IABPs and Complications, 24X7, August 8, 2011,
http://www.24x7mag.com/2011/08/iabps-and-complications, retrieved November 29,
2014
Q943EXPL
Reliable, noise-free measurements of a patient's electrocardiogram (ECG) require
that the electrodes make good (low resistance) contact with the skin. The skin’s
natural electrical resistance is high due to the presence of dead skin cells, oil
and dirt on the outermost layers of the skin. In addition, the presence of hair
can also be a problem.
In order to reduce the tissue-electrode interface impedance, several techniques

are used to properly prepare the skin, including rubbing the skin with a gauze
pad or alcohol pad until slight redness appears, and sometimes shaving any hair
at the electrode site.
Finally, the electrode must make good mechanical contact with the skin. When
disposable electrodes are used, the adhesive on the foam portion of the electrode
must be in good condition to hold the electrode in place. Disposable electrodes
also have a conductive electrode gel that is used to make contact between the
skin surface and the conductive portion of the electrode.
If the electrodes are old, the conductive gel may have dried out and may no
longer function as intended, and/or the adhesive may no longer hold the electrode
firmly to the skin surface. Poor skin preparation can also lead to poor
electrical contact.
Patient monitors generally do not allow the user to set the amplifier gain, so
this would not account for the low amplitude trace.
The patient's cardiac output is a mechanical value, and has nothing to do with
the amplitude of electrical signal generated by the ECG.
While it is possible that the monitor is defective, in general, it is far more

likely that an electrode or skin prep problem accounts for the problem described
in this question, so that should be the first line of investigation.
Reference:
Biomedical Instrumentation & Technology, March/April 2011, volume 45, number 2,
pages 130-133
Q953EXPL
An anesthesia machine is used to deliver gases (oxygen, air, and nitrous oxide)
and inhalation anethestic agents (such as isoflurane, sevoflurane and desflurane)
in order to induce general anesthesia. General anesthesia is the reversible loss
of consciousness that allows surgery to be safely performed on a patient by
preventing the patient from experiencing pain.
The color codes associated with anesthesia gases are green for oxygen, yellow for
air, and blue for nitrous oxide. These gases are generally available at a wall
outlet within the operating room, and are typically delivered to the machine at a
pressure of about 50 psi.
Since a patient must get oxygen in order to stay alive, there are several safety
mechanisms in the anesthesia machine to assure that oxygen is constantly
delivered to the patient. One of those safety features is a low oxygen pressure
alarm, which will generate an alarm if the oxygen delivery pressure falls below
25 to 30 psi. If the low oxygen pressure alarm is triggered, the other gases may
be reduced or terminated, in order to assure that a sufficient volume and
percentage of oxygen is delivered to the patient.
References:
[1] Noblitt, John, The Basics of Anesthesia, 24X7, October 11, 2011,
http://www.24x7mag.com/2011/10/the-basics-of-anesthesia, retrieved December 2,
2014
[2] ABA: Wall oxygen failure – Signs, Open Anesthesia website,
http://www.openanesthesia.org/ABA:Wall_oxygen_failure_-_Signs, retrieved December
30, 2014
[3] Anesthesia Machines, Orbis,
http://frankshospitalworkshop.com/equipment/documents/anaesthesia/background/Anes
thesia_machines.pdf, retrieved December 30, 2014
Q961EXPL
A continuous sinusoidal waveform cuts tissue with very little hemostasis. This
represents the cut or pure code mode. Each positive and negative swing of the
sinusoidal waveform produces a new discharge at essentially the same tissue
location. The electric current concentrates at this tissue location, causing a
sudden increase in temperature due to resistive heating. This rapid rise in
temperature vaporizes intracellular fluids, increases cell pressure, and ruptures
the cell membrane, thereby parting the tissue. This chain of events is confined
to the vicinity of the arc, since the current spreads to a larger volume of
tissue and the current density is no longer high enough to cause resistive
heating damage.
The other waveforms described in the choices represent other electrosurgery

modes. Blend mode, which provides for both effective cutting and hemostasis,
produces a waveform with approximately equal periods of a sine wave output
followed by a period with no output. Coagulation mode, which is used primarily to
stop bleeding with minimal cutting effect, has short periods of a sine wave
followed by longer periods with no output. The other mode associated with
electrosurgery is fulguration, which is used to destroy tissue by sending sparks
from a needle electrode into the tissue. The waveform associated with this mode
is a very short cycle, high amplitude sine wave followed by a long period of no
output. Reference [2] shows a diagram with the various waveforms associated with
the different electrosurgery modes.
References:
[1] Eggleston, J. L. and Von Maltzahn, W. W., Electrosurgical Devices, The
Biomedical Engineering Handbook: Second Edition, Joseph D. Bronzino, editor, CRC
Press LLC, Boca Raton, 2000
[2] Taheri, Arash, Electrosurgery: Basics and Principles, DermQuest website,
https://www.dermquest.com/expert-opinions/surgery-and-
cosmetics/2014/electrosurgery-basics-and-principles, retrieved January 23, 2015
Q963EXPL
A primary goal in troubleshooting a problem in a patient care area is to isolate
the potential problem as quickly as possible, and with as little disruption to
the user and patient as possible. The BMET should also be aware of those
components in a system that are most likely to fail, and whenever practical, take
steps to determine if one of those components has failed. This usually allows you
to solve most problems quickly.
While ECG cables do fail, this would not be the best first step among the choices
given because experience shows that the ECG cable is less likely to fail than the
ECG electrodes.
Replacing the ECG monitor is also not the best first step, because the monitor is
far less likely to fail than other parts of the system, and obtaining a
replacement monitor and putting it into place would generally take a significant
amount of time.
By using an ECG simulator, you can divide the system into two parts: the
connections to the patient as one part, and the ECG cable, telemetry transmitter
and monitor as the second part. If the ECG simulator produces a good signal on
the monitor, then you have verified that the ECG cable, telemetry transmitter and
monitor are all functioning correctly. If not, then you would need to look more
closely at those components. If the signal is good, then it is appropriate to ask
the nurse to replace the electrodes on the patient, as these might no longer be
conducting properly. Therefore, connecting a simulator is the best first step.
Replacing the electrodes before running any other tests is not an appropriate
strategy. While experience shows that electrodes are often the source of the type
of problem described, replacing them does involve some inconvenience and possible
discomfort to the patient as the old electrodes are removed, and the skin prep
redone to assure good contact between the new electrodes and the skin. Therefore,
the best troubleshooting first step is to connect the simulator.
Reference:
None
Q964EXPL
Of the four components cited as choices, only one is used to measure fetal heart
rate.
The toco transducer is a non-invasive pressure transducer that measures the

strength of uterine contractions, not fetal heart rate.
The IUP transducer invasively measures intrauterine pressure. It is an

alternative to using a toco transducer. The IUP transducer does not help detect
fetal heart rate.
The maternal ECG cable is used to measure the mother’s ECG signal, which helps
determine the mother's heart rate, but not the heart rate of the fetus.
An ultrasound transducer is used to measure the fetal heart rate non-invasively

using ultrasound Doppler shift phenomena. Therefore, it is appropriate to check
the ultrasound transducer if there is a problem with the detection of the fetal
heart rate.
Reference:
None
Q965EXPL
A waveform that shows ringing is an underdamped waveform. An overdamped waveform
will show a diminished response to the input waveform, resulting in a failure to
get to the maximum or minimum values of the waveform. On the other hand, an
underdamped waveform will show an overshoot to the input pressure, and at points
go above the true value of the input pressure. This is the result of oscillations
within the pressure measurement system.
Oscillations will occur when the resonant frequency of the tubing approaches the
highest frequency in the pressure waveform. The fundamental frequency of the
blood pressure waveform is from 3 to 5 Hz. While short lengths of non-compliant
tubing will make a system with a much higher resonant frequency, as the length of
the pressure line increases, its resonant frequency will drop, and underdamping
(ringing) can be the result.
Overdamped waveforms will not show ringing. One possible cause is the presence of
air bubbles in the line. Another reason for overdamping is the use of a compliant
tubing, such as an IV tubing. The tubing designed to be used in pressure lines is
very stiff (or non-compliant). If a softer tubing is used, it can tend to stretch
slightly in response to the pressure inside the tubing, causing the waveform to
be overdamped.
References:
[1] Kar, Sandeep, et al., Arterial Lines, January 19, 2012,
http://www.anesthesiology-network.com/blogs/251/43/arterial-line-and-invasive-
blood-pressure-measurement, retrieved December 30, 2014
[2] Kern, Morton J. and Appleby, Steven, Interpretation of Cardiac
Pathophysiology from Pressure Waveform Analysis, from Hemodynamic Rounds, John
Wiley & Sons, Inc., 2009,
http://www.dmmserver.com/DialABook/978/047/008/9780470085769.html, retrieved
December 30, 2014
[3] Common errors in clinical measurement, Anaesthesia UK website,
http://www.frca.co.uk/article.aspx?articleid=100382, retrieved December 30, 2014
[4] Carr, Joseph J. and Brown, John Michael, Introduction to Biomedical Equipment
Technology, Fourth Edition; Prentice Hall, 2001,, page 266
Q966EXPL
Since the new bed alarms work properly in the new nursing unit, and the old bed
alarms, which are the same model as the new bed alarms, work properly in the old
units, the bed alarm sensors are very unlikely to be faulty.
Most nurse call systems are designed to accept input from external devices, such
as a bed alarm. The nurse call system can be configured to accept an input from
either a normally open switch (i.e., the switch inside the alarm will be open
when everything is normal, and then close when the alarm condition, in this case,
a patient leaving the bed, is detected), or a normally closed switch. If the
configuration on the bed alarm and the nurse call system do not match, you will
see the condition described here, with the alarm going off as soon as the sensor
is plugged in.
From the description, it appears that the vendor tested his bed alarms only on
the new nursing unit, with its new nurse call system, but never with the nurse
call systems on the older units. In all likelihood, the nurse call system on the
new unit was set up to accept inputs that were opposite from the inputs on the
older units.
Since we know that the bed alarms do work properly with the nurse call systems on
both the older and new nursing units, there is no reason to believe that any of
the nurse call systems will only work with the nurse call manufacturer’s own bed
alarm.
The sensitivity of the nurse call system is also not an issue. The nurse call
system is designed to accept an input that is either On or Off. The system does
not do any analysis of the bed alarm signal. If there were a sensitivity
adjustment, that would be on the bed alarms not within the nurse call system. But
since we know that the alarms work fine under some conditions (the new alarms on
the new unit and the old alarms on the old units), there is not a sensitivity
problem.
Reference:
None
Q967EXPL
Because of the very high voltages generated by an electrosurgery unit, its output
should never be connected directly to an oscilloscope. Doing so could damage the
oscilloscope.
Most ESU analyzers address this problem by including an output connector that has
an attenuated signal that can be safely connected to an oscilloscope. By
examining the coagulation waveform on the oscilloscope in this way, and comparing
it to the waveforms shown in the ESU’s service manual, you can determine if there
is a problem with the ESU.
Asking another surgeon to use a suspected defective piece of equipment is an
inappropriate response. Your responsibility as a BMET is to keep medical
equipment in good running order, and you should know how to do this by using the
appropriate test equipment and procedures.
Replacing the cables does not help you determine if the coag waveform is
distorted. This may become part of a later stage of troubleshooting, but is not
an appropriate response to the goal of determining whether or not the waveform is
distorted.
References:
[1] QA-ES II Electrosurgical Analyzer User Manual, Fluke Biomedical,
http://assets.fluke.com/manuals/qa-esii_umeng0000.pdf, retrieved December 31,
2014
[2] Uni-Therm Electrosurgical Analyzer User Manual, Rigel Medical,
http://www.rigelmedical.com/downloads/398a550_rigel_unitherm_ume_v11_vREV%201.1.p
df, retrieved December 31, 2014
Q971EXPL
A centrifuge uses centrifugal force to separate different density solids and
liquids in a solution. Forces much greater than gravity are generated in
controlled periods of time by the centrifuge. In a hospital lab, a typical
operation that uses a centrifuge is the separation of blood into its components:
red cells, white cells, and platelets. Centrifuge types include table-top
centrifuge, ultracentrifuge, refrigerated centrifuge, hematocrit centrifuge and
standing centrifuge.
The components of the centrifuge include the rotor, electric drive motor, and
electrical controls. The controls available on most centrifuges include an on and
off function and a timer to control the time that the centrifuge rotor spins.
Some centrifuges include a control to change the rotational speed, while
refrigerated centrifuges typically allow control of the temperature. Centrifuges
also generally include an indicator to notify the user when the rotor is
unbalanced, and a brake system to stop the rotor rotation once the timer has
finished. The rotors of a centrifuge have different configurations depending upon
the application and have specifications for capacity, speed, and other factors.
The rotors must be protected from damage. One step taken by the manufacturer to
protect them is to apply a protective coating. This coating must be protected to
avoid deterioration of the metal base. The rotors are generally made of aluminum
covered by a thin film of anodized aluminum. This film can be damaged by the use
of alkaline solutions or detergents, so these should not be used to clean the
rotors. Metal brushes can scratch the protective coating and provide a location
for future corrosion to start, which is why plastic brushes should be use for
cleaning. The substances being processed by the centrifuge may damage the
protective film, so any spills should be cleaned quickly to prevent damage. Once
cleaned, the rotor should be air dried before using it again.
References:
[1] WHO Maintenance Manual for Laboratory Equipment, Chapter 7, Centrifuges,
http://apps.who.int/iris/bitstream/10665/43835/1/9789241596350_chapters1-
9_eng.pdf?ua=1, retrieved December 30, 2014
[2] Thermo Scientific Rotor Care Guide,
http://www.thermoscientific.com/content/dam/tfs/LPG/LED/LED%20Documents/Catalogs%
20%26%20Brochures/Centrifuges/Maintenance%20and%20Care/RotorCareGuide.pdf,
[3] Sorvall Rotor Care Guide,
http://www.chem.purdue.edu/chemsafety/newsandstories/SorvalRotorCareGuide.pdf,
retrived December 30, 2014
[4] Beckman Coulter Rotor Safety Guide,
http://www.chem.purdue.edu/chemsafety/Equip/BeckmanRotorCareGuide.pdf, retrieved
December 30, 2014
Q976EXPL
measurement of the percentage of oxygenated hemoglobin in the blood. Takuo Aoyagi
of Nihon Kohden in Japan invented the pulse oximeter in 1974.
The basis for pulse oximetry is the Beer-Lambert Law of optical absorption which
states that the concentration of a substance can be determined by its absorption
of light. In pulse oximetry, a differential measurement of spectrophotometric
absorption is used based on the absorption curves of oxygenated hemoglobin (HbO 2)
and deoxygenated hemoglobin (Hb) at different wavelengths of light. Two
wavelengths of light generated by light emitting diodes (LED) are used in
conjunction with a photodetector to make the measurement across a vascular bed.
One LED emits light in the 660 nm (red) range, which is highly absorbed by
deoxygenated hemoglobin. A second LED emits 920 nm infrared (IR) light, which is
highly absorbed by oxygenated hemoglobin. The LEDs are sequentially pulsed on and
off, and the photodetector is synchronized to make simultaneous readings during
the red and infrared light transmissions.
The measurement is a ratio of the AC pulsatile component of the red light

absorption divided the non-pulsatile, DC static component, which is then divided
by the pulsatile component of the infrared light absorption again divided by its
static component, times a constant used for calibration. The term pulse oximeter
was coined due to the relationship between the reading and the pulse component
when arterial blood is flowing - this is the only signal that changes with time.
The "static" tissue absorbers such as bone, soft tissue and the venous blood are
canceled out.
Pulse oximetry device calibration and accuracy is developed through the use of
empirical studies on human volunteers. Proprietary algorithms are developed by
each oximeter manufacturer based on these tests and incorporated into their
instruments in the form of R-curves, which specify the relationship between the
Red/IR ratio measured by pulse oximeters and the SaO 2 value displayed.
As the curves are slightly different for each company, finger type pulse oximetry
simulators must provide SaO2 simulations matched to the company's specific
algorithm.
Pulse oximetry finger simulators do not require an electrical connection, thus

cable configuration is not required. Because an oximeter is used to determine
oxygen saturation values on a large population of potential patients, oximeters
must be calibrated to work properly over a wide range of potential oxygen
saturation values, rather than just one specific value for each manufacturer.
Also, they must work over a wide range of finger translucency, rather than one
specific value.
References:
[2] Pulse Oximeter Sensor Accuracy, The Electrode Company,
http://www.electro.co.uk/TCPOexp8.php, retrieved December 31, 2014
[3] ProSim SPOT SpO2 Tester – pulse oximetry analyzer, Specifications, Fluke
Biomedical, http://www.flukebiomedical.com/Biomedical/usen/Patient-
Simulators/ProSim-SPOT-Light-SpO2-Tester-Pulse-Oximeter-Analyzer.htm?PID=74249,
[4] SmartSat technical specifications, Clinical Dynamics,
http://www.clinicaldynamics.com/smartsat_specs2.htm, retrieved December 31, 2014
Q977EXPL
An ultrasound therapy unit is utilized to provide treatment in the Physical
Therapy department. The unit consists of an applicator or transducer applied to
the patient with a gel interface to the patient’s body. The transducer has a
piezoelectric crystal which converts the electrical energy from a radio frequency
transmitter to vibration producing ultrasound waves. These ultrasound waves enter
the body and produce a thermal treatment effect.
Measurement of the ultrasound therapy unit's output requires carefully following

the wattmeter manufacturer’s recommendations. The wattmeter transducer well must
be filled with de-ionized and degassed room temperature water to the recommended
level, and the meter must be level. The wattmeter should have sufficient warmup
and be zeroed. To do the measurement, the sound head is placed in the transducer
well, but not on the membrane, so that it is centered and vertical. The sound
head should be completely coupled with water. Start the ultrasound machine with a
continuous duty cycle and bring the output to the maximum setting. The measured
output should be within 20% of the set output.
In order to test the output of a therapeutic ultrasound unit, the wattmeter must
use degassed, distilled water, because bubbles and particles in the water will
reduce the readings due to absorption and reflection of energy. Acoustic coupling
gel is not used for checking the calibration of the ultrasound therapy system. If
the transducer is placed on the transducer well membrane, it will cause
inaccurate readings.
The device settings mentioned in the choices: B-mode, M-mode and time-gain, are
not used with therapeutic ultrasound. These settings are available in a
diagnostic ultrasound machine.
References:
[1] Therapeutic ultrasound, Wikipedia,
http://en.wikipedia.org/wiki/Therapeutic_ultrasound, retrieved December 31, 2014
[2] Operator's Manual for Ultrasound Wattmeter UW 5, Fluke Biomedical, 2006,
pages 3-5 to 3-6, http://assets.fluke.com/manuals/UW-5____omeng0000.pdf,
[3] Calibration Study of Therapeutic Ultrasound Units, Physical therapy, Volume
82, Number 2, March 2002,
http://www.udel.edu/PT/PT%20Clinical%20Services/journalclub/caserounds/03_04/nov0
3/artho.pdf, retrieved December 31, 2014
[4] Vectra Genisys Service Manual, Intelect Transport, pages 3, 12,
http://www.djoglobal.com/sites/default/files/Service%20Manual%20-
%202782%20Transport%20Ultrasound.pdf, retrieved December 31, 2014
Q978EXPL
Sterilizers (also known as autoclaves) are designed to reliably kill all
microorganisms in contaminated materials via sterilization. Sterilizers range in
size from tabletop units to large room sized units.
Steam sterilizers use the heat generated by high pressure steam to kill
microorganisms. At sea level, under normal atmospheric conditions, water boils
and is converted into a vapor at a 212° F (100° C). By raising the pressure
inside a sterilizer’s chamber, water will boil at a higher temperature, raising
the temperature of the steam inside the chamber above 212° F.
Key components of a steam sterilizer are: a high pressure chamber with a secure,
sealable door, a steam source, indicators and controls for temperature, pressure,
and time, safety valves and an enclosure.
At the end of a sterilization cycle, the material that was to be sterilized

should be dry. If it is damp, this is known as a wet load and is not considered
sterile. To prevent wet loads, routine maintenance must be done on a sterilizer,
including inspection and testing of system components, replacement of parts known
to wear, such as gaskets, and cleaning.
Two critical items that are part of routine maintenance are the cleaning and
operational verification of the vapor trap and the drainage system. If they are
not cleaned or are defective, this could cause a wet load due to improper
circulation or lack of drainage.
Another cause of a wet load could be an overloaded chamber which is generally a

user-generated cause. In an overloaded sterilizer, the condensate on the material
to be sterilized will not have the opportunity to properly evaporate during the
sterilizer’s drying cycle, resulting in a wet load.
References:
[1] WHO Maintenance Manual for Laboratory Equipment, World Health Organization,
pages 81-92,
http://apps.who.int/iris/bitstream/10665/43835/2/9789241596350_eng_low.pdf?ua=1,
retrieved January 7, 2015
[2] Havrilla, Gale, et al., Troubleshooting Steam Sterilization Process Failures,
http://multimedia.3m.com/mws/media/402732O/troubleshooting-steam-sterilization-
failures.pdf, retrieved January 3, 2015
[3] Amsco Century Medium Steam Sterilizer Operator Manual 26” x 26”, Steris
Corporation, 2005, pages 12-1 to 13-6, https://medschool.vanderbilt.edu/vbi-core-
labs/files/vbi-core-labs/public_files/steris%20manual.pdf, retrieved January 7,
2015
Q979EXPL
Infusion pumps are medical devices used to provide a controlled delivery of
drugs, fluids or nutrients. These electromechanical devices include a pumping
mechanism, user interface, methodology for connecting the machine with the tubing
administration set, and a control system for performance, safety, and interface
functions.
A patient-controlled analgesia (PCA) pump is a specialized type of syringe

infusion pump that is used with post-surgical, oncology, and other types of
patients where pain control is an issue. The PCA technology allows the patient to
self-administer, within prescribed limits, pain medication (generally, an opiate)
on an as-needed basis. As the pain medication can have deadly effects at high
doses, it is generally desirable to limit the amount of pain medication
delivered, while still effectively controlling the patient's pain. By allowing
patients to choose the timing and amount of pain medication delivered, studies
have shown that patients tend to experience greater pain relief with less
medication than they would experience if the medication was administered on a
prescribed basis by a nurse.
PCA pumps generally administer medication at both a continuous rate, as well as

in bolus doses at times selected by the patient. This bolus capability is common
in PCA pumps to stop acute pain through a patient administered painkiller dose.
PCA pumps have a programming option that allows the clinician to prescribe a
limit to the frequency of bolus doses by setting a lock out interval, as well as
a limit on the total medication delivered to the patient.
A patient usually indicates the need for a bolus dose by activating a control:
typically a cable with a patient activation button at the end.
Cables are well known for being a primary source of device failure. A broken
patient hand control cable which activates the bolus capability is a prime
suspect as the cause of this failure.
As the device works correctly in the continuous mode we can conclude that it must
be unlocked, the syringe is loaded properly, and the microprocessor is
functioning. A microprocessor failure would lead to a complete shutdown of pump.
References:
[1] Infusion Devices Training Tutorial, EBME website,
http://www.ebme.co.uk/articles/clinical-engineering/46-infusion-devices-training-
tutorial, retrieved January 2, 2015
[2] Patient Controlled Analgesia, Wikipedia,
http://en.wikipedia.org/wiki/Patient-controlled_analgesia, retrieved January 2,
2015
Q980EXPL
Surgical tourniquets are used to prevent blood flow to a limb during surgical
procedures on the extremities, enabling surgeons to perform delicate procedures
in a bloodless operative field. A pneumatic tourniquet consists of an inflatable
cuff, an air pump, pressure sensors, and a processor to control cuff pressure.
The cuff is placed on the limb proximal to the operative site. The cuff is then
inflated to a preset pressure, occluding vessels and arteries and preventing
blood flow past the cuff. The pneumatic tourniquet measures and displays the cuff
pressure and inflation time. The cuff itself is typically dual chambered,
allowing for alternation of the pressure site.
Serious injuries have been caused by pneumatic tourniquets including those where
the cuff pressure was high enough to cause nerve damage. Pneumatic tourniquets
have a cuff pressure setting. For safety, there is also a high pressure relief
valve that releases the pressure if the cuff pressure reaches the valve's limit,
which is usually a value of 550 mmHg or less. In order to test that the high
pressure relief valve is working properly, you will need to generate a pressure
of at least 550 mmHg. Inflating the cuff to the maximum pressure setting, and
then using an auxiliary source of pressure, such as a squeeze bulb, will allow
you to increase the pressure to the point where the valve should open.
Like an automated non-invasive blood pressure monitor, the pneumatic tourniquet

has an inflatable cuff that wraps around a limb. However, while the NIBP cuff
will inflate to a value over the systolic pressure, and then slowly deflate in
order to determine the systolic and diastolic pressure values, the tourniquet
cuff will stay inflated at the static value selected by the surgical team
throughout the period of the operation. Electrical safety testing and the cuff
pressure capacity will not provide any information about the pressure limit.
References:
[1] Tourniquet, Wikipedia, http://en.wikipedia.org/wiki/Tourniquet, retrieved
January 3, 2015
[2} Tourniquet Use and Care: Calibrating and Testing the Equipment,
Tourniquets.org website, http://www.tourniquets.org/use_care.php, retrieved
January 3, 2015
[3] Clark, Tobey, Lane, Michael and Francoeur, David, Medical Equipment Quality
Assurance: Inspection Program Development and Procedures, 2nd edition, Fluke
Biomedical/University of Vermont, 2014, pages 143-146
Q981EXPL
during contractions are an important measure of potential problems such as fetal
hypoxia. Fetal monitors record uterine contraction events and strength, and
monitor the fetus’ heart rate during contractions to determine fetal response to
the stress of labor. The measurements of contraction intensity and frequency
during labor can help assess the progression of labor, the effect of medications
including those which induce labor, and detect abnormal contraction efforts.
Patterns of heart rate variability called accelerations and decelerations seen
before, during and after contractions, are monitored and analyzed to determine if
medical interventions are required.
During pregnancy before the amniotic membrane has ruptured, fetal monitors
utilize an ultrasound transducer that uses the Doppler Effect to measure fetal
heart rate. Labor contraction strength and timing is sensed through the use of
external toco strain gauge transducers. After the water has broken, additional
options become available. At that point, the clinician also has the option to use
a fetal scalp ECG electrode to monitor the fetal ECG, and contraction strength
can be sensed via an internal fluid-filled catheter connected to a pressure
transducer.
There are several different types of ultrasound transducers available. The

simplest uses one transmitting and one receiving crystal. This tends to produce a
fairly narrow beam that often requires repositioning of the transducer as the
fetal heart moves outside the beam’s area. Other ultrasound transducers produce a
wider beam which makes it easier to properly position the transducer and tend to
require much less frequent repositioning. The array transducer generally has a
single transmitting crystal surrounded by multiple receiving crystals. (See, for
example, Figure 8.6, page 272 in the Khanpur reference.) If any of the receiving
crystals on the transducer become damaged, then the width of the allowable area
where the fetal heart beat can be detected will be narrowed. Therefore, of the
choices offered, this is a possible reason for the problem described.
Because the monitor is able to pass its internal self-test, the internal
electronic circuitry is working correctly, including the envelope filter and the
oscillator. The problem here cannot be associated with the fetal scalp electrode
because that is not in use.
References:
[2] Fetal Monitoring Equipment, Center for Experiential Learning, East Tennessee
State University, http://www.utilis.net/fhm/2624.htm, retrieved January 7, 2015
Q982EXPL
measurement of the percentage of oxygenated hemoglobin. The basis for pulse
oximetry is the Beer-Lambert Law of optical absorption which states that the
concentration of a substance can be determined by its absorption of light. In
pulse oximetry, a differential measurement of absorption is used based on the
absorption curves of oxygenated hemoglobin (HbO 2) and un-oxygenated hemoglobin
(Hb) at different wavelengths of light. Two wavelengths of light generated by
light emitting diodes (LED) are used in conjunction with a photo-detector to make
the measurement across a vascular bed - typically the finger. An LED emitting in
the 660 nm (red) range is a wavelength highly absorbed by un-oxygenated
hemoglobin, whereas a second LED emitting 920 nm (infra-red) light is highly
absorbed by oxygenated hemoglobin. The LEDs are sequentially pulsed on and off,
and the photo-detector is synchronized to make simultaneous readings for the red
and infra-red light transmission.
Several patient, environmental and procedural issues can cause inaccurate pulse
oximetry saturation readings. Patient movement and poor perfusion are two, but
they have been ruled out by the nurse's description of the patient.
Intermittent, not continuously incorrect saturation readings, would result from

an NIBP cuff cutting off blood flow to the arm with the probe attached. When the
nurse put the probe on the nurse's own finger, there was an appropriate reading,
so we can conclude that it is very likely that the probe is correctly attached to
the patient. Bright light could cause inaccurate readings, but the room is
described as darkened, so the exam room lights should not be interfering with the
readings.
As the patient is female and was at an evening formal party, it is very possible
that the patient is wearing nail polish, which would interfere with the optical
readings. You should ask the nurse to check to see if nail polish is present on
the patient’s fingernails. If it is, the nail polish should be removed from the
finger where the probe is placed or an alternative site and/or probe type should
be used. Alternative sites that can be used to measure oxygen saturation include
an earlobe or a toe.
References:
[1] Pulse Oximetry, How Equipment Works website,
_oximeter.html#problems,retrieved November 18, 2014
[2] Pulse Oximetry: Training Material, World Health Organization,
http://www.who.int/patientsafety/safesurgery/pulse_oximetry/tr_material/en,
Q983EXPL
Syringe infusion pumps apply a force to the plunger of a syringe containing
medication via a motor driven, gear reduced, lead screw mechanism. The rate is
typically controlled by the speed of the motor. For stepper motor driven pumps, a
specific volume is delivered with each pulse, so that an increase in the pulse
frequency results in an increase in the infusion rate. The operator must use the
correct make and size of the syringe and ensure it is properly inserted into the
pump, or errors will occur.
Many syringe pumps can identify the size of a loaded syringe, if the pump and the
syringe model/brand are appropriately matched. With this information, motor speed
is automatically adjusted to achieve the desired flow rate. Syringe pumps
generally can administer up to 100 ml of a drug at flow rates of 0.1 to 100
ml/hr. Syringe pumps tend to deliver more accurate flow rates than a peristaltic
type of infusion pump.
One issue with syringe-type infusion pumps is the delayed start of infusion.
While syringe pumps deliver accurate continuous flows, the flow produced at the
start of an infusion might be considerably less than the set value. One possible
cause of a delay in infusion is if the syringe plunger is not tightly in contact
with the pusher block. Especially at low flow rates, the mechanical slack between
the pusher block and the syringe leads to a delay in delivering fluid when the
pump is first turned on. At low flows it can be some time before any fluid is
delivered to the patient. To reduce startup delays, experts recommend (Neff et
al., 2007) using a high flow rate and the smallest possible syringe.
References:
[1] Vascular Infusion Systems, EMBE website,
http://www.ebme.co.uk/articles/clinical-engineering/101-vascular-infusion-
systems, retrieved January 4, 2015
[2] Neff, S.B., Neff, T.A., Gerber, S., et al., Flow rate, syringe size and
architecture are critical to start-up performance of syringe pumps, European
Journal of Anaesthesiology, July 2007, volume 4, number 7, pages 602-608
McGraw-Hill, 2005, page 872
Q984EXPL
An electroencephalograph uses electrodes placed on a patient's scalp to measure,
amplify, display, and record the electrical activity of the brain. A summation of
the action potentials generated by the brain, primarily in the cortex, generates
the waveforms observed.
EEGs are low level bio-potentials on the order of microvolts which typically are
in four distinct frequency bands: beta (greater than 13 Hz), alpha (8-13 Hz),
theta (4-7 Hz) and delta (less than 4 Hz). Electroencephalography employs a
larger number of electrodes typically placed on the head using the International
10/20 system of placement. The linking of pairs of electrodes connected to each
amplifier of the EEG machine is called a montage. Conventional EEG machines
primarily consist of an amplifier, a galvanometer and a writing device whereas
newer digital machines convert the analog signals to a digital representation and
analyze, display, store and print the EEG data.
Because EEG potentials are of such low voltage, artifacts can be problem.
Artifacts can be broken down into three categories: equipment deficiencies,
environmental interference sources, and patient sources. Patient artifacts are
low frequency non-periodic events. Often, the EEG technician can observe the
patient action, such as a movement, that is the cause of the artifact.
Environmental or equipment generated interference usually show higher frequency
activity (50 Hz or greater). Equipment issues include electrode/leadwire defects,
poor common mode rejection, or internal failure of circuits or connections.
Environmental interference can be caused by poor grounding and electromagnetic
radiation sources showing as AC periodic interference.
As the reported problem is intermittent, slow artifacts with a U or V shape, AC

interference or fluorescent light interference is not a likely source as this
would appear as 50 Hz or greater continuous artifact on the tracing. Muscle
artifact, such as might be caused by a patient grinding his teeth, would exhibit
itself as a signal between 5-350 Hz, and so would not be defined by the observer
as a slow artifact.
On the other hand, if the patient were blinking, it could account for the
reported problem. For an example of the U shape added to the EEG by a blinking
patient, see slide 7 of reference [3]. There is a voltage potential between the
front and back of the eye. This is the basis for the electronystagmography
measurement, but when it appears during an EEG study, it is considered an
unwanted interference source.
References:
[1] Electroencephalography, Wikipedia,
http://en.wikipedia.org/wiki/Electroencephalography, retrieved January 4, 2015
[2] Introduction to EEG, EBME website, http://www.ebme.co.uk/articles/clinical-
engineering/56-introduction-to-eeg?showall=1, retrieved January 4, 2015
[3] Aftifacts in EEG, Slideshare website,
http://www.slideshare.net/ranjithpolusani/artifacts-in-eeg-final, retrieved
January 4, 2015
Q985EXPL
Defibrillation is a resuscitation technique used to stop ventricular fibrillation
through a high current depolarization of the heart. Optimally, the heart then
regains its normal sinus rhythm. For external defibrillation, the technique is
typically performed with large paddle or pad electrodes applied to the chest.
During cardiac surgery, where the heart is exposed, a defibrillator will
generally deliver its shock through electrodes applied directly to the heart
using internal spoon shaped electrodes.
For patients that are considered to be at high risk for developing ventricular
fibrillation, an implantable automated defibrillator might be used. This is a
small defibrillator implanted in a patient's chest that is designed to constantly
analyze the heart’s rhythm and deliver a shock through implanted leadwires
automatically when fibrillation is detected.
As a safety measure, most modern external defibrillators incorporate circuitry to

detect the presence of paddles. If the paddles are not in place, a warning will
appear, and the defibrillator will not deliver a shock.
In this case, any one of the failures described in the answers could cause the No
Paddles message. Either the paddle set or the paddle sensing circuit may be
defective. It is also possible that the paddle set is not properly connected to
the defibrillator. Most defibrillators have paddle cable connectors with a
positive locking mechanism to insure a reliable connection. Given that the device
was recently transferred from the Cardio-thoracic surgery suite where internal
paddles would have been connected to the unit, rather than the external paddles
that would be in use in the Recovery Room, it is possible that the person
connecting the external paddles to the defibrillator did not apply the pressure
needed to insure that the connector lock was properly engaged.
Without more information, it is not possible to identify the source of the

described problem, so “All of the Above” is the best answer.
References:
[1] Defibrillation, Wikipedia, http://en.wikipedia.org/wiki/Defibrillation,
Delmar Cengage Learning, 2010, pages 244-269
[3] Hewlett Packard Codemaster XL Service Manual, Edition 6, Hewlett Packard
Corporation, 2000, page 4-12,
http://www.frankshospitalworkshop.com/equipment/documents/defibrillators/service_
manuals/HP_M1722_-_Service_manual.pdf, retrieved January 4, 2015
Q989EXPL
A syringe pump is a small programmable infusion pump that delivers small amounts
of fluid and/or medication from a syringe to a patient at precise flow rates
without pulsation. Syringe pumps employ a precision lead-screw driven by a
stepper motor to induce a constant linear advancement of the syringe plunger that
corresponds to the prescribed rate of infusion. The device estimates the infused
volume by measuring the linear distance traveled by the syringe plunger and
multiplies that by the cross-sectional area of the syringe used. The pump
continues to work until it estimates that the delivered medication volume is
equal to the value entered by the clinician or the syringe becomes empty.
In some circumstances, the pump is unable to deliver the programmed amount to the
patient and an alarm is triggered to alert the user. For example, occlusion
alarms are caused when tubing is partially or completely blocked so that fluid
cannot flow and pressure builds up and is sensed by the infusion pump. In this
case, this condition was excluded by the problem statement.
Also, when the pump is battery operated, an exhausted battery would trigger a low
battery alarm and stop the delivery. As a battery ages, it will no longer hold
its rated capacity, even after being adequately charged. Since the nurse
indicates that the battery should normally last eight hours, and that it has been
charged overnight, you should suspect that the battery will no longer hold a full
charge.
When there is fluid leakage in the delivery circuit, the device cannot detect
this leakage and hence continues to work as usual and no alarms are triggered.
So, this condition is not related to the symptoms in this problem.
When programming the syringe pump, the nurse is required to enter the size and
type of syringe, so that the pump knows the cross-sectional area of the syringe.
If the nurse mistakenly entered a larger syringe size than the actual syringe,
then the pump would empty the syringe too quickly, but this would not generate an
alarm before the syringe emptied.
References:
[1] McKinley T34 Syringe Pump: Guidelines for use in Adult Palliative Care
Patients, pages 28, 31,
http://www.palliativecareggc.org.uk/uploads/file/guidelines/11956_McKinley_Pump_G
uidelines_Feb_09.pdf, retrieved January 9, 2015
[2] ANSI/AAMI ID26:2004, Medical electrical equipment, Part 2: Particular
requirements for the safety of infusion pumps and controllers, Association for
the Advancement of Medical Instrumentation, pages 5, 13
Q991EXPL
Failure to efficiently transmit therapeutic ultrasound dosages to the patient may
occur during the treatment of an irregular area, such as a bony area with little
soft tissue coverage. In this case, it may be difficult to keep the applicator
surface in good contact with the skin surface, resulting in loss of energy and
poor treatment. Underwater treatment, assuming the treatment area can be immersed
in water, allows good coupling to be achieved between the transducer and the
treatment site and so can be used to overcome this problem.
When a therapeutic ultrasound unit has a hardware problem, whether in the control
board or the output amplifier, the device will usually not work for any type of
treatment. Since the device described in the question works in underwater
treatment, a hardware problem is very unlikely.
While the transducer head could be overheating, causing it to deliver less power
than intended, this is much less likely than a failure to have good acoustic
coupling between the transducer and the treatment site.
References:
[1] Physiological Therapeutics: Therapeutic Ultrasound, New York Chiropractic
College, pages 3-4,
http://www.nycc.edu/webdocs/ic/IQA/IQAFiles/Protocols/Chapter4/TherapeuticUltraso
und4_3.pdf, retrieved January 9, 2015
[2] Sonicator 740 Maintenance Manual, Mettler Electronics Corp., page 29,
http://www.baltmedika.lv/files/740_service_manual__1_.pdf, retrieved January 9,
2015
Q994EXPL
The likely causes of a continuously running pump motor include a leaky circuit in
either in the hoses, fittings, O-rings, or manifold, which could prevent the pump
from reaching the target pressure setting. If the leak were not quite as severe,
the pump would stop once it reached the target pressure. However, in this case,
while the pump is running continuously, the cuff pressure is going beyond the set
pressure, so a leaky circuit could not be the cause.
However, if the pressure sensor were not working properly, this would account for
the symptoms described, with the pressure in the cuff exceeding the set pressure,
and would also account for the motor continuing to run, because the electronic
control might not get the signal required to indicate that the target pressure
had been reached.
If the inflation switch has a problem, the pump would not continuously inflate,
but would not work at all or would stop inflating once the pump pressure set
point had been reached. A problem with the alarm silence switch would not affect
the control of the pump and would not cause the pressure to continuously run
beyond the set point.
Reference:
[1] Operator & Service Manual, A.T.S. 2000 Tourniquet System, Zimmer, pages 16-
17,
%20Service%20manual.pdf, retrieved January 9, 2015
Q995EXPL
EEG recording is sensitive to environmental factors due to the very low amplitude
of EEG signals, which make them vulnerable to many sources of degradation.
When electrodes are not properly connected to the scalp, this results in a high
source impedance that makes it more difficult to acquire the EEG signal from the
electrodes.
Cellular phones cause electromagnetic interference that is often much stronger

than the EEG signals and therefore can result in significant artifacts being
superimposed on the EEG traces.
The EEG recording room, patient bed (if metallic), and the EEG equipment should
be properly grounded to avoid picking up noise from such sources as fluorescent
light and other electronic devices in the room. Poor grounding results in noisy
EEG waveforms.
When using more than one type of electrodes in the recording, this increases the
electrode polarization/bias voltage that interferes with the operation of the EEG
amplifier and causes the waveform to be not stable.
The number of EEG signal channels depends on the available number of amplifier
channels. Increasing or decreasing the number of channels should not affect the
quality of the EEG recording.
Reference:
[1] Nihon-Kohden Encephalograph Neurofax EEG-9100/EEG-9200 Service Manual, Nihon-
Kohden, pages 3.3-3.4,
ce_manuals/eeg/Nihon_Kohden_EEG-9100-9200_-_Service_manual.pdf, retrieved January
9, 2015
Q996EXPL
If the surgical tourniquet will not power up at all, the problem is likely a dead
battery.
If the tourniquet is out of calibration, then it may fail to operate at the

settings selected by the user. Depending upon the particular model of tourniquet
and the particular error condition, there may be an error code generated. A
calibration problem might also be indicated by the unit failing to pass a
calibration test using a calibrated pressure meter.
If the inflation/deflation valve is stuck, then the unit will not inflate or
deflate. If the connectors are loose or leaky, then the tourniquet may never
inflate to the pressure set point, causing the pump to run continuously.
Alternately, if the leak is not as severe, the pump may continuously start and
stop, or the unit may display an error message.
Reference:
[1] Operator and Service Manual: A.T.S. 2000 Tourniquet System, REF 60-2000-101-
00, 1996, Zimmer,
%20Service%20manual.pdf, retrieved January 13, 2015
Q997EXPL
If the PCA pump delivered more than the intended dose, the problem is likely a
programming error. Misprogramming of the PCA (patient-controlled analgesia) pump
is the most frequently reported practice-related issue. You can confirm this
assessment by noting the dose prescribed by the clinician and comparing it to the
dose programmed into the machine, as it was captured in the pump's history log.
Performance Verification will also confirm whether the unit is delivering the
dosage properly.
Because of the very serious consequences of a misdelivered medication dose,

particularly for the kinds of narcotics delivered by a PCA pump, all PCAs include
numerous checks that are part of the self-test procedure that runs whenever the
pump is turned on. If the unit is out of calibration, then an error will likely
be detected and displayed. Error messages may be viewed in the pump's error log.
A defective pendant switch may cause a unit to not deliver a medication dose when
the patient indicates a need for the pain medication by pressing on the button.
However, a problematic switch will not allow an overdose to occur, because the
maximum dosage and delivery rate are controlled by the program settings, not by
the pendant switch.
Tubing misconnection will not affect the rate and volume of the dose delivery,
but instead will affect whether or not the dosage is being properly administered.
Reference:
[1] Safety Issues With Patient-Controlled Analgesia (Part 1), Institute for Safe
Medication Practices, 10 July 2003,
https://www.ismp.org/newsletters/acutecare/articles/20030710.asp, retrieved
January 13, 2015
Q998EXPL
Any of the choices indicated may cause an occlusion alarm to go off. An occlusion
alarm will occur if the back pressure seen by the pump is higher than expected.
Therefore anything that causes the back pressure to increase could lead to an
occlusion alarm.
These causes could include the occlusion set point being set too low. If the
tubing set diameter is too small in relation to the viscosity of the fluid being
delivered by the pump, this could also generate an occlusion alarm. Similarly, a
clamped or kinked tubing may also be a cause.
Finally, it is also possible that the force sensor which senses the back pressure
that indicates an occlusion may also be out of calibration and require
calibration.
Reference:
[1] Medfusion Syringe Infusion Pump Model 3000: Technical Service Manual, Smiths
Medical, 2008, page 48, http://photos.medwrench.com/equipmentManuals/3354-
1665.pdf, retrieved January 13, 2015
Q999EXPL
At the end of a steam sterilization cycle, all of the items which have been
sterilized should be dry. If one or more items is wet, this is referred to as a
"wet pack" or a "wet load." A surgical instrument set with any visible moisture
inside is not considered sterile and should not be used.
To sterilize surgical instruments, the instruments are assembled inside a wrapped

pack or another sterilizing container, and then those instruments are exposed to
high temperature, high pressure steam. This steam penetrates the pack so that all
surfaces are exposed to heat that will kill all microorganisms. But before the
packs can be used, they must be given sufficient time to dry completely.
There are many possible causes for a wet pack.
At the end of a steam sterilization cycle, sterilized packs are allowed to dry
inside the sterilizer chamber. If the drying time selected is not sufficient to
assure that all of the moisture inside the packs has evaporated, a wet pack might
result.
Another possible problem is overloading the sterilizer. Steam sterilizers are

validated to sterilize a certain quantity of dry weight sets. If the weight limit
is exceeded, then the amount of condensate formed during the drying and cooling
period can be more than the sterilizer is able to handle.
At the conclusion of the drying cycle inside the sterilizer, the warm packs are
removed from the sterilizer chamber and placed on a cart to cool down to room
temperature. If air vents blow on the packs as they are cooling, then they might
cool too quickly, with the result being that condensate can form inside the
packs. Therefore, packs should not cool in an area where air vents are blowing.
If the packs are not assembled or packaged properly, then that could cause wet
packs. Items in pouches should not contain too much metal. The space between
basins should contain absorbent material. High density items should be wrapped
separately. If this is not done, then steam may be trapped in the pack, which
will form condensate as it cools.
Among the choices presented, the one thing that could not cause a wet pack is an
improper sterilization time setting. If the sterilization time were too short,
then the packs would not be sterilized. But this would not have any affect on the
ability of condensate to be removed from the packs while they were drying and
cooling.
References:
Approach to Steam Sterilizers, 24x7 magazine, http://www.24x7mag.com/2007/08/a-
commonsense-approach-to-steam-sterilizers/, retrieved January 14, 2015
2005,
7.5OperatorManualP129373-461.pdf, retrieved January 14, 2015
[3] Chobin, Nancy, Wet Packs - Proactive Solutions, Sterile Processing University
website, http://www.spdceus.com/wet_packs.htm, retrieved January 14, 2015
[4] AAMI/ANSI ST-79(R)2014: Comprehensive Guide to Steam Sterilization and
Sterility Assurance in Healthcare Facilities, AAMI, 2013
Q1001EXPL
The problem described in this question indicates an absence of AC power input to
the power supply of the device, causing the device to rely on its internal
battery for power, rather than the AC power mains. There are two possible reasons
for this.
First, it could be caused by a problem with the AC mains from the outlet, such
that there is no power at the outlet. For example, this could be the result of a
tripped circuit breaker.
Alternatively, this can also result from a problem in the device's internal power
supply. A possible reason for this could be a blown fuse.
Since the device was in operation for two years, the possibility of having a
firmware problem that went unnoticed for this period or suddenly began after two
years causing these symptoms is highly unlikely. Therefore, that would not
account for the problem described, while the other two answers are realistic
possibilities.
Reference:
None
Q1002EXPL
Modern glucometers can now produce more accurate results with much smaller blood
samples than older generations of glucometers. They also incorporate more self
checks that allow the device to identify problems such as a low battery condition
or an insufficient blood sample volume. Therefore, since there were no warning
messages displayed by the glucometer, both of those possibilities are very
unlikely to be the source of the variability seen.
Hand washing has always been a problem for glucometers, but with microsample
meters, the smallest amount of contaminant can significantly raise the apparent
blood glucose level. For example, with a sample of 0.3 µl, 1 µg of glucose (the
weight of a dust particle) could increase the blood glucose reading shown on the
glucometer by as much as 300 mg/dl [see reference 2]. So if the patients' hands
were not being properly washed before obtaining a blood sample, the contaminants
remaining on their hands and mixing with the blood sample could account for the
wide variations seen in the measurements recorded by the glucometer.
Infection control measures are very important in avoiding the risk of exposing
healthcare personnel to potentially infectious blood-borne pathogens during
testing and cleaning procedures. However, these measures, or the lack of them,
will not affect the measurement process itself in any way and therefore cannot
cause the variations seen by the nurse.
Reference:
[1] Glucose Analyzer, Core Medical Equipment, World Health Organization, 2012,
page 22, http://whqlibdoc.who.int/hq/2011/WHO_HSS_EHT_DIM_11.03_eng.pdf,
[2] Ginsberg, Barry H., Factors Affecting Blood Glucose Monitoring: Sources of
Errors in Measurement, Journal of Diabetes Science and Technology, volume 3,
issue 4, July 2009, pages 903–913,
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2769960, retrieved January 14, 2015
Q1003EXPL
Sterilization is required if the device is classified as a critical device (that
is, a device that enters otherwise sterile tissue, such as might happen during an
intraoperative procedure). High level disinfection is appropriate for devices
that might come in contact with mucous membranes or non-intact skin. These types
of devices are classified as semicritical items, according to CDC guidelines. A
device that would only come in contact with intact skin, but not mucous
membranes, is classified as a noncritical device, and requires only low level
disinfection.
Given that ultrasound transducers are generally made of plastics and

piezoelectric materials, they should not be sterilized by methods that involve
heating, such as steam or dry heat sterilization, since heat can destroy the
plastics and the piezoelectric materials. Also, because of the materials used in
the transducer, gas sterilization may not always be a manufacturer-approved
method of sterilization (for example, Philips does not approve of its use while
Toshiba does). So, this method is not always the right method for this purpose.
The most commonly used method is to immerse the waterproof sections of the
transducer into a compatible disinfectant liquid. The FDA-approved compatible
disinfectant solutions are widely available and easy to use by properly trained
healthcare personnel, so this is the method generally used to prepare ultrasound
transducers.
Both sterilization and high level disinfection use the same sterilization
solutions. The difference is that high level disinfection requires a shorter
contact time. Disinfection is defined as the complete elimination of all
microorganisms, except for small numbers of bacterial spores. Sterilization also
assures that these spores are killed, as well as the other microorganisms.
References:
[1] Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008,
Centers for Disease Control and Prevention,
http://www.cdc.gov/hicpac/Disinfection_Sterilization/2_approach.html, retrieved
January 15, 2015
[2] Ultrasound Transducer High-level Disinfection and Sterilization, Philips,
http://www.healthcare.philips.com/main/products/ultrasound/Transducers/transducer
_care/Ev_iU22_iE33_HD11_HD3/steril_cleandisandsteril.wpd, retrieved January 14,
2015
[3] Guidelines for cleaning, disinfection, and sterilization of transducers,
Toshiba,
http://www.toshibamedicalsystems.com/tmd/english/products/us/cleaning/pdf/Aplio_X
ario_Viamo_E.pdf, retrieved January 14, 2015
Q1004EXPL
Bright light such as a surgical light shining on the oximeter probe may interfere
with the light detector and cause inaccuracy.
While a patient is under general anesthesia, voluntary patient movement would be

very unlikely. Under general anesthesia, the shivering reflex is usually
suppressed, so this is unlikely to be a source of the described problem. If a
patient is shivering during surgery, which is uncommon, because this can
interfere very directly with the surgical procedure, steps are usually taken to
counteract this shivering so that the surgeon can do his or her work with minimal
interference from patient movement.
The movement caused by shivering can be a problem in other settings, such as in

the Recovery Room, where the patient's reflexes are no longer suppressed, and
post-anesthesia shivering is quite common.
In general, oximeters are not good at distinguishing hemoglobin bound up to

carbon monoxide from hemoglobin bound up to oxygen. Therefore, if a patient has
carbon monoxide poisoning, the patient's oxygen saturation level, as determined
by the pulse oximeter, will tend to read higher than it actually is, because both
types of hemoglobin will appear to be oxyhemoglobin as seen by the oximeter.
While this is a possibility in this case, it is not very likely. A patient with
carbon monoxide poisoning would probably have symptoms that would have been
picked up by the anesthesiologist or another clinician as part of the pre-
surgical check-in process. Since this did not happen, it is unlikely that carbon
monoxide poisoning would account for the reported inaccurate readings.
References:
[1] Pulse Oximetry: Tutorial 2 – Advanced, World Health Organization, pages 11,
15, 17 and 22,
_tutorial2_advanced_en.pdf, retrieved January 15, 2015
[2] Limitations of Pulse Oximetry: Effects of Light Interference on Pulse
Oximetry, Oximetry.org website, http://www.oximetry.org/pulseox/lim_light.htm,
[3] Carbon monoxide, Pulseox.info website,
http://www.pulseox.info/pulseox/limits5.htm, retrieved January 15, 2015
[4] General anaestheia, Wikipedia,
http://en.wikipedia.org/wiki/General_anaesthesia, retrieved January 15, 2015
Q1005EXPL
The color of the nail polish can absorb the light emitted by the oximeter probe
and interfere with the detection of reflected/transmitted light used to estimate
SpO2 (oxygen saturation). So, it is always best to remove nail polish from the
finger used to obtain the measurement. In an emergency situation, the probe may
be turned sideways to avoid the nail polish.
Using a larger probe will not solve the problem identified here, given that the
same optical path interference remains regardless of the size of the probe.
Therefore, only removing the nail polish or turning the probe sideways are
possible solutions to the problem described in this question.
Reference:
[1] Pulse Oximetry: Tutorial 2 – Advanced, World Health Organization, pages 11,
15, 17 and 22,
_tutorial2_advanced_en.pdf, retrieved January 15, 2015
Q1006EXPL
Given the symptom that the tourniquet's pump is running continuously, but that
there is no mention that the cuff pressure has exceeded its setting, the problem
is likely to be a defective cuff pressure regulator. If the regulator is
defective it may keep the pressure in the cuff from reaching its setting, which
would cause the pump to run continuously as it tries to inflate the cuff to the
desired pressure.
The timer does not control the starting of the pump. Instead, it is used to
record the elapsed time that the cuff has been inflated, so that an alarm can be
generated if that time is longer than the intended total cuff inflation time. If
the timer was defective, it might not properly record the elapsed time, but since
it is not part of the inflation circuitry, it could not be a cause of the
described problem.
The function of the high/low pressure detector is to detect an over-

pressurization or under-pressurization condition. This works as a fail-safe for
the cuff pressure sensor. If the low pressure detector portion was defective, it
could erroneously measure a low pressure condition, which would generate an
alarm. However, there is a separate cuff pressure sensor that is used to
determine the pressure in the cuff and then control the pump to maintain the
pressure at the appropriate setting. The high/low pressure detector does not
control the inflation, but only functions to generate an alarm.
If the high pressure portion of the high/low pressure detector was defective, it
might not detect an over-pressure condition in the cuff, and so not generate an
alarm if that pressure exceeded the setting. This could also prevent the cuff
from automatically deflating as a safety measure if the pressure were exceeded.
However, since the pressure in the cuff is controlled by the cuff pressure
sensor, and not the high/low pressure detector, this would not cause the pump to
run continuously.
A problem in the alarms would also not cause the tourniquet to run continuously,
because the alarms do not control the pump directly. The function of the alarms
is to provide an audible and/or visual indication of a problem.
Reference:
[1] McEwen, JA, How Are Advances Improving Safety, Accuracy, and Reliability?,
Tourniquets.org website, http://www.tourniquets.org/tourniquet_technology.php,
[2] Operator & Service Manual A.T.S. 2000 Tourniquet System,
ce_manuals/various/Zimmer ATS-2000 Tourniquet System - Service manual.pdf,
Q1007EXPL
A DART (Daily Air Removal Test), or the similar Bowie-Dick test, measures the
ability of a prevacuum sterilizer to remove all of the air from the sterilizer
chamber and thus validates the vacuum system. Any leaky components could prevent
all of the air in the sterilizer chamber from being removed and so could cause a
failed DART test.
A defective pressure regulator may reduce the amount of steam going to the
sterilizer, or, alternately, could cause too much steam to enter the chamber.
However, this would not cause a vacuum leak, and so would not be the cause of a
failed DART test. If insufficient steam entered the sterilizer, the load inside
the sterilizer might not be properly sterilized. This would be detected by the
biological indicator put into the sterilizer during the sterilization cycle. If
too much steam entered the chamber, the safety valve would open, allowing the
excess steam to be released safely.
A leaky door seal could limit the ability of the sterilizer to create the vacuum
needed to remove the air, which could account for a failed DART test.
When performing the DART test, it is up to the operator to select the proper test
cycle. If the operator has erroneously selected the wrong cycle, it is possible
that test will fail, because the parameters required to pass the DART test are
not achieved, even if the sterilizer is operating properly.
References:
2005,
7.5OperatorManualP129373-461.pdf, retrieved January 14, 2015
Q1008EXPL
A DART (Daily Air Removal Test), or the similar Bowie-Dick test, measures the
ability of a prevacuum sterilizer to remove all of the air from the sterilizer
chamber and thus validates the vacuum system. Any leaky components could prevent
all of the air in the sterilizer chamber from being removed and so could cause a
failed DART test.
The DART test detects air leaks, inadequate steam penetration and other vacuum
system failures. The DART test is run each day prior to running any loads and the
results are documented.
If the DART test fails, then the first step for resolving a failed DART test is
to re-run the test and to examine the unit and the cycle tape to eliminate user
errors.
In order to perform the DART test, the DART indicator barrel must be placed in a
heated and otherwise empty sterilizer on the lowest shelf over the drain. The
DART Cycle has a temperature set-point of 270° - 274° F (132° - 134° C) with a
steam exposure time of three and a half to four minutes. If the test passes, the
DART test indicator will display the proper color change indicating that the air
was removed and was replaced with steam. If the operator has selected the wrong
test cycle, this could account for a failed test, even if the sterilizer is
working properly.
The DART test cycle does not include a drying cycle, so the length of the drying
cycle is not a factor in whether or not the test passes.
References:
[2] Instructions for Validation of Autoclaves, University of Mississippi Medical
Center, September 22, 2008,
http://www.umc.edu/uploadedFiles/UMC.edu/Content/Research/IACUC/autoclavevalidati
on.pdf, retrieved January 22, 2015
[3] Dart Daily Air Removal Test, Steris, http://www.steris.com/products/chemical-
indicators/dart-daily-air-removal-test, retrieved January 22, 2015
Q1012EXPL
A reverse osmosis (RO) system purifies the water used in a hemodialysis machine.
The water that is the endproduct of an RO system is mixed with various chemicals
to form the dialysate. This dialysate is on one side of a semipermeable membrane
and the patient's blood is on the other side of the membrane. By maintaining the
required concentration gradient across the membrane, urea and other waste
products, as well as potassium and phosphate, diffuse out of the blood into the
dialysate solution. That way, clean blood is returned to the patient. It is very
important to maintain the purity of the water used to make the solution in order
to prevent any contaminants in the water from getting into the patient's blood.
In addition, because the concentration of dialysate chemicals is monitored by
checking the conductivity of the dialysate solution, and any contaminants can
raise the conductivity of that solution, the water must be kept free from
contaminants to assure that the conductivity readings are an accurate reflection
of the dialysate solution concentration.
To assess the quality of RO output water, conductivity is measured of both the

input water and the output water. The water's conductivity is a measurement of
the Total Dissolved Solids (TDS) in terms of parts per million (ppm). By
comparing the input conductivity to the output conductivity, the RO system
indicates the percentage reduction of TDS, which is displayed as the Percent
Rejection. For example, if the input water's conductivity is measured as 100 ppm,
and the output water's conductivity is 8 ppm, then the Percent Rejection is [1 -
(output conductivity)/(input conductivity)] = [1 - (8/100)] = 0.92 = 92%
rejection.
Note that conductivity is actually measured in the electrical unit microsiemens

(μS), and that this is converted in the RO control unit to ppm, which is how it
is displayed by the RO water quality meter.
Since calculating the Percent Rejection display is done by measuring

conductivity, if this display fluctuated, it would likely indicate a problem with
the conductivity meters on the input and output water sides. The other options
presented, relating to pressure, temperature or flow, are not used as part of the
calculation of Percent Rejection, and so would not be appropriate answers.
Reference:
2005, page 18, http://www.nwrenalnetwork.org/watermanual.pdf, retrieved January
24, 2015
Q1013EXPL
Without more information, any of the answers presented are possible. Further
investigation, including interpreting and analyzing the log file, would have to
be completed to see what dose was actually entered and whether or not it matched
the intended dose.
While entering 1.1, it is possible with a key bounce problem to accidentally

enter 11. It is also possible that the user did not enter the decimal point.
With regard to the drug error reduction system (DERS), DERS configurations cannot
handle all situations. For some narcotics, a 10 times range in dosage might still
be reasonable, and so the DERS rules may not have been programmed to catch this
kind of error. In the end, if configuration changes in the allowable DERS rules
are being considered, they would need to be investigated by the Pharmacy and
other clinical staff to assure that any new rules are appropriate for the
hospital's patients.
References:
[1] Misprogramming PCA concentration leads to dosing errors, Institute for Safe
Medication Practices, August 28, 2008,
http://ismp.org/newsletters/acutecare/articles/20080828.asp, retrieved January
24, 2015
[2] Misprogram a PCA Pump? It's Easy!, Institute for Safe Medication Practices,
July 29, 2004, https://ismp.org/newsletters/acutecare/articles/20040729_2.asp,
[3] Part II - How to prevent errors - Safety issues with patient-controlled
analgesia, Institute for Safe Medication Practices, July 24, 2003,
http://www.ismp.org/newsletters/acutecare/articles/20030724.asp, retrieved
January 24, 2015
Q1015EXPL
When evaluating the suitability of a home to perform home hemodialysis, all of
the requirements indicated in this question need to be considered.
Water is a critical part of the dialysis procedure, so the quality and pressure
of the water must be adequate to assure that a sufficient volume of pure water is
available to allow the safe preparation of the dialysate solution.
Similarly, some dialysis machines have special electrical requirements. Because

of the relatively high current requirements of some machines, it may be necessary
to insure that the machine will be on a dedicated circuit so that power to the
machine will not be interrupted by an overloaded circuit.
In addition, a dialysis machine can produce a large amount of waste water. While
this should not be a problem for a patient whose home receives municipal water
and sewer service, if the home is on a septic system, the volume of waste water
needs to be considered to verify that the system can handle the anticipated extra
load.
Finally, the dialysis machine itself along with all of the supplies associated
with the machine can require a considerable amount of space. So the evaluation of
the home needs to look at whether or not the space available is adequate.
Reference:
[1] Frequently Asked Questions About Home Dialysis: Will my home need changes for
home dialysis?, Davita website, http://www.davita.com/treatment-options/benefits-
of-dialyzing-at-home/what-is-home-dialysis/frequently-asked-questions-about-home-
dialysis/t/5369&cmp=dva0113_home_lp_largest_provider, retrieved January 24, 2015
[2] Lore, Gordon, Home Hemodialysis Patient Advocate George Harper Doesn't Let
Retirement Slow Him Down One Bit, For Patients Only magazine, March/April 1997,
http://www.cc.utah.edu/~cla6202/GeoH.htm, retrieved January 24, 2015
Q1016EXPL
In order to use a ventilator in the home, there are many factors that need to be
considered.
Electrical requirements are a key consideration. The amount of electricity

available in the home and its reliability must be assessed to determine that a
ventilator's power requirements are met.
The ventilator itself will need to be located close to the patient, so the
available space in the patient's home needs to be evaluated to assure this can be
done safely. In addition, there are many supplies associated with the ventilator,
and these will need to be stored properly so that they remain clean and available
for use. There is also a need to assure that there is space available to properly
clean all of the equipment associated with the ventilator.
While the ventilator itself does not use water, there must be adequate water
available to properly clean the equipment, to wash hands, and to provide water
for the humidifer that is generally used in conjunction with the ventilator.
Depending upon the specific needs of the patient, there may also be a need to
prepare solutions, such as a saline solution. If this is to be done, rather than
purchasing pre-made solutions, there must be clean water available to allow the
solutions to be properly and safely made.
Reference:
[1] Home Ventilator: Patient Instructions, Apria Healthcare, page 7,
http://www.apria.com/wps/wcm/connect/15b8635f-a5b8-4d08-91eb-9b1fc27fedea/RES-
2041+Home+Ventilator.pdf?MOD=AJPERES, retrieved January 25, 2015
Q1019EXPL
Any of these problems identified in this question could cause the basin to not
fill correctly. Without more information, it is not possible to isolate the
problem.
Low incoming water pressure could cause the basin to not fill completely in the
time allotted by the control mechanism. Similarly, if the water valve was not
opening properly, or if the incoming water filter was clogged, the basin might
not fill completely. If the controller were not properly activating the water
valve for the amount of time required to fill the basin, this also could account
for the problem.
Reference:
None
Q1020EXPL
When dealing with any equipment, it is important to keep in mind what the
equipment was designed to do. In this case, the purpose of an OR Status Camera is
to allow a gross overview of the status of a case. It is not designed to allow
remote observation of the detailed view of the progress of a case. If that is
what the surgeon wants, other systems will need to be purchased and deployed that
allow a much higher resolution remote view of an OR procedure.
It is not within your scope as a BMET to purchase that equipment for the OR or
the surgeon. Of course, if the camera is not working correctly, it should be
repaired, but, assuming it is working as designed, then the surgeon should be
informed of that fact, and reminded about the overall purpose of the Status
Camera.
Replacing the display in the surgeon's office with a larger display will not fix
the problem. The resolution on the screen is only going to be a good as the
resolution provided by the camera, regardless of the size of the display.
Reference:
None
Q2006EXPL
The skin has three primary layers: the epidermis, the dermis, and the
subcutaneous layer. The outermost portion of the epidermis is the stratum
corneum. It contains several layers of dead cells on the skin's surface, which
impede measurements. In order to get a good quality, low-impedance electrical
connection to the skin, the skin is usually cleaned to remove a portion of the
stratum corneum.
Typically, the contact resistance of skin is reduced by shaving excessive hair,
cleaning the skin with alcohol and allowing the skin to completely dry, rubbing
the skin with a mild abrasive to remove its outermost layer, and using a
conductive gel where the electrode is applied to the skin.
Reference:
[1] Baura, Gail D., Medical Device Technologies, A System Based Overview Using
Engineering Standards, Academic Press, Boston, Massachusetts, 2012, page 14.
[2] Skin, https://en.wikipedia.org/wiki/Skin, retrieved July 9, 2018.
[3] Stratum corneum, https://en.wikipedia.org/wiki/Stratum_corneum, retrieved

July 9, 2018.
Q2007EXPL
Microtomes are laboratory instruments used for cutting extremely thin slices of
tissue. It is essentially an ultrafine "deli-slicer." Before being sliced, the
tissue is infiltrated with (embedded in) paraffin, forming a block. The paraffin
replaces the water in the sample, allowing for its long-term preservation. The
microtome advances the tissue block in micrometer increments across a cutting
knife so that very thin slices of tissue (generally 2 to 50 μm in thickness) are
obtained. These tissue sections are then mounted on glass slides for subsequent
staining or other processing. Once all that is completed, the sample can be
examined with a light.
A cryostat (or cryostat microtome) is a specialized type of microtome that

freezes the sample quickly before slicing it. This allows much more rapid
examination of the tissue sample (5 minutes versus 16 hours of preparation) and
is often used in conjunction with medical procedures that require a quick
diagnosis. Typically, a cryostat is used while a patient is still in surgery to
determine if all of the diseased tissue (such as cancerous tissue) has been
excised.
References:
Delmar Cengage Learning, Clifton Park, NY, 2010, page 588.
[2] Microtome, https://en.wikipedia.org/wiki/Microtome, retrieved July 9, 2018.
Q2008EXPL
A cryostat is a specially designed microtome contained in a refrigerated chest
and is used to slice frozen sections of a tissue sample. A microtome is
essentially an ultrafine "deli-slicer" used to make very thin slices of tissue to
be examined under a microscope. The microtome portion of the cryostat has a very
sharp wheel to cut very thin tissue slices (generally 5 to 15 μm thick).
The temperature can be varied, depending on the tissue being cut. Most tissues
are processed at about -20 degrees Celsius, although different types of tissue
may use different temperatures.
A cryostat (or cryostat microtome) freezes the tissue sample quickly before
slicing it. This allows much more rapid examination of the tissue sample (5
minutes versus 16 hours of preparation) and is often used in conjunction with
medical procedures that require a quick diagnosis. Typically, a cryostat is used
while a patient is still in surgery to determine if all of the diseased tissue
(such as cancerous tissue) has been excised.
The sample quality of a standard, fixed-section paraffin wax-mounted sample is

generally much better than that of a frozen section. The cost of processing a
frozen section is comparable to that of a fixed section. Both frozen sections and
fixed sections are read by highly trained personnel, usually a histology
laboratory pathologist.
References:
Delmar Cengage Learning, Clifton Park, NY, 2010, page 588.
[2] Cryostat, Biological microtome type,

https://en.wikipedia.org/wiki/Cryostat#Biological_microtome_type, retrieved July
9, 2018.
[3] Fischer, Andrew H., Jacobson, Kenneth A., Rose, Jack, and Zeller, Rolf,
Cryosectioning Tissues,
http://cshprotocols.cshlp.org/content/2008/8/pdb.prot4991.full
Q2009EXPL
Pressure is an important physiological parameter and measurements of various
pressures are often used as part of the diagnosis of a patient's condition. Some
of the typical pressures that can be measured in the human body include arterial
blood pressure, central venous pressure, pulmonary artery pressure, left
ventricular end-diastolic pressure, and intracranial pressure. These pressures
can be measured with a manometer, or, alternatively, with a pressure transducer.
In the United States, blood pressure is generally recorded in millimeters of
mercury (mm-Hg), while other pressures are often recorded in centimeters of water
(cm-H2O). In European countries, blood pressures are generally recorded in
kiloPascals (kPa).
Manometers are one of the earliest pressure measuring instruments and continue in
wide use today because of their inherent accuracy and simplicity of operation.
Manometer measurements are functions of gravity and the liquid's density. The
field of hydrostatics deals with the characteristics of a liquid at rest, a
condition that applies for manometer measurements.
For a simple U-tube manometer, such as those shown below, if the pressure on both
arms is the same, then the height of the liquid in each arm will be the same.
This is the condition for the manometer on the left, where both arms are open to
atmospheric pressure. On the other hand, if there is a difference in the
pressures on each arm, then the height of the liquid on each side will be
different. For the manometer shown on the right side of the diagram, the pressure
on the left arm, P2, is greater than the pressure on the right arm, P 1. This
generates a height different of h, where h can be found from the equation: h =
[(P2 - P1) / ρg]
where:
h = difference in column heights
P2 = pressure at the high pressure connection
P1 = pressure at the low pressure connection
ρ = density of the indicating fluid
g = gravitational constant (acceleration due to gravity)
The third reference below, the article on Central Venous Pressure Monitoring, has
a diagram illustrating how a water manometer would be used in a clinical setting
to measure central venous pressure.
References:
[1] Thomas, Dave, Manometer Basics, Sensors Online,
https://www.sensorsmag.com/components/manometer-basics, retrieved July 10, 2018
[2] Applications of Hydrostatics,

http://www.mne.psu.edu/cimbala/Learning/Fluid/Hydrostatics/applications.htm,
[3] Central Venous Pressure Monitoring, https://nursekey.com/central-venous-

pressure-monitoring/, retrieved July 10, 2018
Q2010EXPL
When measuring blood pressure using a sphygmomanometer, the sphygmomanometer cuff
pressure is increased until the brachial artery is completely occluded, blocking
all blood flow below the sphygmomanometer cuff. A stethoscope placed on the
brachial artery at the elbow is used to listen for sounds associated with blood
flow. Those sounds are known as Korotkoff sounds.
The cuff pressure is reduced until the first Korotkoff sounds are heard. The
initial sound corresponds to turbulent blood flow in the brachial artery caused
by the artery opening when the instantaneous blood pressure in the artery is
higher than the cuff pressure, and then closing when the pressure drops below the
cuff pressure. The first sounds corresponds to the systolic blood pressure, while
the final sounds correspond to the diastolic blood pressure.
In this problem, the systolic pressure is 150 mmHg, which is where the first
sounds are heard. The Korotkoff sounds continue until the blood flow becomes
laminar, signifying that the brachial artery is no longer occluded. This happens
when the lowest pressure in the artery (the diastolic pressure) is above the cuff
pressure. In this problem, the diastolic pressure is approximately 110 mmHg.
The drawing below shows the method used to manually measure blood pressure.
source: https://www.researchgate.net/figure/Measurement-of-blood-pressure-with-a-
sphygmomanometer-9_fig4_43940731, uploaded by Harshad Sanghvi
References:
[1] Blood Pressure Measurement, University of California San Diego,
http://isn.ucsd.edu/courses/beng186b/lectures/beng186b-lecture13-notes.pdf,
retrieved July 12, 2018.
[2] BENG 186B Winter 2014, Quiz 3, University of California San Diego,
http://isn.ucsd.edu/courses/beng186b/reviews/Practice_Q3_2014_solutions.pdf,
Q2011EXPL
When measuring blood pressure using a sphygmomanometer, the sphygmomanometer cuff
pressure is increased until the brachial artery is completely occluded, blocking
all blood flow below the sphygmomanometer cuff. A stethoscope placed on the
brachial artery at the elbow is used to listen for sounds associated with blood
flow. Those sounds are known as Korotkoff sounds.
The cuff pressure is reduced until the first Korotkoff sounds are heard. The
initial sound corresponds to turbulent blood flow in the brachial artery caused
by the artery opening when the instantaneous blood pressure in the artery is
higher than the cuff pressure, and then closing when the pressure drops below the
cuff pressure. The first sounds corresponds to the systolic blood pressure, while
the final sounds correspond to the diastolic blood pressure.
The drawing below shows the method used to manually measure blood pressure.
source: https://www.researchgate.net/figure/Measurement-of-blood-pressure-with-a-
sphygmomanometer-9_fig4_43940731, uploaded by Harshad Sanghvi
References:
[1] Blood Pressure Measurement, University of California San Diego,
http://isn.ucsd.edu/courses/beng186b/lectures/beng186b-lecture13-notes.pdf,
[2] BENG 186B Winter 2014, Quiz 3, University of California San Diego,
http://isn.ucsd.edu/courses/beng186b/reviews/Practice_Q3_2014_solutions.pdf,
Q1016EXPL
Carbon dioxide (CO2) production is a byproduct of cell metabolism. In the
capillaries, CO2 is transferred from the cells into the blood, which then carries
CO2 into the lungs. CO2 is then excreted by the lungs during ventilation. Since
ETCO2 is a result of metabolism, circulation, and respiratory effectiveness,
changes in exhaled CO2 can indicate changes in all of these body functions.
End-tidal carbon dioxide (ETCO2) (also called capnometry or capnography)

monitoring is a non-invasive technique that provides continuous monitoring of the
level of carbon dioxide in the expired air. Because ETCO 2 monitoring is done non-
invasively, and provides continuous monitoring of the status of the patient's
respiration, circulation, and metabolism, it is generally used in almost all
surgical cases where patients are given general anesthesia.
The ETCO2 monitor displays the partial pressure of CO2 in the expired air at the
end of exhalation, when the CO2 is the highest.
The capnograph displays the value of the partial pressure of CO 2 throughout the
respiratory cycle. The capnometer displays the single value of the partial
presssure of CO2 at the end of expiration. This is the ETCO 2 value.
There are two primary types of ETCO2 monitors: sidestream and mainstream. Each
uses infrared absorption of CO2. The sidestream technique relies on a separate
monitor or analyzer connected to the patient's airway by tubing. It withdraws air
from the patient's airway, passes it through a water trap to remove patient
secretions, and finally performs carbon dioxide analysis. Mainstream monitors use
a sensor placed directly in the ventilator airway circuit. They allow a more
rapid response time and requires a smaller amount of sample gas than sidestream
monitoring, but they add weight on the airway.
Each measures the amount of infrared light absorbed by the CO 2 in the sample of
gas. Carbon dioxide's infrared absorption characteristics are different from
those of other gases involved in respiration, allowing this technique to be used
to determine CO2 levels.
Blood gas analysis is only used in a limited number of surgical cases. This
technique requires that a blood sample be taken either via a single arterial
puncture or an arterial catheter. While it is considered the most accurate
measurement of the levels of oxygen and carbon dioxide in the blood, its use in
surgery is limited. This is because it requires a blood sample, and only
generates a value for the single point in time when the sample was taken.
Collecting the blood sample from an arterial puncture requires expertise and
skill. For a conscious patient, this can be a painful procedure. In addition,
because of the time required to collect the blood sample and then run it through
the appropriate laboratory analyzer, it can require a significant amount of time.
Blood gas analysis is useful for critically ill patients in the intensive care
unit (ICU), where the values of blood gases may need to be monitored over a
period of several days.
Pulse oximetry is a non-invasive technique for measuring the oxygen saturation of

the hemoglobin in the blood. It relies on the fact that oxyhemoglobin absorbs
light differently than deoxygenated hemoglobin. The pulse oximetry sensor is
generally placed on a finger, and the characteristics of the light transmission
through the finger are used to determine the oxygen level. While pulse oximetry
is generally used in surgery, the value generated by this test can be affected by
problems such as poor circulation in the extremities, anemia, blood volume
deficiencies, and the presence of carbon monoxide in the blood. Further, while
the oximeter can determine the level of oxygen in the blood, it responds much
less quickly to changes in the patient's metabolic or circulatory status.
Therefore, ETCO2 is considered the more reliable measure of a patient's
respiratory, circulatory, and metabolic status.
Venous blood is blood that has passed through the cells, and has a much lower
level of oxygen than arterial blood, which is coming directly from the lungs.
Therefore, to determine the effectiveness of respiration, a clinician would
examine the levels of respiratory gases (oxygen and carbon dioxide) in arterial
blood, rather than venous blood.
References:
[1] How capnograph monitors work explained simply,
https://www.howequipmentworks.com/capnography/, retrieved August 5, 2018.
[2] Bauman, Mark and Cosgrove, Cindy, Understanding End-Tidal CO2 Monitoring,
American Nurse Today, November 2012, Vol.7, No. 11,
https://www.americannursetoday.com/understanding-end-tidal-CO2-monitoring/,
retrieved August 5, 2018.
[3] Capnometry/Capnography, https://www.ebme.co.uk/articles/clinical-

engineering/16-capnometry-capnography, retrieved August 5, 2018.
[4] Huttmann, Sophie E., Windisch, Wolfram, and Storre, Jan H., Techniques for
the Measurement and Monitoring of Carbon Dioxide in the Blood, Annals of the
American Thoracic Society, Vol. 11, No. 4, May 01, 2014.
Q1017EXPL
Carbon dioxide (CO2) production is a byproduct of cell metabolism. In the
capillaries, CO2 is transferred from the cells into the blood, which then carries
CO2 into the lungs. CO2 is then excreted by the lungs during ventilation. Since
ETCO2 is a result of metabolism, circulation, and respiratory effectiveness,
changes in exhaled CO2 can indicate changes in all of these body functions.
End-tidal carbon dioxide (ETCO2) (also called capnometry or capnography)

monitoring is a non-invasive technique that provides continuous monitoring of the
level of carbon dioxide in the expired air. Because ETCO 2 monitoring is done non-
invasively, and provides continuous monitoring of the status of the patient's
respiration, circulation, and metabolism, it is generally used in almost all
surgical cases where patients are given general anesthesia.
The ETCO2 monitor displays the partial pressure of CO 2 in the expired air at the
end of exhalation, when the CO2 is the highest.
References:
[1] How capnograph monitors work explained simply,
https://www.howequipmentworks.com/capnography/, retrieved August 5, 2018.
[2] Bauman, Mark and Cosgrove, Cindy, Understanding End-Tidal CO2 Monitoring,
American Nurse Today, November 2012, Vol.7, No. 11,
https://www.americannursetoday.com/understanding-end-tidal-co2-monitoring/,
[3] Capnometry/Capnography, https://www.ebme.co.uk/articles/clinical-

engineering/16-capnometry-capnography, retrieved August 5, 2018.
[4] Huttmann, Sophie E., Windisch, Wolfram, and Storre, Jan H., Techniques for
the Measurement and Monitoring of Carbon Dioxide in the Blood, Annals of the
American Thoracic Society, Vol. 11, No. 4, May 01, 2014.
Q2020EXPL
Blood samples are routinely taken to assess the health of a patient. One test
frequently done on a blood sample is a blood cell count, which determines how
many red and white blood cells are found in a specified volume of blood. A low
red blood cell count, for example, might indicate that a person has anemia, while
a high red blood cell count may be an indication of heart disease. A high white
cell count might be a sign of an infection, while a low count might be a sign of
a serious disease, including cancer. So, the ability to accurately and quickly
count the number of different blood cells in a sample is an important diagnostic
tool.
Before the development of automated blood cell counters, blood counts were done
by a technician who would count the number of cells in a drop of blood smeared on
a slide by looking through a microscope. This method was slow and prone to error.
In 1953, engineer Wallace H. Coulter proposed a method to count and measure the
size of particles suspended in a fluid. This Coulter counter, using a method he
called the "electric sensing zone," uses the difference in resistance between a
particle and the surrounding fluid.
To perforrm counts, the Coulter method pulls blood particles through an orifice.
Blood cells are relatively poor conductors of electricity in comparison to the
diluent fluid. As the blood cells flow through the orifice, the blood cell
produces a change in electrical impedance that is proportional to the size of the
particle traversing the orifice. If the current between the two electrodes is
being monitored, each drop in the current can be noted and the particles
"counted." The result is a count of cells of different sizes. Because white blood
cells are slightly larger than red blood cells, they will show different
impedances as they go through the orifice, making it possible to differentiate
between them when the count is performed.
Thus, the Coulter counter relies upon a change in electrical impedance to count
blood cells.
The drawing below shows the concept behind the change in impedance caused by a
particle flowing through an orifice.
source:
https://en.wikipedia.org/wiki/Coulter_counter#/media/File:Particle_Transit_Channe
l.gif by Reimar Spohr - own work, CC BY-SA 3.0,
https://commons.wikimedia.org/w/index.php?curid=16938198
References:
[1] Dondelinger, Robert M., Hematology Analyzers, Biomedical Instrumentation &
Technology, July 2009, vol. 43, no. 4, pages 300-304.
[2] Lesson: Particle Sensing: The Coulter Counter,

https://www.teachengineering.org/lessons/view/duk_retcoulter_les1, retrieved
August 12, 2018.
Q2021EXPL
Of all the tasks listed, replacing defibrillator batteries that are reaching the
end of their useful life presents the highest risk to the patients and therefore
should be completed first. The scheduled maintenance and incoming inspection
tasks can wait another day until the assigned technician or others on her team
can help get those completed. Most of the time, a common sense risk assessment
will prevail, although management may make regulatory-required inspections a
higher priority.
References: None
Q2022EXPL
One way that ICU patient monitors measure respiration is by measuring the
changing transthoracic impedance with each breath. As the lungs fill with air,
there is a small impedance change between the ECG electrodes connected to the
Right Arm and Left Leg. To measure this impedance, a small AC current is applied
between these electrodes and the changing impedance (approximately half an ohm)
can be measured and then used to display as a respiration waveform and/or just
the respiration rate.
Reference:
[1] Respiration Rate Measurement Based on Impedance Pneumography, Texas
Instruments, http://www.ti.com/lit/an/sbaa181/sbaa181.pdf, retrieved August 12,
2018
Q2023EXPL
The ETCO2 (end tidal CO2) value is a measure of the level of the partial pressure
of carbon dioxide at the end of expiration. There are a number of equipment
problems that could cause the level of ETCO 2 to start increasing, even if the
patient appears to be stable.
The CO2 absorber is the part of the anesthesia machine that is responsible for
removing CO2 from the inspired air going into the patient's lungs. If the absorber
is no longer capable of removing CO2, because it is exhausted, then the level of
CO2 in the inspired air would rise, and this would lead to a rise in the CO 2 of
the expired air.
Similarly, if there were inadequate fresh gas flows, the CO 2 getting to the
patient would increase, leading to an increase in the amount of CO 2 in the expired
air.
If the ventilator tubing were leaking, it could have the same effect, providing
inadequate ventilation of the patient's lungs, leading to an increase in ETCO 2.
Finally, if the ventilator itself malfunctioned, depending upon the nature of the
malfunction, it could also account for an increase in the ETCO 2 level.
However, if the sample tubing had developed a leak, for example, because the
tubing connection to the breathing circuit or the ETCO 2 inlet port became loose,
then it is likely that the amount of CO2 getting to the CO2 monitor's inlet port
would decrease, because more room air, which has a lower level of CO2 in it, would
get to the monitor. As a result, you could expect the ETCO 2 level to decrease.
Therefore, this could not account for the observed problem.
Reference:
[1] Capnography Waveform Interpretation, Life in the Fast Lane,
https://lifeinthefastlane.com/ccc/capnography-waveform-interpretation, retrieved
August 13, 2018
Q2028EXPL
A primary factor in setting the priority for repair of a failed medical device is
the impact on patient care. If the lack of availability of the device has a
significant adverse effect on patient care, especially with regard to patient
safety or continuity of care, then there is reason to move up the priority.
Even if the failure does not substantially affect patient care, some equipment
failures can have significant adverse effects on hospital finances. For example,
if an operating room is out of service because of an equipment failure, surgical
cases may need to be rescheduled or cancelled. Even if the effect on patient care
is negligible, the impact on revenue could be significant. Similarly, if some
imaging or laborabory equipment is unavailable, especially if backup equipment is
not readily available, it may have the same effect. Therefore, it is appropriate
to consider hospital finances when assigning a priority to a repair.
The availability of alternative devices should also be considered. If another

device is available that can serve the same purpose as the failed device (in the
inventory or readily available from a rental provider, for example), it may be
reasonable to reduce the repair priority. Indeed, redundancy can be an effective
tool for improving reliable access to important devices.
If immediate repair is not essential, it also makes sense to consider

alternatives to repair. In some cases, it may be more economical to replace some
devices than to repair them.
Reference: None
Q2029EXPL
Three of the methods identified here measure blood pressure non-invasively by
using a blood pressure cuff to occlude an artery (typically, the brachial artery
above the elbow). These methods are the ausculatory, oscillometric, and Doppler
ultrasound methods. As the pressure in the cuff is reduced, the pressure at which
blood flow resumes is the patient's systolic blood pressure. As the cuff pressure
is further reduced, the pressure at which there is no longer any restriction in
blood flow is the patient's diastolic blood pressure. These methods differ in how
they identify the changes in blood flow.
Auscultatory method: The operator uses a stethoscope to identify changes in the

sound of blood flow in the patient's artery (alternatively, this can be
accomplished electronically by monitoring the sound with a microphone). The
operator (or electronic device) monitors Korotkoff sounds, which vary with
restrictions in blood flow. The Korotkoff sounds reflect the turbulent flow of
blood in the artery. As the cuff pressure is reduced, the Korotkoff sounds appear
at the beginning of blood flow, which indicates the patient's systolic blood
pressure. When the cuff pressure is between the systolic and diastolic pressures,
blood flow in the artery occurs for only a portion of the heart cycle, leading to
turbulent flow when the arterial blood flow starts and stops. As the cuff
pressure is further reduced, the Korotkoff sounds become "muffled" and eventually
disappear. The point at which the Korotkoff sounds disappear is when the cuff
pressure is equal to the patient's diastolic blood pressure.
Oscillometric method: In oscillometric NIBP devices, the pressure in the cuff is

monitored electronically. The systolic pressure level is identified by the onset
of oscillations in the cuff pressure that correspond to the patient's heartbeat.
The diastolic pressure level is identified by the cessation of these oscillations
as the cuff pressure no longer restricts the patient's blood flow.
Doppler ultrasound: In Doppler ultrasound NIBP devices, heartbeat-to-heartbeat

changes in blood flow rates are monitored electronically. Characteristic changes
are used to identify when systolic and diastolic blood pressure levels are
reached.
The fourth method that can be used to detect blood pressure non-invasively does
not use a cuff to occlude blood flow. This is the arterial tonometry method.
Instead, arterial blood pressure is measured directly by an electronic sensor
that is applied above the patient's artery, where the artery is directly above a
bone. Generally, this method uses a sensor placed on the wrist above the radial
artery. This method can produce good quality pulse waveforms, but accurate
systolic and diastolic numbers can be difficult to obtain.
The final choice in this question, arterial cannulation, is an invasive method

used for the determination of blood pressure. In this method, a catheter
(cannula) is inserted into an artery. Typically, the radial artery in the forearm
is used as the catheter insertion site. Tubing then connects the catheter to an
external pressure transducer, which is then used to continuously monitor the
blood pressure.
References:
[1] Chan, AYK, Biomedical Device Technology: Principles and Design (2nd edition),
Charles C Thomas Publisher, Ltd., 2016, pages 350-361.
[2] Blood pressure measurement,

https://en.wikipedia.org/wiki/Blood_pressure_measurement, retrieved September 5,
2018.
[3] Birch, Tony, Continuous non-invasive blood-pressure measurements,

http://www.maths-in-medicine.org/uk/2007/blood-pressure, retrieved September 5,
2018.
Q2030EXPL
EEG electrode placement has been standardized by the use of the 10-20 system.
This is an internationally recognized system used to describe the placement of
electrodes based upon standard locations on the skull. The system is designed to
provide uniform coverage of the entire scalp. The numbers 10 and 20 refer to the
relative distances between adjacent electrodes. Under this system, adjacent
electrodes are either 10% or 20% of the total front-back or right-left distance
of the skull.
The four anatomical landmarks used by this sytem are:
1. Nasion, which is the point between the forehead and the nose. This is also
referred to as the root of the nose.
2. Inion, which is the lowest point of the skull from the back of the head. For
most people, there is a prominent bump in this location. This is also referred to
as the occipital lobe ossification.
3. Right pre-auricular point, which is the point on the skull just in front of
the right ear.
4. Left pre-auricular point, which is the point on the skull just in front of the
left ear.
While the vertex of the skull is an important anatomical landmark on the skull,
it is not used as a landmark for the determination of EEG electrodes in the 10-20
system.
The second reference below (10/20 System Positioning Manual) provides diagrams
and detailed information about how to locate the skull landmarks used by the 10-
20 system, and how to use these landmarks to correctly place EEG electrodes.
References:
[2] 10/20 System Positioning Manual, Trans Cranial Technologies,

https://www.trans-cranial.com/local/manuals/10_20_pos_man_v1_0_pdf.pdf, retrieved
September 6, 2018.
Q2031EXPL
One of the common modes of operation for mechanical ventilators is controlled
mandatory ventilation (CV). This mode consists of ventilator-initiated mandatory
(VIM) breaths at prescribed time intervals. It is used for patients who cannot
breathe for themselves.
PEEP may be used with mandatory breath to maintain the lung at a positive
pressure at the end of expiration. It can be used to increase the patient's
arterial oxygen saturation without increasing the inspired oxygen percentage.
All of the other suggested answers are entirely made up.
References:
[2] Positive end-expiratory pressure, https://en.wikipedia.org/wiki/Positive_end-

expiratory_pressure, retrieved September 7, 2018.
Q2034EXPL
The problem is described as just affecting a single bed (one patient). The
important observation here is that Lead I (lead 1) shows up fine on the monitor.
If we were looking at a network problem, then none of the leads would appear on
the monitor. If even a single lead is being displayed, we know that the
connection to the network is probably functioning properly.
Once the network problem is eliminated as a cause, we can look at the various
lead wires and electrodes. Recall that Lead I (lead 1) uses the Right Arm (RA)
and Left Arm (LA) connections. Therefore, we can conclude that both of those
connections are good. Lead II (lead 2) uses the Right Arm (RA) and Left Leg (LL)
connections. As this is not working, it is reasonable to conclude that there is a
problem with either the lead wire going to the left leg, or that electrode.
Changing the LL lead wire, the LL electrode, and/or the ECG cable would be
logical next steps in determining the source of this problem before looking for a
problem with the wireless network.
References:
[1] 12-Lead ECG Placement Guide with Illustrations,
https://www.cablesandsensors.com/pages/12-lead-ecg-placement-guide-with-
illustrations#31, retrieved September 7, 2018.
[2] Einthoven's Triangle, https://en.wikipedia.org/wiki/Einthoven%27s_triangle,

Q2035EXPL
First, because beds 2, 3, 4, 7 and 8 appear to be sending data and it is being
displayed on the central station monitor, it is reasonable to conclude that the
central station is working properly.
Therefore, you should look for something else that is common between beds 1, 5
and 6. A reasonable assumption is that we are looking at intermittent signal loss
or dropout communication issues (e.g. packet loss).
Depending on the layout of the unit, one access point may be servicing beds 1, 5,
and 6. If that is the case, then a failure of this access point could account for
the problem seen in this question. Further troubleshooting of the wireless system
is the logical next step for troubleshooting.
Reference: None
Q2036EXPL
Since all of the displays for rooms 1 through 8 are working properly in the
central telemetry monitoring area (central telemetry studio), which should
display the same information as the central station display on the inpatient
floor, we can rule out several of the choices presented. Specifically, it is very
unlikely to be a problem with:
- the telemetry acquisition computer system
- a connectivity problem with the central telemetry monitoring display
- a wireless network problem
- a bad batch of electrodes
The choice that is left, a failure of the inpatient floor central station display
for rooms 1 through 8, is a reasonable assessment of the problem. It might be
something as simple as the central station display becoming unplugged, or a
disconnection of the network cable going to that display. Alternately, it might
be a problem with the electronics in the display itself that is preventing the
display of the monitoring data from rooms 1 through 8. At this point, the job of
the BMET is go investigate further why the data is not being displayed on that
monitor.
Reference: None
Q2037EXPL
The ophthalmoscope is an instrument for inspecting the interior of the eye.
During an eye examination, the ophthalmoscope is used to inspect the interior of

the eye. The ophthalmoscope directs a bright light through the pupil of the eye
by bouncing light from a light bulb against a mirror or prism so it is directed
into the interior of the eye.
at the back of the eye, including the retina, optic disk, retinal blood vessels,
To measure how well a patient can see from side to side, a visual field test is
performed. Typically, this test would be used to detect if a patient is
developing glaucoma; although it can also be useful for detecting other
conditions that affect the quality of a person's peripheral vision.
Electrical waveforms are typically examined with an oscilloscope.
A Snellen chart is usually used to measure visual acuity in both adults and
children. This chart presents a series of letters of different sizes, and the
patient is asked to identify the letters being shown to them. Patients who are
able to identify smaller letters accurately have better visual acuity than those
who are only able to identify larger letters at the same distance. For children
who are unable to correctly identify letters, alternate format charts are
available to test their visual acuity, such as a "tumbling E" chart, which shows
the letter E in different orientations, and a chart that shows different common
objects, such as a house, umbrella, and apple, or a chart with different types of
animals being displayed.
References:
September 10, 2018.

[3] What are the different types of visual field tests?,

https://www.medicinenet.com/visual_field_test/article.htm#what_are_the_different_
types_of_visual_field_tests, retrieved September 10, 2018.
[4] Snellen chart, https://en.wikipedia.org/wiki/Snellen_chart, retrieved

September 10, 2018.
[5] Visual acuity, https://en.wikipedia.org/wiki/Visual_acuity, retrieved

September 10, 2018.
Q2038EXPL
The pupil is a hole through which the eye's interior can be viewed.
During an eye examination (funduscopy), the ophthalmoscope is the instrument used

to inspect the interior of the eye. The ophthalmoscope directs a bright light
through the pupil of the eye by bouncing light from a light bulb against a mirror
or prism so it is directed into the interior of the eye.
at the back of the eye, including the retina, optic disk, retinal blood vesses,
The iris is the colored portion of the eye. Muscles in the iris can contract or
relax to allow less or more light into the eye.
The cornea of the eye is the front of the eye. It covers the iris, pupil, and
anterior chamber of the eye. It, along with the lens, serves as an optical system
that focuses light coming into the eye on the retina.
The lens is a structure behind the cornea that helps to focus light coming into
the eye on the retina. Muscles in the eye are used to change the shape of the
lens to help focus light coming from objects at different distances.
The retina is the light-sensitive layer of cells found at the back of the eye.
When light is focused on the retina, the many cells in the retina are activated
to allow the individual to see what is in front of the eye. The retina contains
specialized cells that allow vision under dim lighting conditions (rods, used
mainly for black-and-white images), as well as other cells that allow color
vision under brighter lighting conditions (cones).
References:
September 10, 2018.

[3] Iris (anatomy), https://en.wikipedia.org/wiki/Iris_(anatomy), retrieved

September 10, 2018.
{4} Cornea, https://en.wikipedia.org/wiki/Cornea, retrieved September 10, 2018.
[5] Lens (anatomy), https://en.wikipedia.org/wiki/Lens_(anatomy), retrieved

September 10, 2018.
[6] Retina, https://en.wikipedia.org/wiki/Retina, retrieved September 10, 2018.
Q2040EXPL
A ventilator is a machine designed to move breathable air into and out of the
lungs to facilitate the oxygenation of the blood, along with the removal of
carbon dioxide. In hospitals, standalone ventilators are found in intensive care
units, while other ventilators are integrated into anesthesia machines, where
they are used during surgery. Because of its role in sustaining the life of a
patient who is unable to breathe without assistance, it is very important that
this be a highly reliable device. As a ventilator contains a number of mechanical
components that are subject to wear, it is advisable to scrupulously follow the
manufacturer's recommendations with regard to preventive maintenance (PM)
intervals, calibration, and performance verification tests.
Optimum ventilator operation depends on regular preventive maintenance that

includes cleaning or replacing inlet filters, lubricating valves, and servicing
compressors. Manufacturers often provide PM kits specifically designed to replace
worn components at various intervals. While most manufacturers specify that
preventive maintenance be performed after a specified number of hours of
operation, a biomedical equipment technician should review the service manual for
any particular ventilator model to determine the specific requirements for each
type of ventilator he or she is responsible for maintaining.
References:
[1] Fanning, James, Breathe New Life Into Your Ventilator Repair Skills,
Biomedical Instrumentation & Technology: January 2006, Vol. 40, No. 1, pages 35-
36.
[2] Medical ventilator, https://en.wikipedia.org/wiki/Medical_ventilator,

[3] Breathing, https://en.wikipedia.org/wiki/Breathing, retrieved September 11,

2018.
Q2041EXPL
A ventilator is a machine designed to move breathable air into and out of the
lungs to facilitate the oxygenation of the blood, along with the removal of
carbon dioxide. In hospitals, standalone ventilators are found in intensive care
units, while other ventilators are integrated into anesthesia machines, where
they are used during surgery. Because of its role in sustaining the life of a
patient who is unable to breathe without assistance, it is very important that
this be a highly reliable device.
Because ventilators are designed to move air into and out of a patient's lungs,
they contain air flow circuits that include air pressurized above atmospheric
pressure. It is not uncommon for the tubing, tubing connections, bellows, valves,
and related components to develop leaks over time. Since the internal pressures
need to remain within precise specifications to assure proper operation of the
ventilator, any leaks need to be promptly corrected.
Often the first sign of a leak is a sound that is outside of the normal sounds
produced by the ventilator. Other possible indications of a leak might include
the loss of volume delivered by the ventilator, or an inability to maintain
pressures within normal operating values. If any of these symptoms develop, they
should be investigated. It is important that the clinical staff be able to depend
upon the ventilator to sustain the patient's life.
Diagnostic self-test routines can be useful tools in isolating a problem to a

particular system. Error codes stored in the ventilator's event log may also be
helpful in identifying the source of a leak or other problem.
References:
[1] Fanning, James, Breathe New Life Into Your Ventilator Repair Skills,
Biomedical Instrumentation & Technology: January 2006, Vol. 40, No. 1, pages 35-
36.
[2] Medical ventilator, https://en.wikipedia.org/wiki/Medical_ventilator,

[3] Breathing, https://en.wikipedia.org/wiki/Breathing, retrieved September 11,

2018.
Q2042EXPL
A sequential compression device (SCD) is a piece of medical equipment that
inflates specialized cuffs placed on the legs to stimulate circulation. These
cuffs have multiple chambers that inflate sequentially to force blood out of the
limb. The cuffs are most commonly placed on the legs after surgery to reduce the
likelihood of a patient developing a deep vein thrombosis (DVT). A DVT is a blood
clot that develops in a vein. The danger is that the clot may then travel to the
lungs, causing a pulmonary embolism (PE). A PE can be fatal.
A patient is most at risk for developing a clot in the lower legs because most
bedridden patients are less likely to move their legs than their arms. However,
in some cases, an SCD cuff will be placed on an arm.
An SCD also helps prevent swelling (edema) of a limb because the sequential
compression of the SCD cuff also helps force lymph fluid out of the limb.
The SCD sleeves are designed to wrap around the legs. Each sleeve contains
several air chambers. These chambers are inflated with air one at a time to help
force blood out of the leg. This compression action imitates the pressures
produced in the circulatory system by walking and helps prevent blood pooling in
the veins, where it might tend to form clots.
References:
[1] What Is a Sequential Compression Device?, https://www.wisegeek.com/what-is-a-
sequential-compression-device.htm#didyouknowout, retrieved September 11, 2018.
[2] Protect Yourself from Deep Vein Thrombosis with Sequential Compression Device
(SCD), University of Michigan Health System,
https://www.med.umich.edu/1libr/NursingUnits/SCD.pdf, retrieved September 11,
2018.
[3] Feldman JL, Stout NL, Wanchai A, Stewart BR, Cormier JN, Armer JM,
Intermittent Pneumatic Compression Therapy: A Systematic Review, Lymphology, 45
(2012), pages 13-25, also available at
https://www.researchgate.net/publication/228437510_Intermittent_pneumatic_compres
sion_therapy_A_systematic_review, retrieved September 11, 2018.
Q2043EXPL
In the auscultatory method of blood pressure determination, the clinician places
a cuff on the arm so it occludes blood flow in the brachial artery, and then uses
a stethoscope to identify changes in the sound of blood flow in the patient's
artery. The operator monitors Korotkoff sounds, which vary with restrictions in
blood flow. The Korotkoff sounds reflect the turbulent flow of blood in the
artery. As the cuff pressure is reduced, the Korotkoff sounds appear at the
beginning of blood flow, which indicates the patient's systolic blood pressure.
When the cuff pressure is between the systolic and diastolic pressures, blood
flow in the artery occurs for only a portion of the heart cycle, leading to
turbulent flow when the arterial blood flow starts and stops. As the cuff
pressure is further reduced, the Korotkoff sounds become "muffled" and eventually
disappear. The point at which the Korotkoff sounds disappear is when the cuff
pressure is equal to the patient's diastolic blood pressure.
As this question indicates, there are five phases of Korotkoff sounds. Phase I of
the Korotkoff sounds represents the subject's systolic blood pressure. On the
other hand, Phase V of the Korotkoff sounds represents the subject's diastolic
blood pressure. Phases II and III have no significance in blood pressure
measurement.
While Phase IV does not by itself indicate either the systolic or diastolic
value, its onset alerts the clinician that the diastolic blood pressure level is
approaching.
References:
[1] Korotkoff sounds, https://en.wikipedia.org/wiki/Korotkoff_sounds, retrieved
September 30, 2018.
[2] Blood pressure measurement,

https://en.wikipedia.org/wiki/Blood_pressure_measurement, retrieved September 30,
2018.
Q2044EXPL
Einthoven's triangle is an imaginary formation that represents the three basic
leads used in electrocardiography.
The voltage difference recorded between the right arm (-) and left arm (+) is
called Lead I.
The voltage difference recorded between the right arm (-) and left leg (+) is
called Lead II.
The voltage difference recorded between the left arm (-) and left leg (+) is Lead
III.
The right leg (RL) electrode is not used to form any of the three standard leads
in electrocardiography, although it may be used as a reference point to improve
the electrocardiographic signal.
If any of the Lead I, II, or III electrodes are reversed, the

electrocardiographic signal is inverted. Although Einthoven's triangle is no
longer used as originally developed, it remains as a fundamental concept
describing the differences in electrocardiographic signals.
Additional leads are also often recorded. These are referred to as the augmented
unipolar limb leads. aVL is recorded by finding the voltage between the left arm
lead (+) and an average of the right arm and left leg leads (-). aVR is recorded
by finding the voltage between the right arm lead (+) and an average of the left
arm and left leg leads (-). The final augmented lead, aVF, is recorded by finding
the voltage between the left leg lead (+) (the F stands for foot) and an average
of the right arm and left arm leads (-).
Reference:
[1] Einthoven's triangle, https://en.wikipedia.org/wiki/Einthoven%27s_triangle,
Q2045EXPL
Physiologic simulators are available for many physiologic parameters. They are
used to test and calibrate physiologic monitoring devices that monitor those
parameters. Of the choices listed, four are available from simulators that are
generally available in most clinical engineering departments: ECG, blood
pressure, SpO2 and respiration rate. Many simulators combine all four of these
parameters into a single test device, allowing a technician to quickly test a
common bedside monitor with just one device.
The references below provide additional information on simulators offered by two

widely used commercial manufacturers.
ECG (electrocardiogram) simulators produce electrical signals that simulate the

electrocardiogram.
BP (blood pressure) simulators simulate various parameters (e.g., systolic and

diastolic pressure for both invasive and non-invasive measurement techniques, as
well as the sounds or oscillations used by non-invasive blood pressure
measurement techniques).
SpO2 simulators produce signals that simulate various signals for blood oxygen
saturation that are measured by pulse oximeters.
Respiration simulators are able to produce waveforms very similar to the

respiration waveform seen when using changes in trans-thoracic impedance, as
measured by electrodes applied to the chest, to determine respiration rate.
Creatinine clearance rate is a laboratory measurement that is used to assess how

well a patient's kidneys are working. Creatinine is a waste product produced by
the normal breakdown of muscle tissue. The kidneys are responsible for removing
creatinine from the blood. This in turn is used to estimate the glomerular
filtration rate, which is a direct measurement of the ability of the kidney to
filter blood. If the level of creatinine is outside the normal range, it could be
an indication of an obstruction within the kidney, kidney failure, or congestive
heart failure. At this time, creatinine clearance is not measured by bedside
monitors, and so there is no need to produce simulators.
References:
[1] Fluke Biomedical: Patient Simulators,
https://www.flukebiomedical.com/products/biomedical-test-equipment/patient-
monitor-simulators, retrieved October 2, 2018.
[2] Pronk Technologies: Products, https://www.pronktech.com/products. retrieved

October 2, 2018.
Q2046EXPL
Commonly available ECG (electrocardiogram) simulators can simulate a wide variety
of parameters, including heart rate, ECG amplitude, ECG waveform, and the various
waveforms typically seen when displaying different ECG leads. However, an ECG
simulator is not able to simulate the signals used by cardiac output monitors.
The references below show ECG simulators produced by two companies, and describe
the parameters that the simulators are able to produce.
Perhaps the most critical parameter is accurately producing different heart

rates. This capability can be used to verify that an ECG monitor displays the
correct heart rate. It can also be used for verifying the function of heart rate
alarms.
In some cases, the amplitude of the signal produced is important. For example,
for a diagnostic ECG, it is essential that amplitude of an ECG signal is
accurately produced on the screen or strip chart. This information is used by
cardiologists to diagnose cardiac function.
The waveform for a particular ECG lead can also be important for more
sophisticated monitoring systems. For example, simulation of arrythmias (e.g.,
runs of PVCs or premature ventricular contractions) support the testing and
calibration of monitoring systems that are capable of arrythmia detection.
ECG waveform simulation can also be used in training clinicians to recognize ECG
patterns and diagnose cardiac problems.
References:
[1] Fluke Biomedical: Patient Simulators,
https://www.flukebiomedical.com/products/biomedical-test-equipment/patient-
monitor-simulators, retrieved October 2, 2018.
[2] Pronk Technologies: Products, https://www.pronktech.com/products. retrieved

October 2, 2018.
[3] Premature ventricular contraction,

https://en.wikipedia.org/wiki/Premature_ventricular_contraction, retrieved
October 2, 2018.
[4] Electrocardiography, https://en.wikipedia.org/wiki/Electrocardiography,

retrieved October 2, 2018.
Q2047EXPL
A forced warm air unit works by forcing warm air through a blanket that is placed
on the patient. The blanket is perforated with thousands of tiny holes that allow
the warm air to escape all around the patient. A forced air unit does not have an
associated water pump, so this choice could not account for a problem with a
forced air warmer. The other components indicated (over-temperature system,
blower motor, temperature sensor, and a heater) are all part of the system that a
forced warm air unit uses to produce the heated air it uses to warm a patient and
to keep it within a safe range so that a patient will not be burned accidentally,
so any of them could account for a problem with the temperature regulation
system.
Typical problems seen with these devices include a temperature sensor failure.
Similarly, malfunctioning blower motors and blower motors with missing propellers
may reduce the flow and reduce the air temperature. If no heat is being produced
at all, the heater may have failed.
Forced air warmers and hypo/hyperthermia units are commonly used during and after
surgery to help the patient return to normal temperature. Different manufacturers
use different mechanical methods to achieve this. The most common patient warming
devices either blow warm air into a blanket or circulate warm water through a
pad. While the forced air units only serve to heat the patient, a
hypo/hyperthermia unit contains a compressor that allows it to either cool the
circulating water, or to heat it, depending upon what is required in a particular
situation.
When attempting to check the performance of hypo/hyperthermia devices and forced

air warmers, the technician should always verify that the temperature and flow
specifications published by the manufacturer are being met.
References:
Instrumentation & Technology, September 2008, vol. 42, no. 5, pages 369-370.
[2] Forced Air Warming, https://the37company.com/forced_air_warming_0, retrieved

October 3, 2018.
[3] 3M Bair Hugger Model 750 Warming Unit Service Manual,

http://multimedia.3m.com/mws/media/798433O/model-750-service-manual-english.pdf,
Q2048EXPL
Aspirators are typically used to remove fluid from body cavities. For example,
during surgery, an aspirator may be used to remove blood, fluids, tissue, or any
other foreign materials and irrigating fluids that accumulate in the operating
field and obstruct the surgeon's ability to visualize what is being repaired.
Aspirators can also be used to remove mucosal secretions in patients with
compromised swallowing or coughing reflexes.
Ventilators aid patients in breathing. A clamp is typically used during surgery

to either hold something out of the way or to close off a blood vessel to keep
blood out of the area where the surgeon is operating. A dilator is used to widen
an orifice. A centrifuge is used separate blood into its different components.
References:
[1] Aspirator (medical device),
https://en.wikipedia.org/wiki/Aspirator_(medical_device), retrieved October 3,
2018.
[2] Aspirator, http://www.who.int/medical_devices/innovation/aspirator.pdf,

Q2049EXPL
A significant danger that a technician might encounter when servicing an
aspirator is the presence of bodily fluids that are trapped inside the device.
Aspirator components come in direct contact with bodily fluids, so it is
essential that a technician utilize PPE (personal protective equipment, such as
wearing gloves, face shields or masks, and gowns) when troubleshooting and
cleaning an aspirator or any suction device.
Because aspirators may be used to remove viscous materials, such as mucus from an
airway, they need to produce large amounts of suction. For example, the aspirator
described in the second reference below is rated to produce 550 mm-Hg.
The tubing that is used with an aspirator is considered a single-use disposable.

It should not be cleaned. It should be disposed of as medical waste, since it has
been in contact with bodily fluids.
While the tubing used with an aspirator is disposable, the aspirator itself is
not. A malfunctioning aspirator is generally repairable by most biomedical
equipment technicians.
While an aspirator is an important device for the treatment of patients, it is

not considered a life support device. If an aspirator were to fail while it is
being used on a patient, the patient would not be in immediate danger.
The most common aspirator malfunctions are clogs, leaks, and motor failures. The
technician needs to check for tube and filter blockages or tubing kinks. An
improperly set up collection container, such as one with a poorly fitting lid,
might cause a leak which would reduce the suction available to the clinician.
References:
[1] Wolfe, Glen L., Suction Devices: Troubleshooting in a Vacuum, Biomedical
Instrumentation & Technology, July 2007, vol. 41, no. 4, pages 295-297.
[2] Allied Healthcare Products DC Portable Aspirator Operation/Service Manual,

https://www.global-medical-
solutions.com/assets/images/Manuals/AlliedHealthcare/Allied-G-180-Suction-zs168-
507-001_h.pdf, retrieved October 3, 2018.
Q2050EXPL
A uroflowmeter is a device that measures urine flow rates during urination.
Uroflowmetry (also known as a urine flow test) is a diagnostic procedure that

helps a clinician determine the function of the lower urinary tract, and can help
determine if there is an obstruction that is causing a change in the normal urine
flow pattern. Some of the reasons that a person might not have a normal urine
flow pattern include benign prostatic hypertrophy (BPH), prostate cancer, bladder
cancer, urinary tract blockage, a problem with the nerves that control the
bladder, or a urinary tract infection.
To perform a uroflowmetry test, the patient is asked to urinate into a special

funnel that is connected to the uroflowmeter. This measuring instrument
calculates the amount of urine, rate of flow, and length of time until completion
of the void. This information is converted into a graph, where it can be viewed
by a clinician for interpretation. The clinician will need to take into account
the person's gender and age to determine whether or not the observed test results
fall within the normal range.
During normal urination, the initial urine stream starts slowly, but almost
immediately speeds up until the bladder is nearly empty. The urine flow then
slows again until the bladder is empty. If there is a urinary tract obstruction,
the flow pattern will be different, usually increasing and decreasing more
gradually.
A sphygmomanometer is a device used to determine blood pressure.
A ureteroscope is an instrument designed to examine the insides of the urinary

tract, including the urethra (the tube leading from the bladder), the bladder,
and the ureters (the tubes leading from the kidneys into the bladder).
A bladder scanner is a portable ultrasound device that is used to determine the

volume of urine retained within the bladder. Bladder scans are a non-invasive
test that are often performed on hospital inpatients.
A peak flow meter is a device that is used to determine how quickly air comes out
of the lungs after taking a deep breath. It is frequently used by asthma patients
to help quantify the severity of an asthma episode, and to determine how well
asthma symptoms are being controlled by a treatment regimen.
References:
[1] Uroflowmeter, https://medical-dictionary.thefreedictionary.com/uroflowmeter,
[2] Urine Flow Test,

https://www.hopkinsmedicine.org/healthlibrary/test_procedures/urology/urine_flow_
test_92,P07724, retrieved October 5, 2018.
[3] Uroflowmetry, http://columbiaurology.org/staywell/document.php?id=38551,

[4] Sphygmomanometer, https://en.wikipedia.org/wiki/Sphygmomanometer, retrieved

October 5, 2018
[5] What is ureteroscopy?, https://www.webmd.com/kidney-stones/what-is-

ureteroscopy#1, retrieved October 5, 2018.
[6] Bladder Scans: Preventing Unnecessary Procedures, https://www.rn.com/rn-

news/bladder-scans-preventing-unnecessary-procedures/, retrieved October 5, 2018.
[7] Peak Flow Meters, http://www.aafa.org/peak-flow-meters/, retrieved October 5,

2018.
Q2051EXPL
Audiometers are used to determine if a person has a hearing loss, and if there is
a loss, to quantify the extent of that loss. These instruments aid in the
diagnosis of hearing loss, and are able to measure any improvement seen over the
course of treatment.
Audiometers generate sounds at specific frequencies and sound levels to measure

individual threshold hearing levels. The results are then shown on an audiogram
in either a graphic or tabular format, or both.
An otoscope is used to examine the ear canal. While an examination of the ear
canal can help a clinician determine if there is a cause for a hearing loss
related to the ear canal, such as excessive ear wax, or a punctured ear drum, the
otoscope does not quantify the extent of hearing loss.
An ophthalmoscope is used to examine the inner eye.
A sphygmomanometer is used to measure blood pressure.
An electroencephalogram (EEG) is an instrument used to detect the electrical

activity of the brain. While this sometimes can be used to help diagnose the
cause of a hearing loss, by itself, the EEG is not used to determine the presence
of a hearing loss.
References:
[1] Dondelinger, Robert M., Audiometersâ€”A Closer Look. Biomedical
Instrumentation & Technology: May/June 2010, vol. 44, no. 3, pages 216-220.
[2] Audiometer, https://en.wikipedia.org/wiki/Audiometer, retrieved October 7,

2018.
[3] Otoscope, https://en.wikipedia.org/wiki/Otoscope, retrieved October 7, 2018.

October 7, 2018.
[5] Sphygmomanometer, https://en.wikipedia.org/wiki/Sphygmomanometer, retrieved

October 7, 2018.
[6] Electroencephalography, https://en.wikipedia.org/wiki/Electroencephalography,

Q2052EXPL
An audiometer must be treated as a complete system. Therefore, when replacing any
component, such as the headphones, the audiometer must be recalibrated to be sure
that a known sound intensity is coming out of each earpiece at the frequencies
used by the audiometer.
Some of the regulatory requirements related to audiometer performance are

established by the US Occupational Safety and Health Administration (OSHA)
because of its mandate to protect hearing in the workplace. OSHA requirements
include that audiometers be individually managed. Maintenance activities must be
tracked by either the device's serial number and/or a unique maintenance
management control number. The maintenance organization responsible for the
audiometer's performance must maintain documentation demonstrating that the
audiometer is properly calibrated.
While audiometers generally are reliable, problems with them are not uncommon
because of the large amount of handling that headphones experience. For example,
headphones often experience significant wear and tear as they are flexed to fit
on to different size patients several times each day.
Perhaps the most common problem experienced by the operator of an audiometer is
the accidental reversal of the earphones so that the right earphone is on the
left ear, and the left earphone is on the right ear. If this happens, the
information registered for the hearing ability of each ear will correspond to the
wrong ear.
References:
[1] Dondelinger, Robert M., Audiometersâ€”A Closer Look. Biomedical
Instrumentation & Technology: May/June 2010, vol. 44, no. 3, pages 216-220.
[2] Audiometer, https://en.wikipedia.org/wiki/Audiometer, retrieved October 7,

2018.
Q2053EXPL
Jaundice is caused by high levels of bilirubin, which is an orange/red pigment
produced by the normal breakdown of red blood cells. Bilirubin is removed from
the bloodstream by the liver. Some newborns develop a high level of bilirubin
because their immature liver is not able to remove the bilirubin quickly enough.
When this happens, bilirubin becomes deposited in the fatty tissue under the
baby's skin. The results is that the skin and the whites of the eyes appear
yellow.
For some newborns, whose jaundice is not resolving quickly enough, treatment with
phototherapy lights is required. This treatment uses a high intensity light at
the blue end of the spectrum. When skin with high levels of bilirubin are exposed
to these lights, the bilirubin breaks down into other products that can be more
easily removed from the bloodstream by the kidneys and the digestive system. The
phototherapy lights used for this treatment are often called "bili lights."
The lamps in these devices need to be periodically tested and replaced. The
intensity of the blue light produced by these lamps is checked to verify that it
remains in the appropriate therapeutic range.
The overall light intensity produced by the phototherapy light is not critical,
as only light in the blue range acts to break down bilirubin.
The therapeutic performance of phototherapy lights is not affected by the unit's

sound intensity, electrical power consumption, or chassis electrical leakage
current.
Reference:
[1] Phototherapy for neonatal jaundice: optimal wavelengths of light,
https://www.ncbi.nlm.nih.gov/pubmed/6875728, retrieved October 7, 2018.
[2] Bili lights, https://medlineplus.gov/ency/article/002394.htm, retrieved

October 7, 2018.
[3] Your Baby, Jaundice, and Phototherapy,

http://www.med.umich.edu/1libr/pa/umphototherapy.htm, retrieved October 7, 2018.
[4] Light therapy, https://en.wikipedia.org/wiki/Light_therapy, retrieved October

7, 2018.
Q2054EXPL
Respiratory depression is a known risk factor for opioid medications. The etCO 2
(end tidal CO2) value is a measure of the level of the partial pressure of carbon
dioxide at the end of expiration. Opioid drugs can often cause a decrease in
respiration (respiratory depression) that will typically be seen soonest as an
increase in etCO2.
Oxygen saturation (SpO2) will also decrease, but not as quickly as etCO 2 will
increase if respiratory depression reaches a dangerous level.
Heart rate (HR) may change, but it generally reacts much more slowly than etCO 2
after an opioid overdose.
Changes in temperature and blood pressure, if any, are late indicators of

respiratory problems.
Reference:
[1] Clinical Experience with Capnography Monitoring for PCA Patients,
https://www.apsf.org/article/clinical-experience-with-capnography-monitoring-for-
pca-patients, retrieved October 7, 2018.
Q2056EXPL
Pulse oximeters measure SpO2 and the pulse optically by examining changes in the
absorption of certain wavelengths of light by the blood. This is typically done
by using a non-invasive sensor attached to a finger. To get accurate
measurements, the finger needs to have good blood circulation.
Non-invasive blood pressure devices inflate a cuff placed on the upper arm to
temporarily stop circulation in order to measure systolic and diastolic blood
pressures. If SpO2 and NIBP are done on the same arm, the NIBP measurement can
decrease blood flow enough that there could be intermittent SpO 2 errors or erratic
SpO2 readings in sync with the blood pressure measurement.
Reference:
[1] Zoll E Series, Non-Invasive Blood Pressure (NIBP), https://www.zoll.com/-
/media/public-site/products/e-series/9650-1214-01-rev--g.ashx, page 4, retrieved
October 7, 2018.
Q2057EXPL
Every manufacturer of pulse oximeters must do in vivo testing of their products
to match their pulse oximeter's SpO2 readings to arterial blood gases. This
testing is used to create ratio (or "R") value curves. Therefore, each
manufacturer's device "calibration" is not based solely on electronics or optical
calibration, but is based on clinical experimentation and statistics.
Therefore, pulse oximeter test devices need to match these clinically-determined

"R" values, and those values will be different for each pulse oximeter
manufacturer, based upon the statistics collected by each manufacturer during its
own independent clinical trials. For this reason, one simulator cannot be used to
test all oximeters without some reconfiguration of that simulator to take into
account the specific manufacturer's equipment being tested.
In addition, while pulse oximeters are very accurate (usually to within 2%), the
simulators that produce a signal designed to test an oximeter can only produce an
approximation of the signal seen when the oximeter is placed on a patient.
Therefore it is also true that the simulators are less accurate than the pulse
oximeters they are testing.
While oximeters do use patented technology to determine oxygen saturation values,

simulators for a particular manufacturer's product are generally available from
several different companies. They do not need to be purchased from the
manufacturer of a particular oximeter. In fact, most simulator manufacturers are
not affiliated with any oximeter manufacturer.
Reference:
[1] There's no such thing as a SpO2 simulator, Fluke Biomedical White Paper,
http://cdn.24x7mag.com/x7mag/2015/04/6001759A_There-is-no-such-thing-as-a-SpO2-
simulator_w.pdf, retrieved October 7, 2018.
Q2059EXPL
While all of these devices (SCDs, physiological monitors, ESUs, surgical lasers,
and heart-lung bypass machines) are commonly used in operating rooms, only one of
them is likely to be placed underneath the operating table while in clinical use.
That is the SCD (sequential compression device).
All of the other devices referenced require good visibility, convenient access,
and ongoing interaction with OR personnel during their operation. Therefore, they
are unlikely to be placed underneath the OR table in a position near the OR table
column.
On the other hand, an SCD can typically be set up to operate without user
attention. In addition, it tends to be significantly smaller than the other
devices, making it a prime candidate for being inappropriately placed on the OR
table base, where it can be hidden by surgical drapes. For these reasons, an SCD
unit may be put in a position where it can potentially interfere with OR table
movement, and possibly causing damage to the table if personnel are not aware of
the presence of the SCD when the table is lowered.
Reference: None
Q2060EXPL
Having HTM personnel test the bulb will have no significant effect on
reliability. It will only identify a failure at the time of testing. Other than
the replacement of defective bulbs, there is no preventive maintenance performed
on light bulbs that will reduce the probability of future failures.
Similarly, placing spare bulbs where they are accessible to users will not
improve reliability. Its only potential effect would be increased convenience,
allowing staff to more quickly replace a defective bulb when that occurs.
LED bulbs are much more reliable than incandescent bulbs. Replacing incandescent
bulbs with this more reliable alternative may be a cost-effective way to improve
reliability and reduce maintenance costs.
In general, turning off the otoscope/ophthalmoscope unit will have no effect on

the bulb's reliability. This is because for most units, power is only provided to
the bulb when the handle is removed from its holder. Even if the main power
switch to the unit is turned on, the bulb will be turned off as long as the
handle is in its holder.
Reference: None
Q2061EXPL
When an otoscope or ophthalmoscope fails, the user will generally be aware of
this immediately because the unit will not produce the light needed for the
user's clinical examination. While this can be quite annoying, in most cases,
there is a minimal effect on patient safety because backup units (another
battery-operated unit that can provide a substitute for either a wall-mounted
unit or a different battery-operated unit that has failed) are usually available
a relatively short distance away from the place where the failure occurred. For
this reason, the interruption in patient care tends to be fairly brief.
The one choice that is not correct relates to the classification of an otoscope
as life support equipment. Otoscopes are used to assess a patient's ear canal, so
that the clinician can diagnose such problems as a perforated eardrum or an ear
infection. If an otoscope were to not be operational, the clinician's diagnosis
might be delayed, but it is very unlikely that the patient would be in any
immediate danger.
For these reasons, otoscope/ophthalmoscope units are often placed into an AEM
(alternative equipment maintenance) program that modifies manufacturer's
recommendations for PM (planned maintenance). This can reduce PM time while
preserving equipment safety and meeting accreditation standards.
Reference:
[1] Baretich, MP, AEM Program Guide: Alternative PM for Patient Safety,
Association for the Advancement of Medical Instrumentation, 2018.
Q2062EXPL
Feeding pumps typically have a flow rate accuracy ranging between +/-5% to +/-
10%, depending upon the particular pump model, so the pump should be checked to
make sure it is operating within the manufacturer's specifications. Each pump
should be checked against the manufacturer's literature to determine the
specification for the particular feeding pump being used.
Even if the manufacturer's literature confirms that the particular pump in

question has a 10% accuracy rating, given the nurse's concern, it would still be
appropriate to check out the pump. In this case, the pump appears at first glance
to be operating within about -9% accuracy (1,100 ml delivered, when the pump was
expected to deliver 1,200 ml, for an actual delivery of 1100/1200 = 91.7%), which
would be close to the lower limit of the accuracy specification. In addition, it
is reasonable to be concerned about the nurse's description of the situation.
While the nurse's judgment should be taken at face value, it is possible that
both the time estimate and the remaining fluid estimate could be off. For all
these reasons, it is appropriate to verify the pump's accuracy.
There is no reason to calibrate feeding pumps to 5% unless that is the
manufacturer's specification for this particular pump model.
The pump should not be recalibrated nor sent back to the manufacturer until after
its flow rate has been accurately measured and determined to be out of
calibration.
While it is common for the pharmacy to overfill a fluid bag to allow extra fluid
for priming sets, without first testing the pump to verify its accuracy, there is
no reason to believe that the amount of overfill in the fluid bag was outside the
pharmacy's specification.
Reference:
[1] Feeding Pumps and Sets, https://www.feedingtubeawareness.org/feeding-pump,
Q2063EXPL
A sequential compression device (SCD) is used to apply intermittent pressure to
limbs, typically the legs, to prevent to formation of a deep vein thrombosis.
Although the high pressure alarm could be caused by a use error, for example, as
the result of kinked tubing or the improper placement of the SCD sleeves, the
pressure settings on the SCD should be checked to make sure they are in
calibration. If there is a log file maintained by the SCD, then the log file
should also be checked to see what information might be stored about the errors
noted by the nurse.
It is not appropriate to send out the SCD for repair or exchange (depending upon
the contract that the hospital has with the pump manufacturer) until at least
some preliminary testing is done by the technician to verify that there is likely
to be a problem.
The reference below is for one particular type of SCD and provides
troubleshooting guidance and general operation information that is typical for
many SCD systems.
Reference:
[1] Kendall SCD 700 Sequential Compression System,
http://www.medtronic.com/content/dam/covidien/library/us/en/product/vascular-
compression/kendall-scd-700-series-controller-operation-and-service-manual.pdf,
page EN-14, retrieved October 14, 2018.
Q2065EXPL
Microtomes are used to cut thin sections from tissues for slides being prepared
for visualization under a microscope. These slides are typically prepared with
paraffin and therefore the microtome cutting these thin sections often gets
contaminated with paraffin. To maintain good performance, the microtome should be
frequently cleaned to remove any paraffin buildup.
There are two general types of microtomes used in medical environments. The
rotary microtome is used to slice sections of a sample embedded in paraffin.
Preparation of these tissue samples can take as long as 48 hours before they are
ready for examination under a microscope.
The second type of microtome is a cryostat microtome. This microtome rapidly

freezes the sample, allowing it to be cut into thin slices. Because this type of
sample preparation can be done in under an hour, this device is generally used
during surgery to determine if all of the tissue that was supposed to be removed
has been removed. For example, this would be used to allow a pathologist to
examine tissue for the presence of cancer to make sure all of the cancerous
tissue was removed, but only minimal amounts of healthy tissue.
Electrical chassis leakage current and electrical shock are not significant
hazards for microtomes any more than for any other electrically powered lab
instrument.
Infection prevention methodologies are the same for microtomes as for any other
lab instrument. (i.e., personnel operating the instrument should employ
appropriate personal protective equipment).
References:
[1] [Histonet] Cleaning of microtomes and accessories,
http://www.histosearch.com/histonet/Dec05/HistonetCleaningofmicroto.html,
[2] An Introduction to Specimen Preparation,

https://www.leicabiosystems.com/pathologyleaders/an-introduction-to-specimen-
preparation, retrieved October 14, 2018.
Q2066EXPL
Enteral tube feedings are used to deliver nutrients directly into the stomach.
For short-term feedings (typically, a few days), the enteral feeding tube used is
usually a nasogastric (NG) tube that is placed through the nose into the stomach.
When a patient requires a tube feeding for a longer period, a percutaneous
endoscopic gastrostomy (PEG) tube will be used. This tube is surgically implanted
into the patient through a hole cut into the patient's skin with the end of the
PEG tube in the patient's stomach.
For some patients, the end of the tube may be placed in the jejunum, the section
of the small intestine that comes after the duodenum. The duodenum is the section
of the small intestine that connects directly to the stomach. When the nutrition
is being delivered directly into the jejunum, then either a nasojejunal (NJ) tube
or a PEG tube with a jejunal extension (PEG-J) tube may be used, depending upon
whether the tube is passed through the nose, or through the skin.
To control enteral tube feedings, an enteral feeding pump is usually used. This
pump allows the nutrition being delivered by the tube to enter the tube in a
controlled manner, at a rate specified by the provider. The pump will also have
alarms that can identify problems, such as an occluded tube.
Note that an enteral feeding tube uses the gastrointestinal tract to deliver
nutrients. If a patient's digestive system is not able to properly digest the
nutrition being provided to the patient through an enteral feeding tube, then
parenteral feeding might be used instead. In that case, nutrients are sent
directly into the veins using an intravenous (IV) catheter. For that scenario, an
IV infusion pump would be used instead of an enteral feeding pump, because of the
more precise control and additional alarms required when sending any fluid
directly into the circulatory system.
While the esophagus, colon, mouth and liver are all different parts of the
digestive system, enteral nutrition is most often delivered into the stomach.
References:
[1] What is an Enteral Feeding Pump?, https://www.wisegeek.com/what-is-an-
enteral-feeding-pump.htm, retrieved December 13, 2018.
[2] What is Tube Feeding?,

https://www.talkaboutwhatmatters.org/documents/Tools/Decision-Guide-Tube-
Feeding.pdf, retrieved December 13, 2018.
[3] Enteral and Parenteral Nutrition, http://patients.gi.org/topics/enteral-and-

parenteral-nutrition, retrieved December 13, 2018.
[4] Enteral Nutrition: Enteral Nutrition (EN), tube feeding, is given via
different types of tubes, https://pinnt.com/Enteral-Nutrition.aspx, retrieved
December 13, 2018.
Q2067EXPL
An enteral feeding pump is an electronic pump that moves nutrients through a
feeding tube at a controlled rate. The prescribed amount of nutrition is
programmed into the electronic enteral feeding pump, which then controls the flow
of the nutrition so that the patient gets a measured amount of liquid
continuously.
An enteral feeding pump is designed to be a significantly more accurate delivery

mechanism than the alternative enteral nutrition delivery methods of gravity or
manually pushed syringe feeding. In addition, enteral feeding pumps generally
incorporate sensors to detect various potential alarm conditions, such as an
occluded feeding tube, the completion of a feeding, or an empty nutrition fluid
bag. This alarm detection capability makes an enteral feeding pump a safer
delivery mechanism than the alternatives.
A syringe pump would not be used to deliver enteral nutritional support to an

adult because of the large volumes required. However, syringe pumps will
sometimes be used to control enteral feedings given to neonates, who require much
less fluid than an adult.
An intravenous (IV) pump is generally used only to control fluid delivery into a
vein. Parenteral nutrition, which is delivered in this way, would be controlled
with an IV pump.
A bolus pump is not a real device. However, insulin pumps are often designed to
allow them to deliver a bolus dose of insulin when that is needed.
References:
[1] Enteral Tube-Feeding: Understanding the Basics,
https://www.neocate.com/blog/enteral-tube-feeding-understanding-basics, retrieved
December 13, 2018.
[2] What is an Enteral Feeding Pump?, https://www.wisegeek.com/what-is-an-

enteral-feeding-pump.htm, retrieved December 13, 2018.
[3] Feeding Pump Alarms and Errors, https://www.feedingtubeawareness.org/feeding-

pump-alarms-and-errors, retrieved December 13, 2018.
Q2068EXPL
Accuracy is often expressed as an allowable percentage error. In this case, the
expected fluid volume would be 672 mL, which is 84 mL/hr multiplied by 8 hours.
The formula for calculating percent error is:
percent error = [(measured value - expected value) / (expected value)] X 100%
For our example:
percent error at upper limit = [(706 mL - 672 mL) / 672 mL] X 100%
percent error at upper limit = (34 mL / 672 mL) X 100%
percent error at upper limit = 0.051 X 100% = 5.1%
Similarly, at the lower allowable limit:
percent error at lower limit = [(638 mL - 672 mL) / 672 mL] X 100%
percent error at lower limit = (-34 mL / 672 mL) X 100%
percent error at lower limit = -0.051 X 100% = -5.1%
Therefore, the pump's accuracy specification is approximately +/- 5%, and for
this particular test, the expected result would typically be expressed as 672 mL
+/- 5%.
References:
[1] Johnson, Curtis D., Process Control Instrumentation Technology, Pearson
Education, Upper Saddle River, New Jersey, 1988, page 27.
[2] Abbott FreeGo Enteral Feeding Pump Operator Manual,

http://www.eastcheshire.nhs.uk/About-The-Trust/policies/N/Nutrition%20-
%20Abbott%20FreeGo%20Enteral%20Feeding%20Pump%20Operator%20Manual.pdf, retrieved
December 13, 2018.
[3] Calculate Percent Error, https://sciencenotes.org/calculate-percent-error,
Q2069EXPL
Probably the most used statistic is the arithmetic average (also known as the
arithmetic mean, sample mean or simply the mean) of the sample values.
To find the mean, simply add up all the numbers and then divide by the number of
samples. For this problem:
mean = (sum of samples) / (number of samples)
mean = (4.94 + 4.96 + 5.03 + 4.96 + 4.99 + 5.00 + 4.96 + 4.97 + 4.98 + 5.00) / 10
mean = 49.79 / 10
mean = 4.979
Therefore, in this case, the mean value of these ten measurements is 4.979 mm-Hg.
References:
[1] Scheaffer, Richard L. and McClave, James T., Probability and Statistics for
Engineers, Duxberry Press, Boston, 1986, page 197.
[2] How to Find the Mean, https://www.mathsisfun.com/mean.html, retrieved

December 13, 2018.
Q2070EXPL
The 10–20 system or International 10–20 system is an internationally recognized
method to describe the location of scalp electrodes in the context of an EEG
exam. This system defines standard locations on the scalp where electrodes are
applied to record EEG (electroencephalograph) signals.
The system relies on the identification of specific anatomical landmarks. Once

those are found, the 10 and 20 refer to distances of 10% and 20% between those
landmarks used to place the electrodes. The specific landmarks that are used to
position the electrodes are:
* Nasion - the depressed area between the eyes, just above the bridge of the
nose.
* Inion - the crest point of the back of the skull
* Preauricular point - the point just in front of the ear
* Skull circumference - as drawn from just above the ears, just above the bridge
of the nose, and just above the occipital point
Once these points are located, electrodes are placed along the lines drawn from
the nasion to inion, left preauricular point to right preauricular point, and
along the skull circumference. In total, 21 electrodes will be placed on the
scalp in the specific locations identified by the 10-20 system. However, for
other types of EEG exams, either fewer or more electrodes might be used.
This method was developed to maintain standardized testing methods ensuring that
a subject's study outcomes (clinical or research) could be compiled, reproduced,
and effectively analyzed and compared using the scientific method. The system is
based on the relationship between the location of an electrode and the underlying
area of the brain, specifically the cerebral cortex.
The 10-20 system has nothing to do with the algorithm used to process the EEG. It
also does not refer to the frequency range of EEG signals. The minimum bandpass
of an EEG machine is usually between 1 and 35 Hz, although a wider frequency
range is often used.
The 10-20 system also does not have anything to do with the type of electrode
used to record EEG signals.
The number of waveforms (or channels) displayed during an EEG exam can vary.
Typical EEG records show either 8 or 16 channels. While the waveform shown in a
particular channel depends upon the electrode placement, the signals from the
various electrodes can be combined in several different ways (similar to the
combining of ECG electrodes to create many different standard and augmented
leads). But the 10-20 system does not define the number of channels to be
displayed.
References:
[1] 10-20 system (EEG), https://en.wikipedia.org/wiki/10%E2%80%9320_system_(EEG),
[2] 10/20 System Positioning Manual, https://www.trans-

cranial.com/docs/10_20_pos_man_v1_0_pdf.pdf, retrieved December 2, 2018.
[3] Electroencephalography, https://en.wikipedia.org/wiki/Electroencephalography,

Q2071EXPL
A cryostat is a rotary microtome placed in a refrigerated cabinet, typically
cooled to -30° Celsius, that slices frozen-tissue specimens, as compared to
histology specimens prepared by a tissue processor. The slices are generally
several micrometers thick and must be viewed quickly. Frozen sections are
completed in minutes, rather than hours or days, to get a gross reading.
Frozen sections are used when a quick determination has to be made, typically
while the patient is on the operating table. This type of exam is often used when
excising cancerous tissue. As it can be difficult for a surgeon to visually
identify cancerous cells from non-cancerous ones, the typical approach used is to
remove tissue conservatively, and then have a pathologist review a frozen section
to determine if all of the cancerous tissue has been removed. If the microscopic
examination shows that the tissue margins still contain cancerous cells, the
surgeon will remove more tissue, if possible, until only non-cancerous cells
remain. This is usually an iterative process, with a little more tissue taken
each time, and then examined, until the surgeon is satisfied that all of the
cancerous tissue that can be safely removed has been, while sparing as much of
the non-cancerous tissue as possible.
A portion of the specimen will also be sent through the full tissue preparation
process for a definitive diagnosis.
The cryostat microtome is not used to preserve frozen samples. That would be done
in a freezer.
A microscope would be used to magnify the slices taken from the frozen samples so
that a pathologist could examine them. The pathologist would be the person
responsible for analyzing the images seen under the microscope.
Frozen samples are not stained. When a sample is processed for a traditional
histology examination, it is embedded in paraffin, sliced into thin sections with
a microtome, and then stained to highlight different features so that the sample
can be more easily examined under a light microscope. However, this type of
tissue processing will often take more than a day, and so is not appropriate for
intraoperative use.
Reference:
[1] Laboratory Devices, Part 3, http://www.24x7mag.com/2007/01/article-18468/,
[2] Cryostat, https://en.wikipedia.org/wiki/Cryostat, retrieved December 2, 2018.
[3] Microtome, https://en.wikipedia.org/wiki/Microtome, retrieved December 2,

2018.
Q2072EXPL
A sequential compresion device (SCD) is a device designed to reduce the
likelihood of a patient developing a deep vein thromobosis (DVT). A DVT is a
blood clot that develops in the deep veins of the body. This can happen if blood
is allowed to pool in a limb. The danger is that this clot can break off and
travel to the lungs, causing a pulmonary embolism. A pulmonary embolism can be a
life-threatening condition if the clot lodges in place in the lungs where it
severely restricts the blood flow through the lungs.
An SCD minimizes the chance of a DVT developing by maintaining blood flow through
a limb. An SCD places a multi-segmented sleeve around a limb. An electrical pump
inside the SCD uses compressed air to successively fill the chambers of the
sleeve, forcing blood out of the limb. When the SCD sleeve deflates, blood will
again fill the extremity.
Typically, SCD sleeves are placed on the legs of a bedridden patient. Because
bedridden patients often have minimal movement of their legs, this makes it more
likely that blood might pool in their legs. However, they can also be placed on a
patient's arms if a clinician believes this would be beneficial. This might be
done if a patient has a history of developing blood clots in the arm.
The SCD has multiple outflow ports on the pneumatic pump leading to distinct
segments of the sleeve that inflate sequentially from the lower part of the limb
to the upper part of the limb until all segments are inflated. Following this
phase, all compartments deflate at the same time.
SCD sleeves are placed in locations where a lack of movement allows blood to
pool, which could lead to a blood clot. While these locations do include the
limbs, they do not include the shoulders, head, abdomen or chest.
References:
[1] Protect Yourself from Deep Vein Thrombosis with Sequential Compression Device
(SCD), https://www.med.umich.edu/1libr/NursingUnits/SCD.pdf, retrieved December
2, 2018.
[2] Enhancing patient outcomes with sequential compression device therapy,

https://www.americannursetoday.com/enhancing-patient-outcomes-with-sequential-
compression-device-therapy, retrieved December 2, 2018.
[3] A Few Corrections, CPMs, and SCDs, http://www.24x7mag.com/2012/02/a-few-

corrections-cpms-and-scds, retrieved December 2, 2018
Q2073EXPL
Enteral feeding pumps infuse a nutrition formula directly into the
gastrointestinal (GI) system. Enteral nutrition formulas are used as nutritional
replacements for patients who are unable to get enough nutrients by an oral
feeding. Enteral feedings are most often delivered by a nasogastric (NG) tube
that ends in the stomach.
Enteral pumps need to be accurate, but they typically do not need to be as

accurate as IV (intravenous) pumps. Remember that the normal GI system is able to
effectively handle varying types and volumes of foods on a daily basis and that
an overdose or underdose of food is not likely to cause significant harm to a
patient over the short term. However, with many medications that are introduced
directly into the circulatory system, as they would be with an intravenous (IV)
pump, a variation from the prescribed dose can be quite dangerous.
Similarly, because the GI system is able to handle large volumes of air and
eliminate them from the body without causing any harm, air bubbles that might be
introduced as part of an enteral feeding represent a minimal danger to a patient.
This is not the case with air bubbles introduced into the venous system. Air
introduced into the venous system (an air embolism) can quickly cause a fatal
reaction. For example, if a large air embolism enters the heart, it can cause
blood flow to stop, resulting in the patient's death.
Catheter connectors are an issue for both IV infusions and enteral feedings. It
is a very serious problem if an enteral feeding is connected to an IV line.
Enteral feeding formulas are not designed for infusion directly into the
circulatory system, and if they are infused directly into a vein, it could prove
fatal. Therefore, enteral feeding pumps and IV pumps should use different
connectors that are incompatible in order to prevent misconnections.
References:
[1] Enteral feeding pumps: efficacy, safety, and patient acceptability,
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4146327, retrieved December 15,
2018.
[2] Significant air embolism: A possibility even with collapsible intravenous

fluid containers when used with rapid infuser system,
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2876914, retrieved December 15,
2018.
[3] Enteral Nutrition Formulas (Systemic), https://www.drugs.com/cons/enteral-

nutrition-formulas.html, retrieved December 15, 2018.
Q2076EXPL
A chloride sweat test helps diagnose cystic fibrosis (CF), an inherited disorder
caused by the disruption of the normal function of epithelial cells, making them
vulnerable to repeated lung and other infections. The sweat test measures the
amount of chloride in sweat. This test is normally performed on infants and young
children who show symptoms that could be related to cystic fibrosis. Children
with cystic fibrosis can have two to five times the normal amount of chloride in
their sweat.
In a sweat test, the skin is stimulated to produce enough sweat to be absorbed

into a special collector and then analyzed. Two electrodes are attached to the
patient, typically on an arm, for about 30 minutes and the sweat collected in a
tube. One of these electrodes contains a disc with pilocarpine gel, a medicine
that makes the sweat glands produce sweat. A weak electric current pushes the
medicine through the skin. The electrical current may cause the child's skin to
become red or to sweat excessively for a short period of time. In rare cases, the
skin may look slightly sunburned.
While this sunburned appearance is not an unknown reaction to a sweat test, it is

good practice to test the analyzer to verify that it is producing the
manufacturer-specified amount of electrical current.
The other choices are not appropriate. While it is known that it is possible that
a mild first degree burn, similar to a mild sunburn, will occur when this device
is used, it is still appropriate to conduct testing to verify that the analyzer
is operating properly. Reports from the clinical staff about something that is
outside of their normal experience should not be ignored.
Because this is a known potential side effect from this type of testing, further
testing should be done before removing the analyzer from service. Assuming the
device is determined to be functioning properly, then there is no reason to
report this event to either the FDA or the manufacturer. However, it would be
appropriate to have the person who conducted the sweat chloride test write up an
incident report, so that this incident is properly documented and to assure that
the hospital conducts appropriate follow-up.
As for testing the analyzer on yourself, while that might yield some information,
testing this device on a healthy adult can yield very different results than
those seen when used on a young child, so it would probably not be a very
informative test. Further, this would not verify if the analyzer is operating
within the manufacturer's specifications, as this is a qualitative test, not a
quantitative test.
The analyzers used for a sweat test produce sweat by applying a small electrical
current to a localized spot on a patient's limb. They do not apply heat, so there
is no thermostat present in the device.
Reference:
[1] Cystic Fibrosis (CF) Chloride Sweat Test,
https://kidshealth.org/en/parents/sweat-test.html, retrieved December 16, 2018.
[2] Sweat Chloride Test (Cystic Fibrosis),

https://www.medicinenet.com/sweat_chloride_test/article.htm#what_is_the_sweat_chl
oride_test, retrieved December 16, 2018.
[3] Sweat Test, https://www.cff.org/What-is-CF/Testing/Sweat-Test, retrieved

December 16, 2018.
[4] Macroduct Sweat Stimulation and Collection System: Sweat Test Equipment for
Cystic Fibrosis, http://www.discovery-
diagnostics.com/Macroduct_Sweat_Stimulation.asp, retrieved December 16, 2018.
[5] Macroduct/Sweat-Chek Sweat Testing System,

http://www.medtechnica.co.il/files/Elitech%20-%20Brochure/MacroductSweatChek.pdf,
Q2079EXPL
Do not make the change. This is a dangerous request that most likely would not
work, and if it did, would give very erroneous results.
Thermistors are electronic devices that change resistance in accordance with

their temperature. By measuring the resistance, the temperature at the surface of
the thermistor can be measured.
Yellow Springs Instruments developed two standardized types of interchangeable

temperature probes in the 1960s: the YSI 400 and YSI 700 series. These two series
of common thermistors have very different electrical characteristics. For
example, at normal body temperature (37 degrees C or 98.6 degrees F) the 700
series has a resistance of about 17.5 kilohms, while the 400 series will have a
resistance of about 1.355 kilohms.
Reference:
[1] YSI History, https://www.ysi.com/about/history, retrieved January 21, 2019.
Q2080EXPL
Gel electrophoresis is a technique used to separate DNA fragments according to
their size. DNA samples are loaded into wells (indentations) at one end of a gel,
and an electric current is applied to pull them through the gel. DNA fragments
are negatively charged, so they move towards the positive electrode. Because all
DNA fragments have the same amount of charge per mass, small fragments move
through the gel faster than large ones. When a gel is stained with a DNA-binding
dye, the DNA fragments can be seen as bands, each representing a group of same-
sized, and therefore identifiable, DNA fragments.
A spectrophotometer relies on passing light through a sample. In this instrument,

monochromatic light is passed through a liquid sample. A photodetector generates
an electrical signal proportional to the amount of light transmitted. The
frequency and measured amplitude are characteristic of the makeup of the
material. Particular light frequencies give rise to sharply defined bands
indicative of the material's molecular content.
When using a mass spectrometer, the sample is placed in a vacuum chamber. The
sample is vaporized and bombarded with a beam of electrons so the atoms or
molecules it contains are turned into ions. The ions shoot out from the vacuum
chamber into an electric field, which causes them to accelerate. Ions of
different atoms have different amounts of electrical charge. The more highly
charged ions are accelerated the most, so the ions separate out according to the
amount of charge they have. The ion beam shoots into a magnetic field. When
moving particles with an electrical charge enter a magnetic field, their path
becomes an arc, with lighter, more positively charged particles bending more than
heavier, more negatively charged ones. The ions split into a spectrum, with each
different type of ion bent a different amount according to its mass and
electrical charge. A computerized, electrical detector records a spectrum pattern
showing how many ions arrive at the detector for each mass and charge. This
pattern can be used to identify the atoms or molecules in the original sample.
Samples processed by a microtome are analyzed under a microscope. A microtome

will cut the samples into extremely thin slices, allowing them to be viewed under
the microscope. This is done with biological samples, such as those removed
surgically to determine if tissue is cancerous or not. A cryostat microtome
relies on quickly freezing the sample to allow it to be sliced. It is generally
used while a surgical patient is still being operated on so that the surgeon can
determine if enough diseased tissue has been removed. A sledge microtome uses
samples that are permanently embedded in paraffin in a way that allows them to be
reviewed at any time in the future. The processing of samples done by a sledge
microtome takes at least 24 hours, so it is not suitable for intraoperative use.
References:
Chapter 19, Delmar Cengage Learning, 2010.
[2] Gel electrophoresis, https://en.wikipedia.org/wiki/Gel_electrophoresis,

[3] Spectrophotometry, https://en.wikipedia.org/wiki/Spectrophotometry, retrieved

January 21, 2019.
[4] Mass spectrometry, https://en.wikipedia.org/wiki/Mass_spectrometry, retrieved

January 21, 2019.
[5] Mass spectrometers, https://www.explainthatstuff.com/how-mass-spectrometers-

work.html, retrieved January 21, 2019.
[6] Microtome, https://en.wikipedia.org/wiki/Microtome, retrieved January 21,

2019.
Q2082EXPL
Accuracy is a measure of how close the DVM reading is to the actual value of the
voltage to be measured. Resolution is the smallest increment the DVM can detect
and display. Range is the distance between the upper and lower limits the DVM can
measure.
The lowest range setting that does not overload the DVM will show the maximum
number of digits while avoiding overload. This allows the display to get as close
as possible to the DVM's rated accuracy.
Because higher range settings will display fewer digits, the resulting lower
resolution will prevent the DVM from displaying at full accuracy. A range setting
that is lower than the voltage to be measured cannot be displayed. Most DVMs will
show this situation with an overload indication on the display.
References:
29, 2019.
[2] How to Determine Digital Multimeter Accuracy,

https://www.designworldonline.com/how-to-determine-digital-multimeter-accuracy,
[3] Digital Multimeter Accuracy Explained, https://brianhoskins.uk/digital-

multimeter-accuracy, retrieved January 29, 2019.
Q2083EXPL
Accuracy is a measure of how close the DVM reading is to the actual value of the
voltage to be measured. Precision is a measure of the repeatability a DVM
reading. A high-quality DVM has both high accuracy and high precision.
Input impedance is a measure of the impedance at the DVM input terminals. When
measuring the voltage at a point in an electrical circuit, a DVM with high input
impedance will affect the circuit less than a DVM with low input impedance and,
therefore, provide a reading that is closer to the actual value of the voltage at
that point in the circuit as compared to when the DVM is not connected to the
circuit.
Therefore, a high-quality DVM has high accuracy, high precision, and high input
impedance.
References:
26, 2019.
[2] Voltmeter Impact on Measured Circuit,

https://www.allaboutcircuits.com/textbook/direct-current/chpt-8/voltmeter-impact-
measured-circuit, retrieved January 26, 2019.
Q2084EXPL
A typical mercury manometer contains about 0.5 tablespoons (100 grams) of
mercury. Although that volume of mercury may seem relatively small, a half-
tablespoon of liquid mercury represents a significant hazard if not cleaned up
quickly and thoroughly. If a sphygmomanometer is broken and the mercury is
released, immediate steps should be taken to protect people from exposure. The
cleanup of the mercury should follow the healthcare facility's policy for
handling hazardous material releases.
Reference:
[1] Memorandum of Understanding between the American Hospital Association & the
U.S. Environmental Protection Agency,
https://practicegreenhealth.org/pubs/h2emou101501.pdf, retrieved January 26,
2019.
[2] Guidance Article: Replacing Mercury Sphygmomanometers, Health Devices, ECRI

Institute, March 2003.
[3] Mercury: Alternative Medical Devices,

https://www.who.int/ifcs/documents/forums/forum5/orris_mercury.pdf, page 2,
[4] How much mercury is in a sphygmomanometer?,

http://www.answers.com/Q/How_much_mercury_is_in_a_sphygmomanometer, retrieved
January 26, 2019.
Q2085EXPL
A direct measurement is one that exactly measures the thing that you want to
determine, while an indirect measure is one that measures something related to
the thing that you want to determine. For example, if you want to take a direct
measurement of how far a car traveled, you could put a tape measure from the
starting point to the end point. However, because this is not very practical in
most cases, distance traveled is generally calculated by checking the car's
odometer. But this is an indirect measurement, rather than a direct measurement.
That is because the odometer measures the number of revolutions of one of the
car's wheels, and by estimating the circumference of the wheel (which will vary
as the tire on that wheel wears down), estimates the distance traveled by the
car. While generally accurate enough for most purposes, this might be very
inaccurate under some circumstances. For example, if the car was running on a
treadmill, its actual distance traveled might be zero, as viewed by an outside
observer, but the odometer might register that many, many miles have been
traveled.
Central venous pressure is considered a direct measurement because the manometer

and catheter used to measure the CVP value are in direct contact with the blood
pressure being measured.
To read this pressure, a central venous catheter is threaded through one of the
large, subclavian veins so that the tip of the catheter rests in the lower third
of the superior vena cava.
CVP helps quantify the amount of blood returning to the heart, along with the
ability of the heart to pump blood into the arterial system. For a healthy
person, the CVP will be fairly low, between 4 and 12 cm-H2O (or 3 to 8 mm-Hg). In
the clinical environment, CVP is often measured using a water manometer, so the
cm-H2O values are read directly from the manometer. A rise in CVP can indicate a
serious medical condition, such as cardiac tamponade, heart failure or pulmonary
hypertension.
References:
[1] Central Venous Pressure Monitoring, http://www.rnceus.com/hemo/cvp.htm,
[2] Measuring Central Venous Pressure, https://nurseslabs.com/measuring-central-

venous-pressure, retrieved January 26, 2019.
[3] Central venous pressure,

https://en.wikipedia.org/wiki/Central_venous_pressure, retrieved January 26,
2019.
[4] Q & A: Direct and Indirect Measurements,

https://van.physics.illinois.edu/qa/listing.php?id=812, retrieved January 27,
2019.
Q2086EXPL
Einthoven's triangle is an important concept in electrocardiography. It is an
imaginary formation of the three limb leads: I, II and III formed by the end
points consisting of electrodes located at the right arm (RA), left arm (LA) and
left leg (LL).
Lead I represents the voltage between the left arm and the right arm, where the
left arm is considered the positive electrode.
Lead II represents the voltage between the left leg and the right arm, where the
left leg is considered the positive electrode.
Lead III represents the voltage between the left leg and the left arm, where the
left leg is considered the positive electrode.
References:
[2] Einthoven's Triangle & Cardiac Monitoring, https://ekg.academy/learn-

ekg?courseid=324&seq=6, retrieved January 26, 2019.
Q2087EXPL
Reversal of the left arm (LA) and right arm (RA) electrodes will cause the Lead I
ECG display to become inverted (polarity reversed). Lead I represents the voltage
between the LA and RA electrodes, where the LA electrode is considered the
positive electrode. If the two leads were reversed, so that the RA electrode is
connected to the circuitry as the positive electrode, the display will be
inverted.
Similarly, this reversal will cause the lead II and lead III waveforms to be
switched. Recall that lead II represents the voltage between the left leg (LL)
and the RA electrodes, where the LL is considered the positive electrode, and
that lead III represents the voltage between the LL and LA electrodes, where the
LL is considered the positive electrode. So if the RA and LA electrodes are
switched, leads II and III will also switch.
The three electrodes discussed: LA, RA, and LL, represent the corners of
Einthoven's triangle. This is an imaginary triangle that is viewed as surrounding
the heart. By using these three electrodes, the three leads mentioned (I, II, and
III) can be recorded.
References:
[1] Lead reversal: Left arm/right arm, https://litfl.com/lead-reversal-left-arm-
right-arm-ecg-library, retrieved January 27, 2019.

Q2089EXPL
An otoscope is a medical instrument routinely used by physicians, audiologists
and other clinicians to provide illuminated magnification of the ear canal and
tympanic membrane (eardrum). Otoscopes may use bulbs that use halogen, xenon, LED
or incandescent technology. While older otoscopes use incandescent bulbs, newer
otoscopes use the other types of bulbs. This is because incandescent bulbs tend
to produce a duller white light than the other types, making it more difficult
for the clinician to visualize the structures inside the ear. In addition,
incandescent bulbs tend to produce much more heat than those relying on the other
technologies.
References:
[1] Bankaitis, A.U., In Search of the Perfect Otoscope: Questions and Answers,
http://canadianaudiologist.ca/in-search-of-the-perfect-otoscope-feature,
[2] Types of Otoscopes, Light Source Technology,

https://www.oaktreeproducts.com/otoscope-overview, retrieved January 27, 2019.
Q2090EXP:
An otoscope is a medical instrument routinely used by physicians, audiologists
and other clinicians to provide illuminated magnification of the ear canal and
tympanic membrane (eardrum). An examination of the characteristics of the eardrum
can be indicative of various diseases of the middle ear space, such as the
presence of an infection in the middle ear (otitis media).
References:
[1] Bankaitis, A.U., In Search of the Perfect Otoscope: Questions and Answers,
http://canadianaudiologist.ca/in-search-of-the-perfect-otoscope-feature,
[2] Otoscope, https://en.wikipedia.org/wiki/Otoscope, retrieved January 27, 2019.
Q2093EXPL
Microtomes are instruments that cut extremely thin sections from a biological
sample for analysis in a histology or pathology laboratory. Once cut, the section
is examined under a light or electron microscope.
To do the cutting, microtomes use special metal, glass or diamond blades,

depending upon the type of sample being examined and the desired thickness. Steel
blades are used to prepare sections of animal or plant tissues for light
microscopy analysis. Glass blades are also used to prepare tissues for both light
microscopy and electron microscopy. Industrial grade diamond knives are used to
slice hard materials such as bone, teeth and plant matter for both light and
electron microscopy. Gem quality diamond knives are used for slicing thin
sections for electron microscopy.
Microtome sections can have section thickness between 50 nm and 100 μm. Electron
microscopes require the thinnest sections.
While there are several different types of microtomes available, the rotary
microtome is the most commonly used type. It is used to prepare sections for
histopathology analysis.
A spectrophotometer is used to analyze a material or solution by examining the

light transmitted through the material as a function of wavelength.
An automated laboratory analyzer is a medical laboratory instrument designed to

measure different chemicals and other characteristics in a number of biological
samples quickly, with minimal human assistance.
A centrifuge is a device that rapidly spins tubes filled with a liquid to be

analyzed, such as blood, creating a force the causes denser particles to move to
the bottom of the tubes, and low-density substances to rise to the top.
For medical applications, both DNA sequencers and protein sequencers are used.
These instruments are used to determine the sequence of the components of a DNA
sample, or the sequence of amino acids found in a protein sample, respectively.
Reference:
[1] Microtome, https://nios.ac.in/media/documents/dmlt/HC/Lesson-09.pdf,
[2] Microtome, https://en.wikipedia.org/wiki/Microtome, retrieved January 29,

2019.
[3] Microtomy - The Art of Section Cutting,

https://paramedicsworld.com/histopathology-cytopathology-notes/microtomy-art-
section-cutting/medical-paramedical-studynotes#.XBrAyVVKiM9, retrieved January
29, 2019.
[4] Microtomes Information,

https://www.globalspec.com/learnmore/lab_equipment_scientific_instruments/microsc
opy/microtomes, retrieved January 29, 2019
[5] Spectrophotometry, https://en.wikipedia.org/wiki/Spectrophotometry, retrieved

January 29, 2019.
[6] Automated analyzer, https://en.wikipedia.org/wiki/Automated_analyser,

[7] Centrifuge, https://en.wikipedia.org/wiki/Centrifuge, retrieved January 29,

2019.
[8] DNA sequencer, https://en.wikipedia.org/wiki/DNA_sequencer, retrieved January
29, 2019.
[9] Protein sequencing,

https://en.wikipedia.org/wiki/Protein_sequencing#Protein_sequencer, retrieved
January 29, 2019.
Q2095EXPL
Uroflow meters measure the flow and force of the urine stream during urination.
Uroflowmetry is a common, noninvasive urinary test used to diagnose the cause of
symptoms such as pain during urination or urinary incontinence. Results from
uroflowmetry can help with the assessment of bladder and sphincter function or to
test for obstructions in the normal flow of urine.
Uroflowmetry is performed by urinating into a special funnel. This funnel is

connected to a measurement device that calculates the amount of urine passed, the
rate of flow in seconds and the length of time it takes to completely empty the
bladder.
Commercially available conventional uroflowmeters are based on a weight

transducer, dipstick, or rotating disk.
Weight transducers measure the volume or mass of the urine voided and this
measurement is converted into flow rate. The most widely used weight transducer
is the load cell.
The dipstick uroflow meter uses a vertical dipstick, which changes its electrical
capacitance depending on the level to which it is submerged in urine. The height
of the collected urine is measured, allowing calculation of the voided volume,
and then the flow rate.
The rotating disk uroflow meter measures the power necessary to maintain a
constant rotation speed for the disk. The construction of this device is such
that the urine stream hits the rotating disk in a way that tends to slow down
that disk. By measuring the additional power needed to keep the speed of the disk
constant as a function of time, the urine flow rate can be calculated from moment
to moment.
During normal urination, the initial urine stream starts slowly, then speeds up,
and finally slows again. Uroflowmetry records any deviation from that norm to
assist the physician in making a diagnosis. In addition to assisting with the
diagnosis of a urinary tract problem, the uroflow meter is also a valuable tool
in assessing the effectiveness of a course of treatment.
References:
[1] Uroflowmetry, https://www.healthline.com/health/uroflowmetry, retrieved
January 30, 2019.
[2] Uroflowmetry, https://medlineplus.gov/ency/article/003325.htm, retrieved

January 30, 2019.
[3] Uroflowmetry, http://columbiaurology.org/staywell/document.php?id=38551,

[4] Noninvasive Medical Tools for Evaluating Voiding Pattern in Real Life,
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5426433, retrieved January 30, 2019.
Q2096EXPL
While a failure of the lamp (bulb) is by far the most likely cause of an otoscope
failing to light up, there are other possibilities. These could include: a
damaged lamp socket (which would prevent power from reaching the lamp), a power
supply failure (which would keep the battery from charging), a power switch
failure (which would also keep power from reaching the lamp), and a defective
battery (which would mean that the power required to illuminate the lamp was not
available). Rechargeable batteries have a limited life, generally expressed as
the number of total charge/discharge cycles.
Otoscopes do not use fiber optic cables to route the illumination. Most otoscopes
have no fiber optics at all, although a relatively small number do use fiber
optic fibers to route the light from the lamp to the end of the otoscope head,
maximizing illumination of the ear canal and ear drum. However, these fibers are
completely contained within the otoscope head, and so are not subject to breakage
from the mechanical stress of bending the way a typical fiber optic cable would
be.
References:
[1] Welch Allyn GS 777 Wall Transformer service manual,
https://www.welchallyn.com/content/dam/welchallyn/documents/sap-
documents/LIT/80017/80017762LITPDF.pdf, retrieved March 24, 2019.
[2] Welch Allyn 23810 Diagnostic Otoscope and 23820 Otoscope/Throat Illuminator
user manual, https://www.welchallyn.com/content/dam/welchallyn/documents/sap-
[3] Welch Allyn Pocketscopes Operating Instruction Manual,

https://www.welchallyn.com/content/dam/welchallyn/documents/upload-docs/Training-
and-Use/User-Manual/PocketScope-Operating-Instruction-Manual.pdf, retrieved March
24, 2019.
[4] Otoscope, https://en.wikipedia.org/wiki/Otoscope, retrieved March 24, 2019.
Q2097EXPL
Even it works to a limited extent, the wrong bulb may not have the same level of
illumination as the right bulb.
A weak battery may not be able to provide adequate power to the bulb. Recall that
rechargeable batteries have a limited life span, usually expressed as the total
number of charge/discharge cycles.
A faulty lamp socket could add resistance to the circuit, resulting in reduced
current to the bulb.
A faulty rheostat could limit current flow to the bulb.
Extended use of the ophthalmoscope can cause the device to become warm to the
touch, especially if it uses an incandescent bulb, but the level of illumination
provided should not be reduced.
References:
[1] Welch Allyn GS 777 Wall Transformer service manual,
https://www.welchallyn.com/content/dam/welchallyn/documents/sap-
[2] Welch Allyn Pocketscopes Operating Instruction Manual,

https://www.welchallyn.com/content/dam/welchallyn/documents/upload-docs/Training-
and-Use/User-Manual/PocketScope-Operating-Instruction-Manual.pdf, retrieved March
24, 2019.
[3] Ophthalmoscopy, https://en.wikipedia.org/wiki/Ophthalmoscopy, retrieved March

24, 2019.
Q2098EXPL
If a heated water bath is not reaching its desired operating temperature, the
problem could be that the bath's heating components are not functioning properly,
or the bath could be losing heat to the environment at a rate higher than it is
designed to compensate for.
A faulty heating element or a faulty temperature control unit could cause

inadequate heating of the water bath. If the heating element were not producing
enough heat, then the bath might not reach the required temperature. Similarly,
if the temperature control unit did not properly detect the bath's temperature,
or if it were not able to supply the current needed by the heating element to
maintain the required temperature, then this also could account for a failure to
reach the desired operating temperature.
If the ambient temperature in the laboratory was too low, the bath's heating
circuitry might not be able to compensate for this colder-than-intended
environment.
In order to keep a bath from losing heat to its surrounding environment, as well
as to prevent excessive evaporation of the bath's water, most baths have a cover
that should be kept on whenever possible. Not using the cover could cause the
bath to lose heat too quickly.
Using non-distilled water should not affect water bath temperature.
References:
[1] Cole Parmer: Service Manual, General Purpose Water Baths, https://archive-
resources.coleparmer.com/Manual_pdfs/12504-05.pdf, page 2, retrieved March 24,
2019.
[2] VWR Scientific: Water Baths, General Purpose, Installation and Operation
Manual,
http://condor.depaul.edu/jmaresh/instruments/Instruments/H2O%20Baths/VWR%201285PC
%20Manual.pdf, page 19, retrieved March 24, 2019.
Q2099EXPL
An aspirator is a device used to produce suction to remove unwanted bodily fluids
from a location in the patient's body. As examples, an aspirator might be used to
remove mucus from a patient's airway, or blood from a surgical wound. For a
portable aspirator, a typical setup includes the vacuum pump inside the
aspirator, along with internal tubing connections, and external tubing
connections to get the suction to the patient, a valve to prevent fluids from
entering the aspirator, a filter to help keep bacteria and fluid out of the pump,
and a collection container to hold the suctioned fluid.
A weak battery could reduce the aspirator's ability to produce adequate suction
(vacuum) from its internal vacuum pump.
Leaky tubing or tubing connections could reduce the level of suction available
for application to the patient.
Similarly, a faulty valve in the vacuum circuit could also cause loss of suction
to the patient.
A plugged bacteria filter that is part of the suction circuit could reduce the
flow rate and limit the suction level.
An undersized collection jar would limit the amount of fluid that the aspirator
could collect, but it would not reduce the available suction level.
References:
[1] Allied Healthcare Products: DC Portable Aspirator Operation/Service Manual,
http://www.alliedhpi.com/images/zs168-507-001_h.pdf, retrieved March 24, 2019.
[2] Gomco Portable Aspirator Models 300 and 3001, operation, maintenance and
service manual, http://www.alliedhpi.com/images/zs168-224-001.pdf, retrieved
March 24, 2019.
Q2100EXPL
Some neonates develop a condition know as hyperbilirubinemia, where a form of
bilirubin builds up in the neonate's body. This happens when the patient's liver
is unable to break down bilirubin into a form that can be excreted by the
kidneys. If high levels of bilirubin are untreated, the newborn may develop
permanent brain damage and hearing loss. The most prominent symptom of
hyperbilirubinemia is a yellowish cast to the patient's skin and eyes, because
the bilirubin is yellow and tends to deposit in the fat cells of the skin.
Bilirubin is created by the breakdown of old red blood cells.
Treatment of hyperbilirubinemia involves phototherapy where a specific frequency

of blue light is shined on the patient's bare skin. Light with a wavelength
between 400 and 500 nm (nanometers) can break down bilirubin into a form that the
body can eliminate through the urine and stools. Bilirubin lights (bililights)
generate an intense blue light, generally at around 460 nm with an initial
intensity of at least 30 microwatts/cm2/nm. To be effective, as much of the baby's
skin should be exposed to the light as possible. The baby's eyes need to be
covered to protect them from the light.
In this case, the nurse did not use specialized instrumentation to quantify the
light intensity on the patient's skin. Instead, the nurse relied on visual
observation and the patient's continued symptoms. When the BMET used an
appropriate instrument to measure the light intensity (a spectral radiometer),
the technician found the device was within tolerance, and that its results were
similar to those of other lights. These results strongly suggest there is nothing
wrong with the light itself, so we can eliminate the choices of a defective power
supply, old bulbs, a dirty light cover, and a defective electronic control board.
It is possible that either the power supply or the control board could have an
intermittent defect, but this is not as likely as the remaining choice.
The intensity of the light on the baby's skin is inversely proportional to the
distance between the light source and the baby. Because of the environment in a
NICU (neonatal intensive care unit) and the need for frequent nursing interaction
with the newborn, there sometimes is a lot of equipment around the baby, and that
can restrict the positioning of the bililight. Ideally, the light should be
placed only about one foot from the patient. If the light is placed further away,
or if it is positioned so it shines at an angle, it may not produce the required
intensity at the patient's skin to make the treatment effective.
At this point, the technician should work with the nurse to determine how the
light was placed to see if it was in an appropriate position to provide effective
phototherapy. If it was not, the BMET should remind the nurse about the
importance of having the light shine directly on the patient from a relatively
short distance.
References:
[1] neoBlue LED Therapy Inservice Guide,
https://partners.natus.com/asset/resource/file/newborncare/asset/2018-
05/051693H_Neoblue_in_service.pdf, retrieved March 24, 2019.
[2] Phototherapy (from New South Wales Sydney Local Health District),
https://www.slhd.nsw.gov.au/rpa/neonatal%5Ccontent/pdf/guidelines/phototherapy.pd
f, retrieved March 24, 2019.
[3] Bili Lights, https://medlineplus.gov/ency/article/002394.htm, retrieved March

24, 2019.
[4] Bilirubin, https://en.wikipedia.org/wiki/Bilirubin, retrieved March 24, 2019.
[5] Light therapy, https://en.wikipedia.org/wiki/Light_therapy, retrieved March

24, 2019.
Q2101EXPL
Aspirators (suction devices) are used to remove bodily fluids from a patient. For
example, they can be used to clear mucus from a patient's airway to make it
easier for the patient to breathe, or remove blood from a surgical wound so a
surgeon has a better view of the surgical field.
Aspirators consist of a vacuum pump, a vacuum regulator, a vacuum gauge, a

collection canister, and an optional bacterial filter. Plastic tubing connects
these components, completing an open-ended system that draws fluids and tissue
debris from the patient into the collection canister.
The vacuum regulator is used to set the suction to the desired level so that the
operator can generate enough suction to remove fluid, but still maintain a safe
level that does not damage the patient's tissues. In conjunction with the
regulator, the vacuum gauge allows the operator to see the vacuum level set by
the regulator, as well as assessing the performance of the pump. It can also help
detect leaks or blockages in the connecting tubing.
The suction produced by the pump is not set by the vacuum regulator. Instead, the
vacuum regulator steps down the level of vacuum produced by the pump to the
desired value. The vacuum pump will produce a constant level of suction at the
input to the regulator. The regulator then reduces this vacuum level at the
regulator's output to the level selected by the operator.
The regulator cannot prevent an overflow of fluid from the collection canister.
That is the function of the float valve at the top of the canister, which is
designed to stop the vacuum once the canister fills up.
The regulator also does not prevent the pump from overheating. Most pumps have a
thermal cutoff switch inside them to automatically shut off the pump if it
reaches an unsafe temperature.
The regulator is not able to store suction.
References:
[1] Surgical Suction System,
https://www.who.int/medical_devices/innovation/aspirator.pdf, retrieved March 24,
2019.
[2] Aspirator (medical device),

https://en.wikipedia.org/wiki/Aspirator_(medical_device), retrieved March 24,
2019.
[3] ECRI Healthcare Product Comparison System: Regulators, Suction,

https://www.boehringerlabs.com/wp-content/uploads/2017/03/healthcare-product-
comparison-on-suction-regulators.pdf, retrieved March 24, 2019.
[4] Allied Healthcare Products: DC Portable Aspirator Operation/Service Manual,

https://www.global-medical-
solutions.com/assets/images/Manuals/AlliedHealthcare/Allied-G-180-Suction-zs168-
507-001_h.pdf, retrieved March 24, 2019.
[5] DeVilbiss Suction Unit Instruction Guide 7305 Series,

http://frankshospitalworkshop.com/equipment/documents/suction_pumps/user_manuals/
Devilbiss%207305%20Suction%20Machine%20-%20User%20manual.pdf, retrieved March 24,
2019.
[6] Medela Vario Suction Pump Instructions for Use,

http://frankshospitalworkshop.com/equipment/documents/suction_pumps/user_manuals/
Medela%20Vario%20Suction%20Pump%20-%20User%20manual.pdf, retrieved March 24,
2019.
Q2102EXPL
An audiometry test is performed to determine how well a person can hear. This may
be done as part of a routine screening or in response to a noticeable loss of
hearing. It is performed with an audiometer that generates a series of tones of
varying intensity (volume or level) and pitch (frequency).
The unit of measure for sound intensity is the decibel (dB). A healthy human ear
can hear quiet sounds such as whispers. These are about 20 dB. A loud sound, such
as a jet engine, can reach levels between 140 and 180 dB.
The tone (frequency or pitch) of a sound is measured in hertz (Hz) or cycles per
second. (1 Hz = 1 cycle per second.) Humans can hear tones between 20 and 20,000
Hz. Bass tones correspond to lower frequencies, while high-pitched tones have
higher frequencies. Human speech generally falls in the 500 to 3,000 Hz range.
An audiometer is made up of four sections: an oscillator, an amplifier, an

attenuator, and headphones. The oscillator produces the audio frequencies
generated during the examination. The amplifier increases the sound level of the
output of the oscillator. The attenuator controls output of the amplifier and
provides a precise sound level. The headphones provide the precise sound level to
each of the test subject's ears. While older audiometers had discrete electronic
components that made up the oscillator, amplifier and attenuator, newer
audiometers incorporate microprocessors that often use software to perform the
same functions.
If the dials and controls were misaligned, or the oscillator was out of
calibration, or the headsets were mismatched, there would be a continous
malfunction of the audiometer, rather than the intermittent problem described in
the problem statement.
While a malfunctioning attenuator could possibly present itself as an

intermittent problem, that is much less likely than the remaining choice: a
defective headphone cord. Because these cords are subject to considerable wear
and tear as they are moved around, wound too tightly, or stored improperly,
breakage of the small wires in a headset cord is a very common problem. Many
breaks present as intermittent problems as the wires inside the cord sometimes
will make contact and other times not, depending upon the position of different
sections of the headset cord. Therefore the defective headphone cord is the most
likely cause of the problem.
References:
[1] Wood, Steve, 7 Tips for Proper Care of Your Audiology Equipment,
http://blog.e3diagnostics.com/7-tips-for-proper-care-and-management-of-your-
audiology-equipment, retrieved March 24, 2019.
[2] Audiometry, https://medlineplus.gov/ency/article/003341.htm, retrieved March

24, 2019.
[4] Dondelinger, Robert M., Audiometers - A Closer Look, Biomedical

Instrumentation and Technology: May/June 2010, volume 44, number 3, pages 216-
220.
Q2103EXPL
Modern anesthesia machines allow rebreathing of a patient's exhaled gases. This
allows a reduction in anesthestic gas usage, and reduces waste anesthestic gas.
However, because exhaled respiration gases contain elevated levels of carbon

dioxide (CO2), carbon dioxide must be removed to allow rebreathing to be safe and
effective.
In the diagram accompanying this question, carefully observe the lowest point of
each respiration cycle. This lowest level is steadily increasing with each
successive breath, which shows that the level of CO2 is steadily increasing over
time. The interpretation of this steady rise is that CO 2 is not being removed from
the rebreathed gases.
Ineffective and unsafe rebreathing of CO2 may be caused by malfunction of the CO 2

absorber, a faulty expiratory valve, inadequate inspiratory flow, or insufficient
expiratory time. While the last two issues are the responsibility of the
anesthesia provider (the anesthesiologist or CRNA), the BMET, along with the
anesthesia team, must assure that the equipment used by that provider is working
properly. Before starting any surgical case, the anesthesia provider should run
the anesthesia machine's self test to make sure the machine is working properly,
and if a problem is found, the provider may need to notify the BMET to help
resolve the problem. Typical problems with the rebreathing circuit include a
malfunctioning expiratory valve, as well as a CO 2 absorber that needs to be
refilled with fresh soda lime.
Soda lime has a limited capacity to absorb CO2 and so needs to be changed
regularly. A color-changing dye is incorporated into soda lime so that it is
visually evident when it is no longer able to absorb CO 2.
Since the waveform is displaying properly on the monitor, it is very unlikely

that there has been a failure of either the power supply or other electronics in
the anesthesia machine or its associated monitor.
References:
[1] Respironics: Capnography Reference Manual,
http://www.oem.respironics.com/wp/CapnographyReferenceHandbook_OEM1220A.pdf,
pages 8-9 and 29, retrieved March 25, 2019.
[2] Soda lime, https://en.wikipedia.org/wiki/Soda_lime, retrieved March 25, 2019.
Q2104EXPL
Uroflowmetry is a diagnostic screening procedure that measures the volume of
urine released from the body, the speed with which it is released, and how long
the release takes. Uroflowmetry is performed by urinating into a special urinal,
toilet, or disposable device that has a measuring device built in. The machine
sends the data to a computer or printer for subsequent analysis and reporting.
This test is useful in evaluating the function of the urinary tract.
Problems with the measuring device may include lack of calibration, liquid
contamination, broken wires, etc. Most systems should be calibrated daily by the
end-user with a calibrated weight or fixed measured amount of liquid.
In this case, because the BMET did not see any physical damage, and the computer
used to record the uroflowmeter's results seems to be working as expected, the
probability of an electronic failure, broken wire, liquid contamination or
missing segments on the digital display is lower than the system being out of
calibration. Therefore, as a first step in troubleshooting this problem, the BMET
should work with the staff in the Urology Clinic to make sure that the
uroflowmeter system is properly calibrated, and then ask the staff to verify that
the numbers produced by the system now appear to be consistent with the expected
results.
References:
[1] Uroflowmeters, https://www.laborie.com/wp-content/uploads/2016/06/0077-BRU-
001-EN-LTR-V05.00_Uroflowmeters.web_.pdf, retrieved March 25, 2019.
[2] What Is Uroflowmetry?, https://www.urologyhealth.org/urologic-

conditions/uroflowmetry, retrieved March 25, 2019.
Q2105EXPL
While there are a variety of techniques that can potentially be used to determine
respiratory rate, most monitors used in an intensive care setting, both for adult
and pediatric patients, rely on measuring transthoracic impedance. This is done
because it allows a single set of electrodes to be used for monitoring both the
patient's ECG and respiration rate.
As the lungs inflate and deflate, the impedance measured across the chest will
vary slightly, showing maximum impedance when the lungs are inflated, and minimum
impedance after deflation. The resistance varies by only a small amount, as
little as 0.2 ohms out of a baseline resistance of as much as 10,000 ohms. The
impedance is measured by injecting a small current (less than 10 microamps)
between two electrodes placed on the chest. The two electrodes usually used for
this measurement are the Right Arm (RA) and the Left Leg (LL) electrodes, which
constitute Lead II of the standard ECG signal.
Many monitors offer a choice of both adult and infant mode to account for the
significant differences between an adult and an infant. These differences include
a difference in baseline transthoracic impedance, baseline heart rate and
baseline respiratory rate.
In order to reliably record the very small changes in transthoracic impedance,

the electrode application site must be properly prepared to allow good electrical
contact between the electrode and the patient's skin. Poor electrode site
preparation is a very common cause of poor ECG and respiratory signals.
In some cases, the depth of a patient's breathing will be relatively shallow

compared to that of most patients. When shallow breaths are being taken, the
chest does not move as much, so the changes in transthoracic impedance will be
less than for the majority of individuals. When this happens, the monitor may not
recognize the patient's breaths, and might generate unwanted alarms. To
compensate for this, some monitors offer a high sensitivity mode, along with the
normal sensitivity mode, to allow better detection of shallow breaths.
References:
[1] Spacelabs Ultraview SL Operations Manual,
http://frankshospitalworkshop.com/equipment/documents/ecg/user_manuals/Spacelabs%
20Ultraview%20SL%20Patient%20Monitor%20-%20User%20manual.pdf, page 14-12,
retrieved March 23, 2019.
[2] ECG Lead Placement Procedure,

https://www.mindraynorthamerica.com/cmsAdmin/uploads/ecg-lead-placement-proc-
7664reva.pdf, page 13, retrieved March 23, 2019.
[3] Bedside ECG Monitoring for Nurses,

http://edutracker.com/trktrnr/Presentation/jh_newcastle_pa/N9ECGMONITOR.pdf, page
17, retrieved March 23, 2019.
[4] GE Medical Systems Solar 8000M Patient Monitor Operator's Manual,

https://www.manualslib.com/manual/1273009/Ge-Solar-8000m-I.html, pages 16-14 to
16-16, retrieved March 23, 2019.
[5] Redmond, C., Transthoracic Impedance Measurements in Patient Monitoring,

https://www.analog.com/en/technical-articles/transthoracic-impedance-
measurements-in-patient-monitoring.html, retrieved March 23, 2019.
[6] Tips for Optimizing ECG Related Monitoring (from London Health Sciences
Centre, London, Ontario, Canada), https://www.lhsc.on.ca/media/2129/download,
retrieved March 23, 2019.
Q2106EXPL
Many medical devices are designed to operate within a specified temperature
range. For laboratory analyzers, this range may be even more critical in ensuring
accurate results. This is because most analyzers rely on chemical reactions with
the sample of blood or other bodily fluid being checked to determine the amount
of a substance in that sample. Those chemical reactions may produce very
different results if they take place at a temperature that is too hot or too
cold.
In this case, the analyzer is reporting that it is too hot. Analyzers often rely
on good air circulation to cool down their internal components. This air
circulation can be compromised if the unit's air vents are blocked. For devices
that have air filters, these filters must be changed or cleaned on a regular
basis. In an environment like the Operating Room, where large amounts of lint are
often present, an air filter can get clogged much more quickly than in a
different environment, and restrict air flow.
While it is less likely, it is also possible that the temperature sensor inside
the analyzer is defective, inappropriately reporting a higher temperature than
the actual temperature.
Another possibility is that too many samples were run in a short amount of time.
Some types of analyzers automatically detect this condition, and prevent
processing additional samples until the analyzer has cooled sufficiently.
All laboratory analyzers require that controls be run periodically to verify the
proper calibration of those analyzers. Typically, analyzers require that a
control be run at least on a daily basis. If an expired control is used, it may
incorrectly report an analyzer's calibration status; however, it would be very
unlikely to be the cause of an excessive temperature alarm.
Reference:
[1] Abaxis Picollo Point-of-Care Chemistry Analyzer Operator's Manual,
http://www.frankshospitalworkshop.com/equipment/documents/automated_analyzer/user
_manuals/Abaxis%20Piccolo%20Analyzer%20-%20User%20manual.pdf, page 5-7, retrieved
March 23, 2019.
[2] Exergen Global: Point-of-Care Testing (POCT) Application Note,

https://uploads-
ssl.webflow.com/5784bc235ff1ffc12fe66d01/5c4066ffd6b53eaaf9b03f50_AN-701-EN-
V0%20Point-of-care%20testing%20(POCT).pdf, retrieved March 25, 2019.
[3] Stoot, LJ, Cairns, NA, et al., Use of Portable Blood Physiology Point-of-Care
Devices for Basic and Applied Research on Vertebrates: A Review,
https://academic.oup.com/conphys/article/2/1/cou011/326997, retrieved March 25,
2019.
Q2107EXPL
A typical uroflowmeter (uroflowmetry system) consists of a funnel to direct the
flow of urine into a container, a transducer to record the weight of that
container over time as the urine enters the container, and a display unit that
allows the system to be controlled and the results displayed.
The display unit is usually separate from the load cell weight transducer. A
cable runs from the transducer to the display unit, and that cable plugs into a
connector on the display unit.
These cables are subject to mechanical stress from being moved around. Over time,
that stress can lead to the breakage of wires inside the cable, which might
account for the intermittently good and invalid results reported by the
technologist.
Another problem sometimes seen whenever connectors are involved is that an

equipment operator fails to properly line up the connector on the cable with the
matching socket on the display unit. If the user tries to force the connector
into the socket, sometimes pins can get bent, which could also account for a
failure to make a reliable connection, and the reported problem.
Any time a transducer is used in a measurement system, that transducer must be

"zeroed" to indicate to the system that there is no load on it. When weight is
being measured, the machine needs to know how much of a signal the empty
container will produce, so that value can be subtracted from the final result.
This weight is referred to as the tare weight. If an operator forgets to tare the
system before measuring the urine weight, the system may display inaccurate
results.
When measuring weight, the transducer must be on a level surface. If it is not,

then the transducer may not be able to make an accurate determination. One cause
of this could be that one of the feet on the transducer has come off, making it
"wobble" as urine enters the container.
While there are anatomical differences between the urinary systems of males and
females, these differences are not relevant to the results produced by the
uroflowmeter. There is no selection for the sex of the person whose urine flow is
being measured by the uroflowmeter.
References:
[1] Pico Flow 2 portable unit for uroflowmetry,
https://www.medica.it/PDF/PicoFlow2_ENG.pdf, retrieved March 23, 2019.
[2] NIDHi Meditech Systems Urine Flow Meter,

https://www.nidhiurologyproducts.com/urine-flow-meter.html, retrieved March 23,
2019.
[3] Definition of tare (second definition),

https://www.dictionary.com/browse/tare, retrieved March 23, 2019.
Q2108EXPL
A rotary microtome is used to cut very thin slices (known as sections) from a
biological specimen usually embedded in paraffin. These sections are then
examined under a microscope as part of a diagnostic procedure. A rotary microtome
can produce sections as thin as 1 micron.
In order to produce consistently thin sections, the components in a microtome

must be in good operating condition and must be set up properly so that the
microtome's blade operates at a steady speed with minimal vibration or chatter.
The variation in section thickness described in this question is a very typical

problem with a microtome. It is often caused by either the blade or the specimen
not being clamped properly.
Another possible problem is that the blade cutting the specimen was allowed to be
come dull. If this happens, rather than cleanly cutting the specimen, the blade
will tear at it, producing the type of thickness variation described in the
question.
The pressure plate in a microtome is used to keep a very constant pressure on the
knife blade. If the pressure plate is damaged, the pressure may vary during the
cutting process, which could also result in thickness variation.
A rotary microtome operates at room temperature. It does not have a temperature

control system, so this would not account for the problem identified in this
question. This is in contrast to a cryostat microtome, which is used to process
frozen sections, rather than paraffin-embedded sections. The cryostat microtome
does have a temperature control system designed to keep the cutting chamber well
below freezing.
References:
[1] Microtome, https://en.wikipedia.org/wiki/Microtome, retrieved March 23, 2019.
[2] Leica RM2235 Rotary Microtome: Instructions for Use,

http://www.stmichaelshospital.com/pdf/research/facilities-equipment/Leica-RM-
2235-Microtome.pdf, page 68, retrieved March 23, 2019.
[3] Leica Histocore Autocut Rotary Microtome: Instructions for Use,

https://www.manualslib.com/download/1500468/Leica-Histocore-Autocut.html, pages
103-104, retrieved March 23, 2019.
Q2109EXP:
A cryostat microtome is used to cut frozen biological samples into very thin
slices (sections) so that they can be examined under a microscope as part of a
diagnostic procedure. The sections sliced by this type of machine may be as thin
as 1 micron. This instrument is typically used during surgery to allow a surgeon
to determine if all of the cancerous tissue at a surgical site has been removed.
Freezing the specimens allows this analysis to be performed in a matter of
minutes, as compared to the days required to prepare a sample embedded in
paraffin for analysis.
This microtome has a cooling chamber that is kept well below freezing. A typical
cryostat can maintain temperatures as low as -35 degrees C. Inside that chamber,
the sample is cut into sections by a very sharp knife.
In this case, the chamber has warmed up as a result of the cryostat being turned
off for several hours. Because of the mass of the whole system, it often takes
many hours for it to cool back down to operating temperature. Therefore, the most
appropriate course of action in this case is to do nothing, after reminding the
technologist that it can take several hours to reach the proper operating
temperature. If the instruction manual is available for the cryostat microtome,
you can find the appropriate reference in there to show the lab technologist.
If the cryostat microtome has been allowed to cool overnight, and it still shows
that it has not been able to get down to the proper operating temperature for the
system, then additional troubleshooting is warranted. At that point, you could
check that the temperature sensor is working properly. It is also possible that
the refrigeration system is not working properly. For example, the mechanical
stress caused by the move might have broken a connection.
While very unlikely, it is possible that the voltage at the outlet is below the
minimum value specified by the equipment manufacturer.
One thing that could not be the cause of this problem is an insufficient supply
of liquid nitrogen. Cryostat microtomes do not use liquid nitrogen as part of
their cooling system.
References:
[1] Leica CM 1850 Cryostat Instruction Manual,
https://www.manualslib.com/manual/1254032/Leica-Cm-1850.html, page 34, retrieved
March 23, 2019.
[2] Microm HM 525 Microtome Cryostat, https://assets.thermofisher.com/TFS-

Assets/APD/manuals/HM%20525%20Cryostat%20387779.pdf, page 16, retrieved March 23,
2019.
Q2110EXPL
A cryostat microtome is used to cut frozen biological samples into very thin
slices (sections) so that they can be examined under a microscope as part of a
diagnostic procedure. The sections sliced by this type of machine may be as thin
as 1 micron. This instrument is typically used during surgery to allow a surgeon
to determine if all of the cancerous tissue at a surgical site has been removed.
Freezing the specimens allows this analysis to be performed in a matter of
minutes, as compared to the days required to prepare a sample embedded in
paraffin for analysis.
This microtome has a cooling chamber that is kept well below freezing. A typical
cryostat can maintain temperatures as low as -35 degrees C. Inside that chamber,
the sample is cut into sections by a very sharp knife.
In order for the cooling system to work properly, the proposed location should
have an environment that is free of things that could cause temperature swings.
These include issues such as:
- the presence of direct sunlight
- the presence of an air conditioning duct, and
- the presence of a door
In addition, for the cooling system to operate properly the internal fan must
maintain adequate airflow to allow the refrigeration unit to blow out warm air.
This requires that there be adequate clearance between the back and sides of the
microtome.
One issue that is not a concern is the elevation above sea level.
References:
[1] Microm HM 525 Microtome Cryostat, https://assets.thermofisher.com/TFS-
Assets/APD/manuals/HM%20525%20Cryostat%20387779.pdf, page 15, retrieved March 23,
2019.

https://www.manualslib.com/manual/1254032/Leica-Cm-1850.html, page 16, retrieved
March 23, 2019.

http://www.stmichaelshospital.com/pdf/research/facilities-equipment/Leica-CM-
1900-Cryostat.pdf, page 14, retrieved March 23, 2019.
Q2111EXPL
The waste collection bottles on analyzers are used to collect waste liquids (such
as biolgical samples and used reagents) associated with the analyzer's operation.
In order to get liquid into the collection bottle, a vacuum system is used to
transport the liquids from the point where the chemistry analysis takes place to
the collection bottle. If the cap on the waste collection bottle is loose, then
the vacuum required to perform the liquid transport may not be available,
generating a vacuum error.
Similarly, if there is a broken connection in the vacuum line, this may also
generate a vacuum error, as there will not be sufficient vacuum available to
allow the analyzer to move liquids to the various locations in the analyzer at
the correct times.
Electrical line interference or a computer disk crash would be extremely unlikely

to cause a vacuum leak error.
References:
[1] Sysmex CA-500 Automated Blood Coagulation Analyzer Instructions for Use,
http://frankshospitalworkshop.com/equipment/documents/automated_analyzer/user_man
uals/Sysmex%20CA-500%20Blood%20Coadulation%20Analyzer%20-
%20Instruction%20manual.pdf, page 12-11, retrieved April 5, 2019.
[2] AVL Compact 3 ph/Bloodgas Analyzer Operator's Manual,

http://frankshospitalworkshop.com/equipment/documents/automated_analyzer/user_man
uals/Roche%20AVL%20Compact%203%20Bloodgas%20Analyzer%20-%20User%20manual.pdf,
page 10-3, retrieved April 5, 2019.
Q2112EXP:
Most multiparameter physiological monitors that monitor respiration do so with
the ECG electrodes using a technique known as impedance pneumography. This
measures the change in impedance across the chest as one breathes. With a
baseline impedance of approximately 1,000 to 2,000 ohms and a change in impedance
of approximately 0.5 ohms, this measurement is sensitive to motion and other
artifact. To reduce false alarms due to artifact, monitors typically have alarm
delay thresholds that must be exceeded before an alarm will occur. On some
monitors, these are fixed alarm delays, while others allow the user to change the
delay.
While it is also possible that the alarm volume was turned down, this is
generally a more unlikely problem than that the alarm delay was not exceeded. In
addition, in keeping with modern care guidelines, ICU environments generally have
fairly low noise levels to minimize patient disturbances, and so promote faster
recovery.
As for the other choices, the ECG alarm setting would not interfere with the
respiration alarm. However, many monitors do check to see if the detected
respiration rate is equal to the heart rate. If this is the case, then the
monitors ignore the detected respiration rate and will trigger an apnea alarm.
The sPO2 alarm generally would not be a higher priority alarm than a respiratory
alarm, because it can take a significantly longer time for the oxygen saturation
level to change, as compared to the respiration rate.
Electrical interference could not explain what the nurse reported. The elevated
respiration rate was displayed on the monitor, so the monitor was apparently
working properly.
References:
[1] Spacelabs Ultraview SL Operations Manual,
http://frankshospitalworkshop.com/equipment/documents/ecg/user_manuals/Spacelabs%
20Ultraview%20SL%20Patient%20Monitor%20-%20User%20manual.pdf, page 14-11,
retrieved April 5, 2019.
[2] Philips IntelliVue MX40 Instructions for Use,
https://data2.manualslib.com/pdf6/132/13183/1318295-
philips/intellivue_mx40.pdf?af821bd5336b09ee8e652bf361aa5e79&take=binary, page
15-29, retrieved April 5, 2019.
Puplic safety
Q272EXPL
The Compressed Gas Association has developed a color code for compressed gas cylinders. For medical gases, the color
code for carbon dioxide is gray.
Reference: White, Gary C., Equipment Theory for Respiratory Care, Delmar Publishers, 1992, pages 36 – 39
Q311EXPL
The use of a redundant ground is a strategy for reducing the risk of losing the ground connection in the primary power
cord. Under certain conditions, such as high incidence of corrosion, a redundant ground can be helpful in maintaining
good grounding. Other strategies, such as isolation transformers, are usually preferred, but redundant grounding can be
used with potentially electrically hazardous devices.
Reference: National Fire Protection Association, ANSI/NFPA 99, 2012 edition, Health Care Facilities Code
Q372EXPL
Compressed gas cylinders represent a distinct hazard. Two major types of hazards are leaks and cross-connections.
Each cylinder yoke is designed to work with a single gasket. If gaskets are allowed to accumulate on the yoke, leak s could
result because the gaskets will not properly seal the cylinder to the yoke.
The pin index safety system places pins and holes in specific locations on the cylinder and the yoke so that a cross-
connection is not possible. (Connecting a nitrous oxide cylinder to an oxygen yoke, for example.) However, if these pins
have sheared off, or are removed, it will be possible to cross-connect gases and yokes, and a hazard could result.
Cylinders that are mislabeled can also lead to a cross-connection. To prevent mislabeling, cylinders are not only labeled
with the gas that is inside them, but the cylinders are painted with distinct colors corresponding to the gas they contain.
Reference: None
Q393EXPL
Practice varies somewhat regarding how to handle such a predicament. While "C" is probably the best answer, it is not
often practical. Most likely the transmitter will have to be opened, cleaned, and dried before it can be tested, and the
hospital's Central Sterilization and Processing Department probably will not do that. Not because they do not want to, but
because they need specific instructions from the manufacturer; oftentimes the manufacturer will not provide such
instructions.
Steam sterilization will most likely melt a plastic transmitter housing. Sending the transmitter to the manufacturer for
repair would involve packaging and shipping of potentially hazardous biological waste.
So that usually leaves the BMET to gown, glove, observe Standard (Universal) Precautions, and crack the transmitter
open.
Reference: ANSI/AAMI ST35-1996, Safe Handling and Biological Decontamination of Medical Devices in Health Care
Facilities and in Nonclinical Settings, AAMI, Arlington, VA, 1996, Section 8.1
Q394EXPL
Because different hospitals have different approaches to handling patient-owned equipment, it is very important for you to
understand your own hospital's policy in this regard, so that you can properly address this problem. While some hospitals
forbid the use of patient-owned equipment under any circumstances, other do allow this equipment to be used. In those
hospitals where patient-owned equipment is permitted, hospitals differ on how to handle any problems related to this
equipment, such as the one identified in this question.
Because there is no general standard that can be applied in this situation, the only appropriate solution is to know your
own hospital's policy on patient-owned equipment and be sure that you follow it.
Reference:
[1] AAMI Electrical Safety Manual, 2015 edition, AAMI, Arlington, VA, 2015, pages 43-44
Q398EXPL
While biomedical professionals tend to gravitate to the technical solution to a problem, other frames of reference must be
considered. Choice A should be the first action taken, relative to patient confidentiality.
HIPAA, the Health Insurance Portability and Accountability Act (passed by Congress in 1996) requires safeguards to
limit the number of people who have access to personal information. Unauthorized people should not be able to view
patients’ private medical records. One of the relevant HIPAA standards (164.502) states: "A covered entity must make all
reasonable efforts not to use or disclose more than the minimum amount of protected health information necessary to
accomplish task."
HIPAA sets a national standard for accessing and handling medical information. Before HIPAA, a patient's right to
privacy of health information varied depending on the state. Now, health care providers, health plans and other health care
services that operate in all states have to abide by the minimum standards set by HIPAA.
Health care providers are held to HIPAA standards if they transmit health information electronically. Even a doctor in a
small practice who keeps only paper records will almost certainly use a billing service that transmits information
electronically. In short, it is nearly impossible to provide health care today without using electronic means in some way.
References:
http://www.privacyrights.org/fs/fs8-med.htm
http://www.cdc.gov/mmwr/preview/mmwrhtml/m2e411a1.htm
Q422EXPL
While choice A is technically correct, the best answer is D. As one hospital may
prefer to check electrical safety on every incoming rental/loaner device, another
may require the manufacturer to guarantee the safety and proper operation of the
device. In the eyes of The Joint Commission, the hospital is responsible for any
equipment used on its premises.
According to NFPA 99 (2012 edition): "The touch current for cord connected
equipment shall not exceed 100 microamps with the ground wire intact (if a ground
wire is provided) with normal polarity and shall not exceed 500 microamps with
the ground wire disconnected."
The "CE" marking on the back of some appliances and medical equipment indicates
that it complies with the relevant European 'New Approach' product safety
directives.
References:
[1] NFPA 99 Healthcare Facilities Code, 2012 edition, NFPA, section 10.3.5, page
99 – 96.
[2] http://www.techintl.com/cemarking.cfm?gclid=CMnkuJvFgq0CFcbd4AodYyp-Tg
Q439EXPL
The most likely possibility is that the drier in the medical air system is not
working. Healthcare facilities have two separate compressed air systems, which
fall under the NFPA 99 Health Care Facilities Code. They are the Medical Air and
Instrumentation Air Systems. They are two completely independent systems that are
not allowed, by code, to be interconnected. Both systems have specific dewpoint
and air quality requirements. Both systems are monitored by specific local and
master alarm systems. Moisture in the pipelines in excess of the specifications
is supposed to trigger alarms.
According to NFPA 99, "The medical air dryer shall be designed to provide air at
a maximum dewpoint that is below the frost point (0 C (32 F)) at any level of
demand." What this means, in effect, is that the medical air system is expected
to be designed to have no moisture in the lines. In reality, compressors, alarms,
and other components of the drier system can fail. Also, the people involved may
not respond appropriately to the alarms.
Water in the air lines can find its way into the medical equipment attached to
the medical air system. Where these problems are persistent, moisture traps are
installed at the air inlet of blenders and ventilators to protect them. However,
this is not a foolproof solution, as some traps will allow water to pass after
the trap fills.
A blender is tightly sealed and under normal circumstances would not allow fluid
infiltration through its body. A blender would not normally be used in a high
humidity environment. The ambient air in hospitals is kept at a level of 50% -
55% relative humidity.
References:
[1] http://www.nda.ox.ac.uk/wfsa/html/u13/u1302_01.htm
[2] http://www.airbestpractices.com/standards/nfpa-99-medical-air/nfpa-99-
medical-air-dewpoint-requirements
Q449EXPL
NFPA 99 is the National Fire Protection Association's Health Care Facilities
Code. It contains standards related to a wide variety of health care issues,
including electrical systems, medical gas and vacuum systems, electrical
equipment, laboratories, and non-hospital health care facilities. This standard
is an American National Standard.
This standard states, in part:
6.4.3.1 - The life safety and critical branches shall be installed and connected
to the alternate power source specified in 6.4.1.1.4 and 6.4.1.1.5 so that all
functions specified herein for the life safety and critical branches are
automatically restored to operation within 10 seconds after interruption of the
normal source.
Reference: National Fire Protection Association, NFPA 99, 2012 edition - Health
Care Facilities Code
Q450EXPL
This standard specified that Class A ground fault circuit interrupters (GFCI)
must trip when a fault current to ground is 6 milliamperes or more.
Reference: National Fire Protection Association, NFPA 99, 2012 edition, section
A.6.3.2.2.4.2 - Health Care Facilities Code
Q452EXPL
All compressed gas cylinders should be stored and used safely.
Some guidelines for compressed gas cylinders include the following:

a. valve protection caps should be used whenever possible;
b. storage should be in designated areas only;
c. cylinders should be away from radiators, direct rays of the sun, and other
sources of heat;
d. cylinders should be at least 20 feet from highly combustible materials, such
as oil and excelsior;
e. the storage area should be away from elevators, stairs, or gangways;
f. the storage area should be where there is no danger they will be knocked over
or damaged by passing or falling objects, or subject to tampering by unauthorized
persons;
g. cylinders should be appropriately identified, including a label with an
appropriate warnings;
h. a pressure-relief device on the cylinder must comply with Compressed Gas
Association standards;
i. the cylinder should never be dragged, dropped, rolled, or carried over the
shoulder; and
j. transportation should be in a cylinder cart or hand truck with a chain
restraint in place.
Reference: Chaff, Linda F., Safety Guide for Health Care Institutions, 4th
edition, American Hospital Publishing, 1989, pages 96 - 97
Q453EXPL
LASER is an acronym that stands for Light Amplification by Stimulated Emission of
Radiation. The laser produces an intense, highly directional beam of light. The
most common cause of laser-induced tissue damage is thermal in nature, where the
tissue proteins are denatured due to the temperature rise following absorption of
laser energy.
The human body is vulnerable to the output of certain lasers, and under certain
circumstances, exposure can result in damage to the eye and skin. Research
relating to injury thresholds of the eye and skin has been carried out in order
to understand the biological hazards of laser radiation. It is now widely
accepted that the human eye is almost always more vulnerable to injury than human
skin.
Reference: http://www.osha.gov/SLTC/laserhazards
Q454EXPL
The ANSI/AAMI ES60601-1:2005/(R)2012 standard specifies the following:
16.6.1 Touch Current - In normal condition, the touch current from or between
parts of the ME [medical equipment] system within the patient environment shall
not exceed 100 µA.
Reference: Association for the Advancement of Medical Instrumentation, ANSI/AAMI

ES60601-1:2005/(R)2012, Medical electrical equipment - Part 1: General
requirements for basic safety and essential performance
Q455EXPL
6.3.2.6.2 Impedance of Isolated Wiring.
6.3.2.6.2.1 The impedance (capacitive and resistive) to ground of either

conductor of an isolated system shall exceed 200,000 ohms when installed.
Reference: National Fire Protection Association, NFPA 99, 2012 edition, Health
Q457EXPL
A microshock is a very low level current applied directly to the heart. This can
lead to inadvertent fibrillation and death.
Microshocks are usually a very low magnitude current, on the order of tens of
microamperes. Because the heart is located deep inside the body, for microshock
to present a hazard, a direct electrical connection to the heart must be present.
A common connection is for an external pacemaker, which presents a highly
conductive path from the external pacemaker, directly to the patient's heart.
While one possible mechanism for microshocks is through chassis leakage currents,
by themselves, leakage currents are not the cause of a microshock hazard. This
hazard requires the direct connection to the heart.
page 409
Q458EXPL
According to ANSI/AAMI ES60601-1:2005/(R)2012 standard for Medical Electrical
Equipment - Part 1: General requirements for basic safety and essential
performance, when measuring leakage current, the measuring device must have the
following characteristics:
8.7.4.4 - Measuring device (MD)

a) The measuring device loads the source of leakage current or patient auxiliary
current with a resistive impedance of approximately 1,000 for DC, AC, and
composite waveforms with frequencies up to and including 1 MHz.
Reference: ANSI/AAMI ES60601-1:2005/(R)2012 Medical electrical equipment — Part

1: General requirements for basic safety and essential performance
Q459EXPL
6.3.2.6.3 Line Isolation Monitor.
6.3.2.6.3.1 In addition to the usual control and protective devices, each

isolated power system shall be provided with an approved, continually operating
line isolation monitor that indicates possible leakage or fault currents from
either isolated conductor to ground.
6.3.2.6.3.2 The monitor shall be designed such that a green signal lamp,
conspicuously visible in the area where the line isolation monitor is utilized,
remains lighted when the system is adequately isolated from ground; and an
adjacent red signal lamp and an audible warning signal (remote if desired) shall
be energized when the total hazard current (consisting of possible resistive and
capacitive leakage currents) from either isolated conductor to ground reaches a
threshold value of 5.0 mA under normal line voltage conditions. The line
isolation monitor shall not alarm for a fault hazard current of less than 3.7 mA.
Reference: National Fire Protection Association, NFPA 99, 2012 edition, Health
Q460EXPL
"Fires involving ordinary combustibles such as rubber, plastic, linen, wool,

paper, and the like are called 'Class A' fires. These may be fought with water or
water-based extinguishing agents."
Q461EXPL
NFPA 99 - Health Care Facilities Code, 2012 edition, identifies the required
tests for fixed and portable medical equipment in section 10.3. The required
tests are physical integrity, resistance, and leakage current.
Q463EXPL
6.3.3.2.4 - The retention force of the grounding blade of each electrical

receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).
Q464EXPL
NFPA 99 states, in part:
3.3.89 Isolated Power System - A system comprising an isolation transformer or

its equivalent, a line isolation monitor, and its ungrounded circuit conductors.
(ELS)
Q465EXPL
Mercury exposure can be the result of many common activities. Typical routes of
exposure include:
- Eating fish or shellfish contaminated with methylmercury
- Breathing vapors in air from spills, incinerators, and industries that burn
mercury-containing fossil fuels
- Release of mercury from dental work and medical treatments
- Breathing contaminated workplace air or skin contact during use in the
workplace
- Practicing rituals that include mercury
Reference:
[1] Mercury - ToxFAQs, CAS # 7439-97-6, Agency for Toxic Substances and Disease
Registry, Division of Toxicology and Human Health Services, U.S. Centers for
Disease Control, http://www.atsdr.cdc.gov/toxfaqs/tfacts46.pdf, retrieved May 30,
2015 http://www.osha.gov/SLTC/healthguidelines/mercuryvapor/recognition.html
Q468EXPL
NFPA 99 explains the various acceptable methods that can be used to measure
grounding resistance as follows in section A.10.3.2:
Two-Wire Resistance Technique. A known current is fed through the unknown

resistance. A high-input-impedance voltmeter measures the voltage drop across the
resistance, R, and R is calculated as voltage divided by impedance, V/I. This
technique measures the lead resistance in series with the unknown resistance.
When the unknown resistance is a ground wire (less than 0.15 ohm), the lead
resistance is appreciable. This is accounted for by shorting the lead wires
together and “zeroing” the voltmeter. The actual resistance, in effect, subtracts
out the lead wire resistance. In order for this technique to be reasonably
accurate for measuring ground wires, an active high-impedance millivoltmeter has
to be used.
Four-Wire Resistance Technique. This technique is very similar to the two-wire

resistance technique. The difference is that the known current is fed to the
resistance to be measured through a pair of leads separate from the pair of leads
to the voltmeter. The voltmeter is measuring the true voltage across the
resistance to be measured, regardless of the resistance of the measuring leads.
This method eliminates the need for zeroing out the measuring lead resistance.
AC Current Method. This technique utilizes a step-down transformer of known

voltage output to feed current through the ground wire and measure the current
that flows. The impedance of the ground wire is then calculated by Ohm's law.
Q469EXPL
NFPA 99 addresses the issue of the pressure that may be in a full medical gas
cylinder in the following section:
3.3.33 Cylinder. A supply tank containing high-pressure gases or gas mixtures at

pressures that can be in excess of 13.8 kPa gauge (2000 psi gauge).
Q471EXPL
The hazard presented by electricity comes from shocks.
A microshock applied directly to the heart can lead to fibrillation and death.
A macroshock, applied to the outside of the body, can cause death if the current
involved is high enough. Even a lower magnitude shock can cause a startle
reaction, which could cause a problem under the wrong conditions. For example, if
a medication were dropped, or if the shock occurred while getting ready to draw
blood.
Electrical safety is traditionally concerned with electric shocks from unintended

grounding paths, such as chassis leakage current, which represents electrical
current flowing outside its intended path to ground via a chassis connection.
Electrical safety must take into account all potential causes of shock, and seek
to eliminate them.
Reference: None
Q472EXPL
A microshock is a very low level current applied directly to the heart. This can
lead to inadvertent fibrillation and death. Microshocks are usually a very low
magnitude current, on the order of tens of microamperes.
One possible mechanism for microshocks is through chassis leakage currents, if

these are sufficiently high, and if an appropriate path to ground exists through
a patient's heart. However, leakage currents can also be a cause of macroshock, a
much higher magnitude shock applied to the external body.
page 409
Q473EXPL
Electrical safety is the responsibility of all those serving the patient.
An inadvertent error on the part of the medical staff or support staff could lead
to a shock and needlessly endanger the patient.
The administrative staff must support an effective program of equipment

inspections to help assure that this program has the resources and support of all
in the hospital so it can function effectively.
Reference: None
Q474EXPL
An electrical safety program's goal should be the reduction and elimination of
electrical hazards.
To be effective, an assessment must be made of the hazards and potential hazards

that are present in the hospital environment. Steps must then be taken to
prevent, where possible, and reduce as much as possible, the risks posed by the
identified hazards.
Documentation to verify that all these activities have taken place is also
essential, so that an outside agency, such as The Joint Commission, can verify
that the hospital has maintained compliance with its own policies.
Reference:
[1] Baretich, Matthew F., Electrical Safety Manual: A Comprehensive Guide to
Electrical Safety Standards for Healthcare Facilities, 2015 edition, AAMI, 2015
Q476EXPL
As explained in section 8.7.3 of the ANSI/AAMI ES60601-1:2005/(R)2012 standard,
Medical electrical equipment - Part 1: General requirements for basic safety and
essential performance:
"The value of electric current flowing in the human or animal body that can cause
a certain degree of stimulation varies from individual to individual, according
to the way in which the connection to the body is made and according to the
frequency of the current applied and its duration.
"Currents of low frequency flowing directly into or through the heart

considerably increase the danger of ventricular fibrillation. For currents of
medium or high frequency, the risk of electric shock is less or negligible, but
the risk of burning remains."
Reference: Association for the Advancement of Medical Instrumentation, Medical

electrical equipment - Part 1: General requirements for basic safety and
essential performance, ANSI/AAMI ES60601-1:2005/(R)2012
Q477EXPL
Leakage current is a low level electrical current that flows out of its intended
path (or circuit) into an unintended portion of the equipment. The unintended
portion is the metal chassis of the equipment, which represents a potential
hazard because an equipment user or patient could touch the chassis, and receive
a shock.
Leakage current may be flowing in a resistor (such as the standard test load used
with a leakage current meter), or it may flow through a patient (in the event
that a patient is completing an electrical circuit between the equipment chassis
and ground), and it may flow through a cable (such as an ECG cable). However,
leakage current, by definition, is the current flowing in the chassis, where it
has the opportunity to cause a shock.
page 417
Q478EXPL
Leakage current is a low level electrical current that flows out of its intended
path (or circuit) into an unintended portion of the equipment. The unintended
portion is the metal chassis of the equipment, which represents a potential
hazard because an equipment user or patient could touch the chassis, and receive
a shock.
Leakage current can leave its intended path through two primary means, either by
capacitive coupling between the circuit and the chassis, or by a resistive
leakage path between the circuit and the chassis. All circuits show some stray
capacitance. Proper equipment design can reduce the stray capacitance between the
energized portions of the circuit and the grounded equipment chassis.
A resistive leakage path can be created by the deterioration of insulation inside

a device, or by a fluid spill within the device creating an unintended resistive
connection between an energized portion of the circuit and the chassis.
page 417
Q479EXPL
NFPA 99 explains the permissible options available for reducing the hazard
associated with excessive leakage current in section A.10.3.5.1:
Where existing equipment exceeds 500 µA, methods to reduce leakage current, such
as the addition of small isolation transformers to that equipment, or methods
that provide equivalent safety by adding redundant equipment ground are
permissible.
Q482EXPL
A ground wire is designed to provide a safe path to ground for leakage currents,
which could cause a shock or electrocution if they were to flow through a patient
or an equipment user.
Power cords are subject to stress, and sometimes the ground wire in a power cord
can break, or the ground pin of an electrical plug can be broken. The shock
hazard that this presents can be reduced by taking one or more of the following
measures:
* reducing internal equipment leakage current;
* continuously monitoring the continuity of the ground wire, so that corrective

action can be taken in the event of a fault;
* adding an additional ground wire (a redundant ground) in parallel with the

power cord safety ground;
* periodically inspecting the ground-connection integrity of equipment; and
* using an isolated power system that isolates the current-carrying wires in the
equipment from the power system ground.
page 419
Q483EXPL
The 60601 standards are a series of standards developed by the International
Electrotechnical Commission (IEC). These standards establish requirements for the
safety and effectiveness of medical electrical equipment. While the basic 60601
standards are international in scope, national deviations are adopted to meet the
requirements of a particular country. In the United States, the versions of the
IEC standards that have been adopted by AAMI (the Association for the Advancement
of Medical Instrumentation) and ANSI (the American National Standards Institute)
have the identifier "ANSI/AAMI" in their title.
The titles of the standards referenced in this question are:
ANSI/AAMI ES60601-1 - Medical electrical equipment - Part 1: General requirements

for basic safety and essential performance
ANSI/AAMI/IEC 60601-2-2 - Medical electrical equipment - Part 2-2: Particular

requirements for basic safety and essential performance of high frequency
surgical equipment and high frequency surgical accessories
ANSI/AAMI/IEC 60601-2-19 - Medical electrical equipment - Part 2-19: Particular

requirements for basic safety and essential performance of baby incubators
ANSI/AAMI/IEC 60601-2-27 - Medical electrical equipment — Part 2-27: Particular

requirements for the basic safety and essential performance of
electrocardiographic monitoring equipment
Therefore, the correct answer is ANSI/AAMI/IEC 60601-2-27.
References:
[1] Table of all IEC 60601-1-X and IEC 60601-2-X Standards, 601 Help website,
http://www.601help.com/Other_601_Standards/other_601_standards.html, retrieved
May 30, 2015
[2] IEC 60601, Wikipedia, http://en.wikipedia.org/wiki/IEC_60601, retrieved May
30, 2015
Q484EXPL
NFPA 99 states, in part:
"The [line isolation] monitor shall be designed such that a green signal lamp,
remains lighted when the system is adequately isolated from ground..."
Care Facilities Code, section 6.3.2.6.3.2
Q485EXPL
An equipotential grounding system consists of a separate connection from each
equipment chassis to a common ground terminal. By connecting all grounds
together, the intention is to reduce the possibility of having a patient or staff
member touch two grounding points that are at different electrical voltages, and
so receive a shock. If a device has a large leakage current, along with a poor
grounding connection, the voltage on the chassis could reach hazardous levels,
while another ground point within the patient environment is still at a low
voltage, creating a potential for a shock.
The equipotential grounding system was a very common method of providing

protection against electrical shocks in the 1970s and 1980s, particularly in
operating rooms, intensive care units, and coronary care units. Many of these
areas still have separate large green grounding connectors intended to be used to
make these separate connections between equipment and the building ground.
However, equipotential grounding systems proved to be an ineffective way of

dealing with this hazard, because they actually served to increase the likelihood
that a patient or equipment user would complete an undesirable path to ground for
an electrical shock. Current ideas promote insulation over equipotential
grounding as a more effective way to control leakage current hazards.
Ground fault interrupters will disconnect electrical power to a device that has a
very high level (several milliamperes) of leakage current. They do not provide
useful protection against the lower level leakage current hazards (on the order
of hundreds of microamperes) that electrical safety programs try to control in a
patient-care environment.
A line isolation monitor is part of an isolated power system. An isolated power

system can provide some protection against macroshock. However, isolated power
systems offer virtually no protection against the smaller shocks that can be
caused by typical leakage currents.
References:
[1] Carr, Joseph J., and Brown, John M., Introduction to Biomedical Equipment
Technology, John Wiley and Sons, 1981, pages 332 - 333
[2] NFPA 99, Health Care Facilities Code, 2012 edition, National Fire Protection
Association
(Note: the first reference provides information on the theory of the

equipotential grounding system at a time when it was still widely used, the
second reference provides current information.)
Q486EXPL
The clinical laboratory is probably one of the most hazardous places in the
hospital. One of the most common hazards found in the laboratory are chemicals.
Chemicals can cause many problems, including poisoning, injury to skin or eyes,
and damage to clothing.
Many chemicals emit hazardous vapors, which, when inhaled, can cause irritation
or damage to the respiratory tract. Fume hoods in laboratories are designed to
contain, and safely exhaust, hazardous gases from the laboratory environment.
Equipment can represent a significant hazard, both to equipment operators and

patients. The equipment in a laboratory is in an area where spills are not
uncommon. These spills can harm the equipment. In addition, if the grounding
system of electrical equipment is not intact, these spills can result in a
significant shock hazard to the operator. Finally, broken or out of calibration
equipment can give erroneous results, and might result in the misdiagnosis or
mistreatment of a patient's illness.
Sons, 1982, pages 56 - 57
Q490EXPL
The National Fire Protection Association publishes NPFA 99 - the Health Care
Facilities Code, which is a compilation of most of the major NFPA standards that
affect health care facilities.
Other NFPA standards also provide useful information for health care
organizations, such as NFPA 101, the Life Safety Code, which primarily addresses
fire safety, and NFPA 70, the National Electric Code, which contains standards
for electrical wiring.
Q494EXPL
An SDS is a document supplied by the manufacturer or vendor of a hazardous
material, such as an irritating or carcinogenic chemical.
SDS stands for Safety Data Sheet. It supplies information about a material, such
as the types of hazards associated with the material and first aid to take if an
exposure takes place. The terminology associated with an SDS was changed from
MSDS (Material Safety Data Sheet) in 2012 by OSHA.
The Occupational Safety and Health Administration (OSHA) regulation related to

the requirement for an SDS says:
29 CFR 1910.1200(g)(1) Safety data sheets. Chemical manufacturers and importers

shall obtain or develop a safety data sheet for each hazardous chemical they
produce or import. Employers shall have a safety data sheet in the workplace for
each hazardous chemical which they use.
Reference: Code of Federal Regulations, Title 29, 29 CFR 1910
Q495EXPL
The ANSI/AAMI ES60601 Medical Electrical Equipment standard defines several types
of current associated with medical equipment. These include the following:
3.25 Earth Leakage Current - Current flowing from the mains part through or
across the insulation into the protective earth conductor.
3.80 Patient Leakage Current - Current flowing from the patient connections via
the patient to earth; or current originating from the unintended appearance of a
voltage from an external source on the patient and flowing from the patient via
the patient connections of an F-Type applied part to earth. [Note: An F-Type
applied part is one that is isolated from other parts of the equipment to such a
degree that no current higher than the patient leakage current allowable in a
single fault condition flows if an unintended voltage originated from an external
source is connected to the patient, and thereby applied between the applied part
and earth.]
3.129 Touch Current - Leakage current flowing from the enclosure or from parts
thereof, excluding patient connections, accessible to any operator or patient in
normal use, through an external path other than the protective earth conductor,
to earth or to another part of the enclosure.
3.77 Patient Auxiliary Current - Current flowing in the patient in normal use
between any patient connection and all other patient connections, and not
intended to produce a physiological effect.
Reference: ANSI/AAMI ES60601-1:2005, Medical electrical equipment — Part 1:

General requirements for basic safety and essential performance
Q497EXPL
A line isolation monitor detects the degree of intentional isolation between
ground and the current-carrying wires of an isolated power circuit. In a normal
power circuit, the current-carrying wires are intentionally referenced to ground.
In an isolated power circuit, these wires are deliberately not referenced to
ground. A common cause of deterioration of this isolation is excessive leakage
current in one or more of the pieces of equipment connected to this circuit.
Isolated power systems are often found in operating rooms. Because interruption
of power is generally an unacceptable condition, except when an extremely serious
hazard is present, a line isolation monitor, which monitors the isolation of the
power system, is constructed so that under fault conditions, an alarm is
generated, but power is not interrupted.
A risk current monitor is the meter found on the line isolation monitor, and
provides a continuous display of the degree of isolation of the isolated power
circuit.
A fault current monitor is not a commonly used device.
A ground-fault circuit interrupter (GFCI) is a device intended for the protection

of personnel that functions to deenergize a circuit or portion thereof within an
established period of time when a current to ground exceeds the values
established for a Class A device. Class A ground-fault circuit interrupters trip
when the current to ground is 6 mA or higher and do not trip when the current to
ground is less than 4 mA.
References:
[1] National Fire Protection Association, National Electrical Code, ANSI/NFPA 70,
2008 edition
[2] Underwriters Laboratories, UL 943, Standard for Ground-Fault Circuit
Interrupters
Q499EXPL
ANSI/AAMI/IEC 80001-1:2010 - Application of risk management for IT Networks

incorporating medical devices - Part 1: Roles, responsibilities and activities
ANSI/AAMI ES60601-1:2005 - Medical electrical equipment — Part 1: General

ANSI/AAMI/IEC 60601-2-2:2009 - Medical electrical equipment - Part 2-2:

Particular requirements for the basic safety and essential performance of high
frequency surgery equipment and high frequency surgical accessories
AAMI/IEC 60601-2-2 specifies requirements for the safety of high frequency (HF)
surgical equipment and HF surgical accessories used in medical practice. Some
low-powered high frequency surgical equipment (for example, equipment used for
micro-coagulation, or for use in dentistry or ophthalmology) is exempt from
certain requirements of this particular standard.
Reference: ANSI/AAMI/IEC 60601-2-2:2009 Medical electrical equipment — Part 2-2:

Q500EXPL
Healthcare associated infections (also known as nosocomial infections) are
infections acquired in the hospital. While there are many ways in which the
possibility of the spread of infection can be minimized, the most effective is
also the simplest: hand washing. Employees should always wash their hands after
contact with an infected person, before meals, after using the restroom, after
removing gloves, and after handling chemicals.
Reference: Chaff, Linda F., Safety Guide for Health Care Institutions, 4th
edition, American Hospital Publishing, 1989, page 48
Q501EXPL
Although ether and other older anesthetic gases did represent a significant fire
and explosion hazard, modern anesthetic gases are not flammable. Virtually all
hospitals now use non-flammable anesthetic agents exclusively in their operating
rooms.
Studies have demonstrated a link between anesthetic gases and malignancies and
birth defects. Modern anesthesia machines use a gas scavenging system that
directly removes these gases from the patient's breathing circuit and exhausts
them to the outside, so that the levels of these gases in the operating room
remain low.
Improper gas administration can be a cause of these gases escaping into the air
in an operating room. However, improper gas administration by itself is not a
reason to perform monitoring of trace gases.
As with many items in health care, the costs associated with wasting anesthetic
gases are not generally considered a significant issue.
Sons, 1982, page 77
Q504EXPL
10.2.3.2.1 - Each electric appliance shall be provided with a grounding conductor

in its power cord.
10.2.3.2.2 - The grounding conductor shall be not smaller than 18 AWG.
10.2.3.2.3 - The grounding conductor of cords longer than 4.6 m (15 ft) shall be
not smaller than 16 AWG.
Q505EXPL
When discussing the property "intrinsically safe", this standard states
3.3.86 Intrinsically Safe. As applied to equipment and wiring, equipment and

wiring that are incapable of releasing sufficient electrical energy under normal
or abnormal conditions to cause ignition of a specific hazardous atmospheric
mixture.
Q506EXPL
The Centers for Disease Control and Prevention (CDC), a part of the U.S.
Department of Health and Human Services, is the primary Federal agency for
conducting and supporting public health activities in the United States.
According to CDC, healthcare-associated infections (HAI) are infections caused by

a wide variety of common and unusual bacteria, fungi, and viruses during the
course of receiving medical care.
Medical advances have brought lifesaving care to patients in need, yet many of
those advances come with a risk of HAI. These infections related to medical care
can be devastating and even deadly. As our ability to prevent HAIs grows, these
infections are increasingly unacceptable.
Recent successes in HAI elimination have been very encouraging. Reductions have
been demonstrated for other HAIs as well, but much more remains to be done.
Wherever patient care is provided, adherence to infection prevention guidelines

is needed to ensure that all care is safe care. This includes traditional
hospital settings as well as outpatient surgery centers, long-term care
facilities, rehabilitation centers, and community clinics.
Reference: Healthcare-associated infections (HAI) http://www.cdc.gov/hai/
Q507EXPL
A macroshock is a high level current applied to the surface of the body. If the
current is high enough, it can lead to inadvertent fibrillation and death. Lower
level macroshocks can cause a variety of problems, ranging from a startle
reaction, to a can't let go reaction as muscles are forced to contract.
Reference: Webster, John G., Medical Instrumentation: Application and Design,

Houghton-Mifflin Company, 1978, page 672
Q508EXPL
The Compressed Gas Association writes standards for the use of compressed
gas cylinders. The color code for compressed gas cylinders is:
Oxygen Green
Medical Oxygen Green with silver rim
Reference: Stoner, David L., Smathers, James B., Hyman, William A., Clapp,
David E., Duncan, Dean D., Engineering a Safe Hospital Environment, John
Wiley and Sons, 1982, page 59
Q509EXPL
The Environment of Care (EC) chapter is part of The Joint Commission's
Comprehensive Accreditation Manual for Hospitals.
The 2015 edition of the EC chapter is organized as shown below, and addresses six
specific areas:
I. Plan (EC.01.01.01)
II. Implement
A. Safety and Security (EC.02.01.01, EC.02.01.03)
B. Hazardous Materials and Waste (EC.02.02.01)
C. Fire Safety (EC.02.03.01, EC.02.03.03, EC.02.03.05)
D. Medical Equipment (EC.02.04.01, EC.02.04.03)
E. Utilities (EC.02.05.01, EC.02.05.03, EC.02.05.05, EC.02.07, EC.02.05.09)
F. Other Physical Environment Requirements (EC.02.06.01, EC.02.06.05)
III. Staff Demonstrate Competence (EC.03.01.01)
IV. Monitor and Improve (EC.04.01.01, EC.04.01.03, EC.04.01.05)
Earlier editions of the EC chapter included Safety and Security as two separate
sections, and the Joint Commission's requirements on Emergency Management were
also part of the EC chapter. Emergency Management is now a separate section of
the manual, and is no longer part of the Environment of Care chapter.
Reference:
Joint Commission, Chapter: Environment of Care
Q511EXPL
This standard defines various types of hazard currents associated with medical
equipment, including the following:
3.3.69 Hazard Current - For a given set of connections in an isolated power

system, the total current that would flow through a low impedance if it were
connected between either isolated conductor and ground.
3.3.69.1 Fault Hazard Current - The hazard current of a given isolated power
system with all devices connected except the line isolation monitor.
3.3.69.2 Monitor Hazard Current - The hazard current of the line isolation
monitor alone.
3.3.69.3 Total Hazard Current - The hazard current of a given isolated system
with all devices, including the line isolation monitor, connected.
3.3.175 Touch Current - Leakage current flowing from the enclosure or from
parts thereof, excluding patient connections, accessible to any operator or
patient in normal use, through an external path other than the protective
grounding (earth) conductor to earth or to another part of the enclosure.
Q512EXPL
When discussing the testing of receptacles, this standard states, in part:
6.3.4.1 Maintenance and Testing of Electrical System.

6.3.4.1.1 Where hospital-grade receptacles are required at patient bed
locations and in locations where deep sedation or general anesthesia is
administered, testing shall be performed after initial installation, replacement,
or servicing of the device.
6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be
performed at intervals defined by documented performance data.
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations
and in locations where deep sedation or general anesthesia is administered, shall
be tested at intervals not exceeding 12 months.
Q513EXPL
A basic method of protecting hospital personnel from the dangers of infection is
the construction of barriers between the potential infectious agent and the
employee. Typical barriers include gloves, gowns and masks.
Filtration typically involves cleaning the air in a room with a high-efficiency

particulate air filter (HEPA filter). This type of filter traps all but the very
smallest particles, providing very effective cleaning of the air.
Isolation involves restricting access to a patient so that the patient's

infection is less likely to spread, or to protect the patient against infections
from other people. Isolation is frequently used in conjunction with barrier
techniques to control the spread of infections.
Reference: None
Q514EXPL
Leakage currents in equipment are generally in the range of 0 to 500
microamperes. Therefore, meters measuring leakage current read this current in
microamperes.
page 417
Q515EXPL
ANSI/NFPA 70, the National Electrical Code, provides requirements for the
electrical power distribution system.
When discussing the requirements for grounded conductors, the standard says:
200.6 Means of Identifying Grounded Conductors.

(A) Sizes 6 AWG or Smaller. An insulated grounded conductor of 6 AWG or
smaller shall be identified by a continuous white or gray outer finish or by
three continuous white stripes on other than green insulation along its entire
length. Wires that have their outer covering finished to show a white or gray
color but have colored tracer threads in the braid identifying the source of
manufacture shall be considered as meeting the provisions of this section.
(The difference between the grounded conductor and the grounding conductor is
that the grounded conductor is intended to carry current during the normal
operation of equipment, while the grounding conductor is a safety device, and is
intended to carry current only under fault conditions.)
Reference: National Electrical Code, ANSI/NFPA 70, 2008 edition, An American

National Standard, National Fire Protection Association
Q516EXPL
A microshock is a very low-level current applied directly to the heart. This can
lead to inadvertent fibrillation and death. Microshocks are usually very low
current value, on the order of tens of microamperes.
Studies done on dogs in the 1960s showed that ventricular fibrillation could be
caused by a current as low as 20 microamperes applied directly to the heart.
Through extrapolation of this data to humans, a level of 10 microamperes was
thought to be a safe current level for the human heart, and so leakage current
standards were written to prevent currents higher than this from entering the
heart.
page 417
Q517EXPL
Misconnection of gases can represent an extremely dangerous hazard. For example,
if nitrous oxide were to be connected into an oxygen line, a patient death could
result.
To prevent this, many standards have been established by the Compressed Gas
Association. These standards are recognized by NFPA 99, which specifies the use
of the CGA Pin-Index and Diameter-Index Safety Systems in 11.6.4, as follows:
11.6.4 Special Precautions for the Care of Safety Mechanisms.
11.6.4.1 Personnel using cylinders and containers and other equipment covered in
this chapter shall be familiar with the CGA Pin-Index Safety System and the CGA
Diameter-Index Safety System, which are both designed to prevent utilization of
the wrong gas.
The pin-index safety system relies on a unique configuration of pins and holes on
compressed gas cylinder yokes and the cylinder outlet valves. Each type of gas
has its own configuration of these pins, so that an inadvertent attempt to
connect a gas cylinder to an incorrect yoke will be unsuccessful.
The diameter-index safety system specifies that cylinder yoke inserts and quick
and threaded couplers must have a noninterchangeable diameter, so that
inadvertent connections can be prevented.
Color coding of cylinders is also important, helping equipment operators quickly
identify the type of gas in a cylinder by the color of the cylinder.
Gas pressure regulators are a safety feature used to lower the pressure inside a
compressed gas cylinder from a very high level to a lower level that is safe for
use in the application being supplied by the gas. While the regulators are a very
important safety feature, they are not designed to prevent incorrect connections.
References:
[1] National Fire Protection Association, NFPA 99, 2012 edition - Health Care
Facilities Code
[2] Stoner, David L., Smathers, James B., Hyamn, William A., Clapp, David E.,
Duncan, Dean D., Engineering a Safe Hospital Environment, John Wiley and Sons,
1982, page 59
[3] Compressed Gas Association, ANSI/ASME/CGA V-1, Standard for Compressed Gas
Cylinder Valve Outlet and Inlet Connections, 2005 edition
Q518EXPL
Fuses in equipment are designed primarily to prevent a fire hazard associated
with the heat that can be generated if an electrical short circuit develops
inside a piece of equipment. Fuses are also used to prevent damage to components
in equipment from the effects of excessive currents.
Ground fault interrupters are used in wet areas to prevent shocks to equipment
operators or patients. They are often used in bathrooms, for example, to turn off
power if an electrical device, such as a hair dryer, is dropped in a sink full of
water.
Insulation is the primary method of protecting personnel and patients against

shock. Insulation provides a very high-impedance path between current-carrying
portions of equipment and those who may have contact with the equipment.
Grounding wires are used to provide a low-impedance path to ground for chassis
leakage currents. In this way, the voltage on the case of the equipment will
remain at a safe level, below the level where a person could experience a
hazardous electric shock.
Reference: None
Q519EXPL
10.3.5 Touch Current - Portable Equipment

10.3.5.1 Touch Current Limits. The touch current for cord-connected equipment
shall not exceed 100 microamps with ground wire intact (if a ground wire is
provided) with normal polarity, and shall not exceed 500 microamps with the
ground wire disconnected.
Q520EXPL
When discussing equipment testing intervals, this standard states, in part:
10.5.2.1 Testing Intervals.
10.5.2.1.1 The facility shall establish policies and protocols for the type of
test and intervals of testing for patient care–related electrical equipment.
10.5.2.1.2 All patient care–related electrical equipment used in patient care

rooms shall be tested in accordance with 10.3.5.4 or 10.3.6 before being put into
service for the first time and after any repair or modification that might have
compromised electrical safety.
Q521EXPL
10.5.2.1.2 - All patient care-related electrical equipment used in patient care

rooms shall be tested in accordance with 10.3.5.4 or 10.3.6 before being put into
service for the first time and after any repair or modification that might have
compromised electrical safety.
Q522EXPL

6.3.2.6.3.2 - The monitor shall be designed such that a green signal lamp,
be energized when the total hazard current (consisting of possible resistive and
capacitive leakage currents) from either isolated conductor to ground reaches a
Q523EXPL
10.3.2.1 - For appliances that are used in the patient care vicinity, the
resistance between the appliance chassis, or any exposed conductive surface of
the appliance, and the ground pin of the attachment plug shall be less than 0.50
ohm under the following conditions:
(1) The cord shall be flexed at its connection to the attachment plug or
connector.
(2) The cord shall be flexed at its connection to the strain relief on the
chassis.
Q524EXPL
6.3.2.6.3.2 - The monitor shall be designed such that a green signal lamp,
be energized when the total hazard current consisting of possible resistive and
capacitive leakage currents from either isolated conductor to ground reaches a
6.3.2.6.3.4 - An ammeter connected to indicate the total hazard current of the

system (contribution of the fault hazard current plus monitor hazard current)
shall be mounted in a plainly visible place on the line isolation monitor with
the “alarm on” zone (total hazard current = 5.0 mA) at approximately the center
of the scale. A line isolation monitor shall be located in the operating room.
Q525EXPL
10.3.5.2 - If multiple devices are connected together and one power cord supplies
power, the leakage current shall be measured as an assembly.
Q526EXPL
NFPA 10 is the standard that applies to fire extinguishers. This standard
classifies fires as follows:
5.2 Classifications of Fires. Fires shall be classified in accordance with the

guidelines specified in 5.2.1 through 5.2.5.
5.2.1 Class A Fires. Class A fires are fires in ordinary combustible materials,
such as wood, cloth, paper, rubber, and many plastics.
5.2.2 Class B Fires. Class B fires are fires in flammable liquids, combustible
liquids, petroleum greases, tars, oils, oil-based paints, solvents, lacquers,
alcohols, and flammable gases.
5.2.3 Class C Fires. Class C fires are fires that involve energized electrical
equipment.
5.2.4 Class D Fires. Class D fires are fires in combustible metals, such as
magnesium, titanium, zirconium, sodium, lithium, and potassium.
5.2.5 Class K Fires. Class K fires are fires in cooking appliances that involve
combustible cooking media (vegetable or animal oils and fats).
Reference: National Fire Protection Association, NFPA 10, 2010 edition - Portable
Fire Extinguishers
Q527EXPL
NFPA 99 offers the following explanation about the properties of oxygen:
A.3.3.129 Oxygen. Oxygen's outstanding property is its ability to sustain life

and to support combustion. Although oxygen is nonflammable, materials that burn
in air will burn much more vigorously and create higher temperatures in oxygen or
in oxygen-enriched atmospheres.
While it does seem somewhat counter-intuititve, oxygen is not flammable, but it

is a high-energy gas that very readily oxidizes other materials. For something to
burn, the reaction requires a fuel (the thing that burns) and an oxidizer like
oxygen. Without the fuel, though, no combustion will take place no matter how
high the concentration of oxygen is.
References:
Facilities Code
[2] UCSB ScienceLine: At what percent oxygen does air become spontaneously
combustible (25%? 30 %?) Or does it ever without an ignition source?,
http://scienceline.ucsb.edu/getkey.php?key=954, retrieved February 22, 2015
Q528EXPL
Disinfection uses powerful chemical agents to kill microorganisms that are
present on the surface of an instrument. In order to work, the disinfectant must
be in contact with the microorganisms to be killed. To accomplish this, the
surface must be cleaned before disinfection.
Disinfection differs from sanitization and sterilization. Sanitization is a

process of surface cleaning that reduces the level of microorganisms to a safe
level for human use.
Disinfection is a more effective process than sanitization, but even with

disinfection, some bacterial spores and viruses survive.
Sterilization is the most thorough process. Only with sterilization are all forms
of microbial life reliably killed. The types of organisms killed by sterilization
include bacteria, spores, fungi, and viruses.
Sons, 1982, page 151
Q529EXPL
In its identification of governance responsibilities for a hospital, the Joint
Commission offers the following information:
"Governance - The individual(s), group, or agency that has ultimate authority and
responsibility for establishing policy; maintaining quality of care, treatment,
or services; and providing for organization management and planning. Governance
may be a separate entity or it may fall within the medical advisory or executive
committee. Other names for this group include the board, board of trustees, board
of governors, board of commissioners, and partnership."
A state health department generally has responsibility for licensing and

regulating the operation of a hospital. However, a state health department does
not establish policies, or provide management or planning of a hospital.
The US Food and Drug Administration generally does not regulate hospital
operations and does not have responsibility for establishing hospital governance.
Similarly, the American Hospital Association may offer suggestions and examples
of best practices to be followed by hospitals but does not have responsibility
for establishing policies or procedures at any given hospital.
Reference: The Joint Commission, Comprehensive Accreditation Manual for

Hospitals: The Official Handbook, 2011
Q530EXPL
The "Authority Having Jurisdiction" is defined in NFPA 99 as:
3.2.2 Authority Having Jurisdiction (AHJ). An organization, office, or

individual responsible for enforcing the requirements of a code or standard, or
for approving equipment, materials, an installation, or a procedure.
Often, the AHJ will be an agency or organization granted enforcement power by

either the federal government, a state government, or a local government. In many
states, the state or local fire marshal is given the responsibility for enforcing
codes, such as NFPA 101 - Life Safety Code. On the federal level, the Centers for
Medicare and Medicaid Services (CMS) has granted The Joint Commission status as
an AHJ, responsible for enforcing CMS regulations.
ECRI Institute, the Association for the Advancement of Medical Instrumentation,

and the American College of Clinical Engineering do not inspect hospitals and
have no legal authority to enforce codes or standards.
Q531EXPL
Requirements related to emergency power systems can be found in NFPA 70, the
National Electrical Code. In part this states:
517.31 Emergency System. Those functions of patient care depending on lighting or

appliances that are connected to the emergency system shall be divided into two
mandatory branches: the life safety branch and the critical branch, described in
517.32 and 517.33.
The branches of the emergency system shall be installed and connected to the
alternate power source so that all functions specified herein for the emergency
system shall be automatically restored to operation within 10 seconds after
interruption of the normal source.
Reference: National Fire Protection Association, National Electrical Code,

ANSI/NFPA 70, 2008 edition
Q532EXPL
This standard contains the following, in part
10.5.3 Servicing and Maintenance of Equipment

10.5.3.1 The manufacturer of the appliance shall furnish documents containing
at least a technical description, instructions for use, and a means of contacting
the manufacturer.
10.5.3.1.1 The documents specified in 10.5.3.1 shall include the following,
where applicable:
(1) Illustrations that show the location of controls
(2) Explanation of the function of each control
(3) Illustrations of proper connection to the patient or other
equipment, or both
(4) Step-by-step procedures for testing and proper use of the
appliance
(5) Safety considerations in use and servicing of the appliance
(6) Precautions to be taken if the appliance is used on a patient
simultaneously with other electric appliances
(7) Schematics, wiring diagrams, mechanical layouts, parts lists,
and other pertinent data for the appliance
(8) Instructions for cleaning, disinfection, or sterilization
(9) Utility supply requirements (electrical, gas, ventilation,
heating, cooling, and so forth)
(10) Explanation of figures, symbols, and abbreviations on the
appliance
(11) Technical performance specifications
(12) Instructions for unpacking, inspection, installation,
adjustment, and alignment
(13) Preventive and corrective maintenance and repair procedures
Q533EXPL
10.5.8 Qualification and Training of Personnel.
10.5.8.1 Personnel concerned for the application or maintenance of electric

appliances shall be trained on the risks associated with their use.
10.5.8.1.1 The health care facilities shall provide programs of continuing

education for its personnel.
10.5.8.1.2 Continuing education programs shall include periodic review of

manufacturers' safety guidelines and usage requirements for electrosurgical units
and similar appliances.
10.5.8.2 Personnel involved in the use of energy-delivering devices

including, but not limited to, electrosurgical, surgical laser, and fiberoptic
devices shall receive periodic training in fire suppression.
Q534EXPL
NFPA 99 - Health Care Facilities Code specifically prohibits the use of oil and
grease on oxygen equipment in the following section:
"11.5.1.2.2 Oil, grease, or other flammable substances shall not be used on/in
oxygen equipment."
While oxygen will not burn, it does support combustion. Materials that burn in
air will burn violently in pure oxygen and explosively in pressurized oxygen.
Oil and grease are easily ignited materials, and in a pure oxygen atmosphere,
they will burn violently.
The breakdown of oil and grease are not affected by the presence of oxygen.
Oil and grease are not soluble in oxygen, and they do not trap moisture.
Q535EXPL
The ANSI/AAMI ES60601-1 Medical electrical equipment - Part 1: General
requirements for safety and essential performance standard specifies the
following:
7.8 Indicator lights and controls
7.8.1 Colors of indicator lights - The colors of indicator lights and

their meanings shall comply with [the table shown below]. NOTE: IEC 60601-
1-8 contains specific requirements for the color, flashing frequency, and
duty cycle of alarm indicator lights. Dot-matrix and other alphanumeric
displays are not considered to be indicator lights.
Colors of indicator lights

and their meaning for Medical Electrical Equipment
Color Meaning
Red Warning - immediate response by the operator is required
Yellow Caution - prompt response by the operator is required
Green Ready for use
Any other color Meaning other than that of red, yellow, or green
Reference: Association for the Advancement of Medical Instrumentation,

Medical electrical equipment - Part 1: General requirements for basic
safety and essential performance, ANSI/AAMI ES60601-1:2005/(R)2015
Q536EXPL
The Food and Drug Administration Modernization Act of 1997 (FDAMA) requires that
manufacturers track certain devices when the agency orders them to do so.
Tracking is intended to facilitate notification and recall in the event a device
presents a serious risk to health that requires prompt attention.
Regulations promulgated by the Food and Drug Administration to enforce this

statute require that certain devices, particularly implantable devices, be
tracked from manufacture to implant.
To facilitate tracking, the FDA requires distributors of tracked devices to keep

records related to those devices and to report the disposition of those devices
to the manufacturer. Under the regulations, the hospital where an implant takes
place is considered the final distributor of the device and must follow all the
required regulations.
Specific items that must be reported to the manufacturer by the hospital include
the following:
- device identification (lot, batch, model or serial number);
- name, address, telephone number and social security number of the patient who
received the device;
- date provided to the patient;
- name, mailing address, and telephone number of the prescribing physician;
- name, mailing address, and telephone number of the physician regularly
following the patient;
- when applicable, the following information also needs to be reported:
- the date of device explant;
- the name, mailing address, and telephone number of the explanting
physician;
- the date of the patient's death;
- the date that the device was returned to the manufacturer; and
- the date the device was permanently retired from use, or otherwise disposed
of permanently.
Under FDA regulations, while a patient may refuse to have their device tracked,
the regulations do not require that patients give written consent to have their
devices tracked or to release their identity to the manufacturer.
Reference: Food and Drug Administration, Medical Device Tracking; Guidance for
Industry and FDA Staff, January 25, 2010,
http://www.fda.gov/downloads/MedicalDevices/DeviceRegulationandGuidance/GuidanceD
ocuments/ucm071775.pdf
Q537EXPL
The NFPA 99 standard states:
3.3.89 Isolated Power System. A system comprising an isolation transformer or its

equivalent, a line isolation monitor, and its ungrounded circuit conductors.
Isolated Power Systems were first used in the hospital environment to reduce the
risk of explosions in operating rooms and any other area where flammable
anesthetizing agents are used.
References:
Facilities Code
[2] The Isolated Power Systems Debate, Matthew F. Baretich, PE, PhD,
http://www.24x7mag.com/issues/articles/2007-12_03.asp
[3] Isolated Power Systems in Health Care Facilities,
http://www.iaei.org/magazine/2007/07/isolated-power-systems-in-health-care-
facilities
Q538EXPL
When discussing the testing of receptacles, this standard states, in part:

6.3.4.1 Maintenance and Testing of Electrical System.
6.3.4.1.1 Where hospital-grade receptacles are required at patient bed locations
and in locations where deep sedation or general anesthesia is administered,
testing shall be performed after initial installation, replacement, or servicing
of the device.
6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be
performed at intervals defined by documented performance data.
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and
in locations where deep sedation or general anesthesia is administered, shall be
tested at intervals not exceeding 12 months.
Q539EXPL
6.3.2.2.6.2 Minimum Number of Receptacles. The number of receptacles shall be

determined by the intended use of the patient care rooms in accordance with
6.3.2.2.6.2(A) through 6.3.2.2.6.2(E).
(B) Receptacles for Patient Bed Locations in Critical Care Areas (Category 1).
Each patient bed location shall be provided with a minimum of 14 receptacles.
Q540EXPL
6.3.2.2.6.2 Minimum Number of Receptacles. The number of receptacles shall be

determined by the intended use of the patient care rooms in accordance with
6.3.2.2.6.2(A) through 6.3.2.2.6.2(E).
(A) Receptacles for Patient Bed Locations in General Care Areas (Category 2).
Each patient bed location shall be provided with a minimum of eight receptacles.
Q542EXPL
The Glossary of the 2015 Joint Commission Accreditation Manual for Hospitals
includes the following definition:
"Life-support Equipment - Any device used for the purpose of sustaining life and
whose failure to perform its primary function, when used according to the
manufacturer's instructions and clinical protocol, will lead to patient death in
the absence of immediate intervention (for example, ventilators, anesthesia
machines, heart-lung bypass machines, defibrillators)."
Reference:
Joint Commission, Glossary
Q544EXPL
3.3.139 Patient Care Vicinity - A space, within a location intended for the
examination and treatment of patients, extending 1.8 m (6 feet) beyond the normal
location of the bed, chair, table, treadmill, or other device that supports the
patient during examination and treatment and extending vertically to 2.3 m (7 ft.
6 in.) above the floor.
Q545EXPL
Joint Commission Standard EC.02.04.01 EP 1 states:
"The hospital solicits input from individuals who operate and service equipment
when it selects and acquires medical equipment."
Reference:
Joint Commission, EC.02.04.01 EP 1
Q546EXPL
Regulations promulgated by the Occupational Safety and Health
Administration (OSHA) are published in Section 1910 of Title 29 of the
Code of Federal Regulations. These regulations include limits on radiation
exposure. 29 CFR 1910.1096(b)(1) states:
"Except as provided in paragraph (b)(2) of this section, no employer shall

possess, use, or transfer sources of ionizing radiation in such a manner
as to cause any individual in a restricted area to receive in any period
of one calendar quarter from sources in the employer's possession or
control a dose in excess of the limits specified in Table G-18"
TABLE G-18
Rems per calendar quarter
Whole body: Head and trunk; active blood-forming organs; lens of eyes; or gonads 1.25
Hands and forearms; feet and ankles 18.75
Skin of whole body 7.5
Reference:
http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_
id=10098
Q547EXPL
Regulations promulgated by the Nuclear Regulatory Commission (NRC) are published
in Section 20 of Title 10 of the Code of Federal Regulations. As defined in Title
10, Section 20.1003, of the Code of Federal Regulations (10 CFR 20.1003), ALARA
is an acronym for "as low as (is) reasonably achievable."
The intent of the ALARA regulations is to make every reasonable effort to

maintain exposures to ionizing radiation as far below the dose limits as
practical, consistent with the purpose for which the NRC-licensed activity is
undertaken. When determining what ALARA is for any given activity, the NRC takes
into account:
- the current state of technology,
- the economics of improvements in relation to state of technology,
- the economics of improvements in relation to benefits to the public health and
safety, and other societal and socioeconomic considerations, and in relation to
utilization of nuclear energy and licensed materials in the public interest.
Reference: http://www.nrc.gov/reading-rm/basic-ref/glossary/alara.html
Q554EXPL
Recalls are actions taken by a firm to remove a product from the market. Recalls
may be conducted on a firm's own initiative, by Food and Drug Administration
(FDA) request, or by FDA order under statutory authority.
Class I recall: a situation in which there is a reasonable probability that the

use of or exposure to a violative product will cause serious adverse health
consequences or death.
Class II recall: a situation in which use of or exposure to a violative product

may cause temporary or medically reversible adverse health consequences or where
the probability of serious adverse health consequences is remote.
Class III recall: a situation in which use of or exposure to a violative product

is not likely to cause adverse health consequences.
Market withdrawal: occurs when a product has a minor violation that would not be
subject to FDA legal action. The firm removes the product from the market or
corrects the violation. For example, a product removed from the market due to
tampering, without evidence of manufacturing or distribution problems, would be a
market withdrawal.
Medical device safety alert: issued in situations where a medical device may
present an unreasonable risk of substantial harm. In some cases, these situations
also are considered recalls.
Reference: http://www.fda.gov/Safety/Recalls/IndustryGuidance/ucm129337.htm
Q555EXPL
The Food and Drug Administration (FDA) has established classifications for
approximately 1,700 different generic types of devices and grouped them into 16
medical specialties referred to as panels. Each of these generic types of devices
is assigned to one of three regulatory classes based on the level of control
necessary to assure the safety and effectiveness of the device. The three classes
and the requirements that apply to them are:
1. Class I - General Controls
2. Class II - General Controls and Special Controls
3. Class III - General Controls and Premarket Approval
Reference:
http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/Overview/ClassifyYo
urDevice/default.htm
Q556EXPL
The Food and Drug Administration (FDA) is an agency within the U.S. Department of
Health and Human Services. It consists of six product centers, one research
center, and two offices.
Center for Biologics Evaluation and Research, which regulates products such as
vaccines, blood, and gene therapy
Center for Devices and Radiological Health, which regulates medical devices
ranging from thermometers to kidney dialysis machines, and electronic products
that give off radiation, such as microwave ovens
Center for Drug Evaluation and Research, which regulates over-the-counter and
prescription medications
Center for Food Safety and Applied Nutrition, which regulates most foods (except
meat and poultry, which are regulated by the U.S. Department of Agriculture),
food additives, infant formulas, dietary supplements, and cosmetics
Center for Tobacco Products, which regulates cigarettes, cigarette tobacco, roll-
your-own tobacco, and smokeless tobacco
Center for Veterinary Medicine, which regulates feed and drugs and devices used
in pets, farm animals, and other animals
National Center for Toxicological Research, which supports FDA’s product centers
by providing innovative scientific technology, training, and technical expertise
Office of Regulatory Affairs, which conducts inspections and enforces FDA

regulations
Office of the Commissioner, which provides leadership and direction to FDA’s

product centers, research center, and Office of Regulatory Affairs.
Reference: http://www.fda.gov/AboutFDA/Transparency/Basics/ucm192695.htm
Q558EXPL
The CAP website provides the following information about its program designed to
review the operation of laboratories.
The CAP Laboratory Accreditation Program is an internationally recognized program

and the only one of its kind that utilizes teams of practicing laboratory
professionals as inspectors. Designed to go well beyond regulatory compliance,
the program helps laboratories achieve the highest standards of excellence to
positively impact patient care.
The program is based on rigorous accreditation standards that are translated into
detailed and focused checklist requirements. The checklists, which provide a
quality practice blueprint for laboratories to follow, are used by the inspection
teams as a guide to assess the overall management and operation of the
laboratory.
The CAP Laboratory Accreditation Program meets the needs of a variety of

laboratory settings from complex university medical centers to physician office
laboratories. The program also covers a complete array of disciplines and testing
procedures. Because of its comprehensive nature, CAP accreditation can help
achieve a consistently high level of service throughout an institution or
healthcare system.
The Centers for Medicare and Medicaid Services (CMS) has granted the CAP
Laboratory Accreditation Program deeming authority. It is also recognized by the
Joint Commission, and can be used to meet many state certification requirements.
The CAP also provides laboratory accreditation to forensic urine drug testing and
reproductive laboratories, co-sponsored with the American Society for
Reproductive Medicine (ASRM).
Reference:
http://www.cap.org/apps/cap.portal?_nfpb=true&cntvwrPtlt_actionOverride=%2Fportle
ts%2FcontentViewer%2Fshow&_windowLabel=cntvwrPtlt&cntvwrPtlt%7BactionForm.content
Reference%7D=laboratory_accreditation%2Faboutlap.html&_state=maximized&_pageLabel
=cntvwr
Q559EXPL
College of American Pathologists (CAP) standards are used to define the
requirements for a clinical laboratory. One requirement related to centrifuge
operations specifies:
GEN.41017 - Centrifuge Operating Speeds: The operating speeds of centrifuges are

checked at least annually as needed for the intended use, and this is done in a
safe manner.
NOTE: For centrifuges having a safety mechanism preventing the opening of the lid
while in operation, the checks of rpm should be performed only by an authorized
service representative of the manufacturer or an appropriately trained clinical
engineer.
Evidence of Compliance: Records of verification of operating speeds documented at
least annually
Reference: CAP, Laboratory General Checklist, 7.11.2011
Q560EXPL
College of American Pathologists (CAP) standards are used to define the
requirements for a clinical laboratory. One requirement related to electrical
grounding specifies:
GEN.75900 - Electrical Grounding: There is documentation that both the laboratory

director and the institutional safety committee have approved a program to ensure
that all laboratory instruments and appliances are adequately grounded and
checked for current leakage before initial use, after repair or modification, and
when a problem is suspected.
NOTE: Exceptions to these requirements are as follows:

1. Devices protected by an approved system of double insulation or its
equivalent. Such devices must be distinctively marked.
2. Equipment operating at 240 volts must be checked for ground integrity only.
In addition, the US Occupational Safety and Health Administration (OSHA) requires

that power cords of portable electrical equipment be visually inspected for
external defects whenever relocated. Grounding configurations may not be bypassed
by, for example, an adapter that interrupts the continuity of the grounding.
References:
[1] CAP, Laboratory General Checklist, 7.11.2011
[2]
http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=9911&p_table=STANDARDS
Q561EXPL
The Centers for Medicare & Medicaid Services (CMS) regulates all laboratory
testing (except research) performed on humans in the U.S. through the Clinical
Laboratory Improvement Amendments (CLIA). In total, CLIA covers approximately
225,000 laboratory entities. The Division of Laboratory Services, within the
Survey and Certification Group, under the Office of Clinical Standards and
Quality (OCSQ), has the responsibility for implementing the CLIA Program.
The objective of the CLIA program is to ensure quality laboratory testing.

Although all clinical laboratories must be properly certified to receive Medicare
or Medicaid payments, CLIA has no direct Medicare or Medicaid program
responsibilities.
42 CFR 493 of the Code of Federal Regulations has regulations related to the CLIA
program. The specific requirement related to the frequency of maintenance checks
can be found in 42 CFR 493.1254, which says:
Sec. 493.1254 Standard: Maintenance and function checks
(a) Unmodified manufacturer's equipment, instruments, or test systems. The

laboratory must perform and document the following:
(1) Maintenance as defined by the manufacturer and with at least the
frequency specified by the manufacturer.
(2) Function checks as defined by the manufacturer and with at least the
frequency specified by the manufacturer. Function checks must be within the
manufacturer's established limits before patient testing is conducted.
(b) Equipment, instruments, or test systems developed in-house, commercially

available and modified by the laboratory, or maintenance and function check
protocols are not provided by the manufacturer. The laboratory must do the
following:
(1)(i) Establish a maintenance protocol that ensures equipment, instrument,
and test system performance that is necessary for accurate and reliable test
results and test result reporting.
(ii) Perform and document the maintenance activities specified in
paragraph (b)(1)(i) of this section.
(2)(i) Define a function check protocol that ensures equipment, instrument,
and test system performance that is necessary for accurate and reliable test
results and test result reporting.
(ii) Perform and document the function checks, including background or
baseline checks, specified in paragraph (b)(2)(i) of this section.
Function checks must be within the laboratory's established limits before patient
testing is conducted.
References:
[1] https://www.cms.gov/CLIA/
[2] http://wwwn.cdc.gov/clia/regs/toc.aspx
Q562EXPL
The Joint Commission's standard related to the maintenance interval for medical
equipment can be found in EC.02.04.01 EP 4. This standard specifies the following
requirement, and includes the explanatory note and footnote indicated below:
EC.02.04.01 EP 4 - The hospital identifies the activities and associated

frequencies, in writing, for maintaining, inspecting, and testing all medical
equipment on the inventory. These activities and associated frequencies are in
accordance with manufacturers’ recommendations or with strategies of an
alternative equipment maintenance (AEM) program.
Note: The strategies of an AEM program must not reduce the safety of equipment
and must be based on accepted standards of practice.
Footnote: An example of standards for a medical equipment program is the American

National Standards Institute/Association for the Advancement of Medical
Instrumentation handbook ANSI/AAMI EQ56: 2013, Recommended Practice for a Medical
Equipment Management Program.
Reference:
Q563EXPL
The Environment of Care chapter of the Joint Commission's Accreditation Manual
identifies the requirements for medical equipment. The contents of this chapter
include the following:
Environment of Care Chapter Outline
I. Plan (EC.01.01.01)
II. Implement
A. Safety and Security (EC.02.01.01, EC.02.01.03)
B. Hazardous Materials and Waste (EC.02.02.01)
C. Fire Safety (EC.02.03.01, EC.02.03.03, EC.02.03.05)
D. Medical Equipment (EC.02.04.01, EC.02.04.03)
E. Utilities (EC.02.05.01, EC.02.05.03, EC.02.05.05, EC.02.07, EC.02.05.09)
F. Other Physical Environment Requirements (EC.02.06.01, EC.02.06.05)
III. Staff Demonstrate Competence (EC.03.01.01)
IV. Monitor and Improve (EC.04.01.01, EC.04.01.03, EC.04.01.05)
Reference:
Joint Commission, Chapter: Environment of Care
Q564EXPL
The Environment of Care chapter of the Joint Commission's Accreditation Manual
identifies the requirements for medical equipment. The section of this manual
that discusses the inspection of nuclear medicine equipment says the following:
EC.02.04.03 EP 14. For hospitals that use Joint Commission accreditation for
deemed status purposes: Qualified hospital staff inspect, test, and calibrate
nuclear medicine equipment annually. The dates of these activities are
documented.
Deemed Status - A provider or supplier that has been accredited by a CMS-approved

national accreditation program and that such accreditation demonstrates
compliance with the applicable conditions of participation, conditions for
coverage, conditions for certification or requirements.
References:
[2]
http://www.hospitalcompare.hhs.gov/(S(bfjhkmqciwepplr4oogb3t55))/staticpages/help
/hospital-glossary.aspx?Choice=D
Q565EXPL
The Joint Commission standard for dialysis water testing states:
EC.02.04.03 EP 5 - The hospital performs equipment maintenance and chemical and

biological testing of water used in hemodialysis. These activities are
documented.
Reference:
Q566EXPL
The Joint Commission infection control standard IC.02.02.01 states:
IC.02.02.01 - The hospital reduces the risk of infections associated with medical
equipment, devices, and supplies.
The BMET should have knowledge of appropriate standards in the Human Resources
(HR), Information Management (IM), and Infection Control (IC) chapters.
Reference:
Joint Commission, IC.02.02.01
Q567EXPL
ANSI/AAMI/IEC 80001-1:2010 - Application of risk management for IT Networks

incorporating medical devices - Part 1: Roles, responsibilities and activities
ANSI/AAMI ES60601-1:2005/(R)2012 - Medical electrical equipment — Part 1: General

ANSI/AAMI/IEC 60601-2-2:2009 - Medical electrical equipment - Part 2-2:

Reference: Application of risk management for IT Networks incorporating medical

devices - Part 1: Roles, responsibilities and activities, ANSI/AAMI/IEC 80001-
1:2010
Q568EXPL
The section of NFPA 99 that identifies the three branches of an electrical system
states:
6.4.2.2.1.1 - The essential electrical system shall be divided into the following
three branches:
(1) Life safety
(2) Critical
(3) Equipment
Q569EXPL
The section of NFPA 99 that discusses the need for a critical branch of the
electrical system states:
6.4.2.2.4.2 - The critical branch shall supply power for task illumination, fixed
equipment, select receptacles, and select power circuits serving the following
areas and functions related to patient care:
(1) Critical care areas that utilize anesthetizing gases, task illumination,
select receptacles, and fixed equipment
(2) Isolated power systems in special environments
(3) Task illumination and select receptacles in the following:
(a) Patient care rooms, including infant nurseries, selected acute nursing
areas, psychiatric bed areas (omit receptacles), and ward treatment rooms
(b) Medication preparation areas
(c) Pharmacy dispensing areas
(d) Nurses' stations (unless adequately lighted by corridor luminaires)
(4) Additional specialized patient care task illumination and receptacles, where
needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7) Telephone equipment rooms and closets
(8) Task illumination, select receptacles, and select power circuits for the
following areas:
(a) General care beds with at least one duplex receptacle per patient
bedroom, and task illumination as required by the governing body of the health
care facility
(b) Angiographic labs
(c) Cardiac catheterization labs
(d) Coronary care units
(e) Hemodialysis rooms or areas
(f) Emergency room treatment areas (select)
(g) Human physiology labs
(h) Intensive care units
(i) Postoperative recovery rooms (select)
(9) Additional task illumination, receptacles, and select power circuits needed
for effective facility operation, including single-phase fractional horsepower
motors, which are permitted to be connected to the critical branch
Q571EXPL
Ethylene oxide (EtO) is produced in large volumes and is primarily used as an
intermediate in the production of several industrial chemicals, the most notable
of which is ethylene glycol. It is also used as a fumigant in certain
agricultural products and as a sterilant for medical equipment and supplies.
Unfortunately, EtO possesses several physical and health hazards that merit
special attention. EtO is both flammable and highly reactive.
Acute exposures to EtO gas may result in respiratory irritation and lung injury,
headache, nausea, vomiting, diarrhea, shortness of breath, and cyanosis. Chronic
exposure has been associated with the occurrence of cancer, reproductive effects,
mutagenic changes, neurotoxicity, and sensitization.
Reference: http://www.osha.gov/SLTC/ethyleneoxide/index.html
Q572EXPL
The risk of burn increases exponentially with temperature. According to a study
(Moritz and Henriques 1947) on thermal injuries to human skin, most human skin
can tolerate exposure to a temperature of 43 o C (110o F) for a duration of about
six hours without thermal injury.
Reference: Moritz AR, Henriques FC, Studies of thermal injury, II: The relative
importance of time and surface temperature in the causation of cutaneous burns,
Am J Pathol 1947 Sep; 23(5):695-720.
Q573EXPL
NFPA 70 is also known as the National Electrical Code (NEC). The NEC is commonly
adopted by most states as the basis for their own regulations related to the
requirements for electrical systems. The NEC is divided into articles. Articles
in the 500 series address special occupancy types, and establish standards
designed to deal with the specific types of hazards typically found in those
types of buildings.
Article 513 addresses aircraft hangars.
Article 517 specifies requirements for the "electrical construction and

installation criteria in health care facilities that provide services to human
beings."
Article 530 applies to motion picture and television studios, and similar
locations.
Article 540 specifies the requirements for motion picture projection rooms.
Reference: National Fire Protection Association, National Electrical Code,

ANSI/NFPA 70
Q598EXPL
Electric shock can result in burns, muscle contraction, heart fibrillation, or
other serious injuries. The effects of electrical shock depend on the current
magnitude, the duration of contact with the current, and the organ through which
the current passes.
The primary function of the original BMETs was to ensure that electrical devices
that came in contact with patients would not shock the patients. Even today,
because of the physical dangers and fiscal threats (litigation) posed by electric
shock, a major function of the BMET is hospital liability reduction, especially
electrical safety. It is important to check the safety parameters of the
particular unit and that the unit is working properly before putting newly
acquired medical units into service, during routine maintenance of medical units,
and after the units have been repaired. Electrical Safety Test Analyzers are the
units used to check the safety parameters of electrically powered medical
equipment, even for the newly acquired units.
There are essentially two forms of shock: macroshock and microshock. Dry skin is
a poor conductor. Hence, current that flows along the skin (macroshock) can be
better tolerated than current that flows through the blood vessels below the skin
(microshock). Skin currents (macroshock) of 5 mA or less may cause a light
sensation of shock with little or no damage to tissue. Currents greater than 10
mA can cause muscles to contract to the point that an individual is unable to let
go of a live wire. Body currents greater than 100 mA, even when applied for a few
seconds, can cause respiratory muscles to become paralyzed, stopping breathing.
At these levels of current, the heart can lose sinus rhythm and go into
ventricular fibrillation.
When the skin is penetrated using a catheter, the body loses the protective
property of the skin. In addition, body fluids (blood-filled veins) are good
conductors. The most dangerous situation is if an electrode or catheter is
carrying electrical current directly into the heart. In this case, even small
amounts of current (microshock) can lead to ventricular fibrillation.
Note that proper grounding is the best defense against macroshock and microshock,
since Ohm’s law states that there can be no current without a voltage difference.
If all the electrically exposed areas are properly grounded, the voltage
differences are zero. Hence, no current flows.
Circulatory shock, commonly known simply as shock, is a life-threatening medical

condition that occurs when the circulation of blood is not adequate to support
cellular respiration. While there are many possible causes for shock, the most
common is a severe loss of blood due to an injury with severe bleeding or a burn.
The typical signs of shock are low blood pressure, a rapid heartbeat and signs of
poor end-organ perfusion or "decompensation/peripheral shut down" (such as low
urine output, confusion or loss of consciousness).
References:
Delmar, Cengage, Clifton Park, NY, 2010, pp. 595-599
[2] Street, Laurence, Introduction to Biomedical Engineering Technology, Second
Edition, CRC Press, Taylor and Francis Group, Boca Raton, 2012, pp. 144-154
[3] Webster, John G., Ed., Bioinstrumentation, John Wiley & Sons, Hoboken, NJ,
2004
[4] Al-Akwaa, Fadhl, Powerpoint presentation: Calibration and Electrical Safety
of Medical Equipment, fadhl-
alakwa.weebly.com/uploads/5/3/6/4/5364958/safety.slide.72, used with permission
of Dr. Al-Akwaa
[5] Wikipedia article on Shock (circulatory),
http://en.wikipedia.org/wiki/Shock_(circulatory), retrieved July 24, 2014
Q647EXPL
The FDA’s authority to regulate medical devices comes from the Federal Food Drug
and Cosmetic Act (FD&C Act) Title 21 Code of Federal Regulations (21CFR) parts
800-1299, and the Medical Device Amendments of May 28, 1976. Section 201(h) of
the Food, Drug and Cosmetic Act defines a medical device as “any healthcare
product that does not achieve its principal intended purposes by chemical action
or by being metabolized.”
The FDA division responsible for medical devices is the Center for Devices and
Radiological Health (CDRH) and its mission is “to get safe and effective medical
devices to market as quickly as possible while ensuring that medical devices
currently on the market remain safe and effective.” There are three
classifications for device approval: Class I – low risk, Class II – medium risk,
and Class III – high risk. All devices, regardless of Class, must comply with
General Controls: Adulteration / Misbranding, Electronic Establishment
Registration, Electronic Device Listing, Premarket Notification [510(k)], Quality
Systems, Labeling, and Medical Device Reporting (MDR).
As the FDA notes in its training materials (see reference 3): “Premarket approval
(PMA) is the FDA process of scientific and regulatory review to evaluate the
safety and effectiveness of Class III medical devices. Class III devices are
those that support or sustain human life, are of substantial importance in
preventing impairment of human health, or which present a potential, unreasonable
risk of illness or injury. Due to the level of risk associated with Class III
devices, FDA has determined that general and special controls alone are
insufficient to assure the safety and effectiveness of class III devices. PMA is
the most stringent type of device marketing application required by FDA. The
applicant must receive FDA approval of its PMA application prior to marketing the
device. PMA approval is based on a determination by FDA that the PMA contains
sufficient valid scientific evidence to assure that the device is safe and
effective for its intended use(s).”
Premarket Approval (PMA) only applies to Class III devices. This classification
requires the PMA process along with general controls.
References:
[1] FDA Medical Devices, http://www.fda.gov/MedicalDevices/default.htm, retrieved
September 13, 2014
[2] CDRH Learn, http://www.fda.gov/downloads/Training/CDRHLearn/UCM400786.pdf,
[3] Premarket Approval,
http://www.fda.gov/medicaldevices/deviceregulationandguidance/howtomarketyourdevi
ce/premarketsubmissions/premarketapprovalpma/default.htm, retrieved September 13,
2014
[4] King, Paul and Fries, Richard, Design of Biomedical Devices & Systems, 2nd
Edition, 2009, CRC press, Chapter 16
Q666EXPL
Under HIPAA regulations, the disclosure of health information must be based on
the minimum amount of disclosure necessary to accomplish the required task. As
part of an incident investigation, patient information can be discussed with
other employees who need to know in order to properly conduct and complete the
investigation.
Protected patient information should never be discussed at home nor with others,
even other employees at work, who do not have a "need to know."
Reference:
[1] Minimum Necessary Requirement, U.S. Department of Health and Human Services
website,
http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/minimumnecessa
ry.html
Q667EXPL
Under HIPAA regulations, the disclosure of health information must be based on
the minimum amount of disclosure necessary to accomplish the required task.
Organizations supporting the efforts of a “covered entity” (an organization such
as a hospital that directly handles PHI, Protected Health Information) must have
a Business Associate Agreement in place with the covered entity to assure that a
patient’s medical information is protected from unnecessary disclosure.
Protected patient information should never be discussed with others, even other
employees at work, who do not have a “need to know.”
Reference:
[1] Business Associate Contracts, U.S. Department of Health and Human Services
website,
http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/contractprov.h
tml
Q695EXPL
The process of use-error risk management involves all the steps described in this
question to reduce the likelihood of the same error being repeated in the future.
If one of these steps is neglected, an important factor contributing to the
problem may not be recognized. Hazards should be prioritized so that the
resources required to prevent recurrence are properly assigned. Any of the first
four choices alone cannot assure that the desired reduction of use-errors will be
achieved.
After implementing the risk controls developed based on the first three steps, it
is important to validate that the controls implemented are indeed effective in
reducing the user errors to an acceptable level and also make sure that they do
not create new risks that were not originally anticipated.
Reference:
[1] Human factors engineering – Design of Medical Devices, ANSI/AAMI HE75:2009,
pages 35-41
Q696EXPL
An effective method of mitigating use-related hazards is to incorporate
safeguards to guard against possible errors in critical device operations. For
example, physical means can be used, such as a cover or door over critical
hardware controls. This significantly reduces the likelihood that unintentional
sources of use-error will cause harm and therefore is among the most preferred
strategies. While not all procedures and devices can be changed to incorporate
safeguards, when this is possible, it is the best option.
Training users to avoid certain use-related hazards generally will not be the
most preferred strategy, since users can and often do forget what they learned
over time and are less likely to remember procedures in chaotic high-workload
environments or when a device is used infrequently. In addition, users will often
look for shortcuts in order to accomplish what they are trying to do more
quickly, even if those shortcuts raise the risk of a hazardous condition.
The effectiveness of warnings and labels depends on the likelihood that they will
be noticed, understood, and followed, which is usually low because of
environmental factors, user distraction, or workload. Also, if a device has too
many warning labels, this likelihood is even lower because of the competition for
visual attention.
While on some occasions it may be necessary to change a well-established clinical

protocol or procedure to avoid a use-error, if another mitigation strategy could
be implemented that provides an equivalent level of risk reduction, it would
generally be highly undesirable to force a change in the clinical practice.
However, there may indeed be times when making a change in clinical practice is
the only way to prevent the use-error condition being evaluated.
Reference:
[1] Human factors engineering – Design of Medical Devices, ANSI/AAMI HE75:2009,
pages 40-41
Q745EXPL
The Health Insurance Portability and Accountability Act of 1996 (HIPAA, Title II)
was passed by Congress to address a number of concerns related to healthcare
records, including patient privacy concerns. The original goal was to make health
care information more portable, so that medical records maintained by one
provider could be accessed by a different provider when a patient came under the
second provider's care. A portion of the act required that those records only be
disclosed to people who actually need to know that information in order to
facilitate the patient's care.
Specifically, the act placed the responsibility of ensuring patient data security
on the health care provider. As implementing regulations were written by the
Centers for Medicare and Medicaid Services (CMS), the responsibility for
protecting private health information (PHI) was explicitly extended to the health
care provider’s employees, associates, vendors, manufacturers, subcontractors,
and consultants.
References:
[2] Baker, Steven D., Knudsen, Jonathan, and Ahmadi, D. Mike, The Wireless
Challenge Security and Safety for Medical Devices and Hospitals. Biomedical
Instrumentation & Technology: May/June 2013, Vol. 47, No. 3, pages 208-211
website,
ry.html
Q746EPL
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires
the protection of personnally identifiable patient health information.
HIPAA was passed by Congress to address a number of concerns related to

healthcare records, including patient privacy concerns. The original goal was to
make health care information more portable, so that medical records maintained by
one provider could be accessed by a different provider when a patient came under
the second provider's care. A portion of the act required that those records only
be disclosed to people who actually need to know that information in order to
facilitate the patient's care.
Specifically, the act placed the responsibility of ensuring patient data security
on the health care provider. As implementing regulations were written by the
Centers for Medicare and Medicaid Services (CMS), the responsibility for
protecting private health information (PHI) was explicitly extended to the health
care provider’s employees, associates, vendors, manufacturers, subcontractors,
and consultants.
While a healthcare provider may not disclose a patient's financial information

unnecessarily, HIPAA regulations focus on the protection of health information,
not financial information.
References:
[2] Baker, Steven D., Knudsen, Jonathan, and Ahmadi, D. Mike, The Wireless
Challenge Security and Safety for Medical Devices and Hospitals. Biomedical
Instrumentation & Technology: May/June 2013, Vol. 47, No. 3, pages 208-211
website,
ry.html, retrieved October 24, 2014
Q748EXPL
The FDA (US federal Food and Drug Administration) is responsible for the
regulation of medical device data systems (MDDSs). An MDDS is a hardware or
software product that transfers, stores, converts formats, and displays medical
device data. An MDDS does not modify the data or modify the display of the data,
and it does not by itself control the functions or parameters of any other
medical devices. An MDDS is not intended to be used for active patient
monitoring. An MDDS is simply a conduit for sending and receiving medical device
data to and from medical devices.
The FDA had classified MDDSs as Class I devices subject to general controls.
These controls include registering with the FDA, listing the MDDS products,
reporting adverse events, and complying with FDA's Quality Systems regulation, a
basic system of manufacturing and design controls that ensures manufacturers test
their products before marketing them.
However, on February 9, 2015, the FDA released the document: "Medical Device Data
Systems, Medical Image Storage Devices, and Medical Image Communications Devices:
Guidance for Industry and Food and Drug Administration Staff." This document
explained that the FDA has determined that MDDSs pose a low risk to the public,
so the FDA decided to modify its regulatory approach to these products. While the
FDA did not formally revoke the classification of Class I as the assignment of
MDDSs, it did announce that it does not intend to enforce compliance with the
regulatory controls that would normally apply to these products. So, effectively,
the FDA has decided to no longer impose any regulatory controls on MDDSs.
Note the device class number is in ascending order of safety risk to the patient
in case of device failure. Class I devices (examples include bandages, medical
tape, tongue depressors, and gloves) are subject to general controls, which
include labeling, registration, reporting and tracking, and adherence to general
quality control requirements. Class II devices (examples include thermometers, IV
pumps, etc.) are subject to special controls, which include clinical trials and
performance requirements. Class III devices (such as pacemakers, knee
replacements, etc.) are subject to the same special controls as Class II devices,
with the additional requirement that these devices must receive premarket
approval (PMA) from the FDA before being sold. To obtain that approval, the FDA
requires the company to submit clinical studies, which the FDA then reviews to
verify that the proposed device is safe and effective.
References:
[1] From the FDA: Overview of Medical Device Data System Rule, Biomedical
Instrumentation & Technology: Managing Medical Devices on the IT Network, volume
45, number s2, pages 15-18
[2] Noblitt, John, ICC Prep: Health Care Information Technology, 24X7, May 13,
2013, http://www.24x7mag.com/2013/05/icc-prep-health-care-information-technology,
[3] Medical Device Data Systems, Medical Image Storage Devices, and Medical Image
Communications Devices: Guidance for Industry and Food and Drug Administration
Staff, Food and Drug Administration, February 9, 2015,
http://www.fda.gov/downloads/medicaldevices/deviceregulationandguidance/guidanced
ocuments/ucm401996.pdf, retrieved March 12, 2015
Q751EXPL
IEC 80001-1:2010, Application of Risk Management for IT-Networks Incorporating
Medical Devices, is a standard that addresses some of the risks associated with
putting medical devices on a computer network. The Scope section of this document
says: "Recognizing that medical devices are incorporated into IT-Networks to
achieve desirable benefits (for example, interoperability), this international
standard defines the roles, responsbilities and activities that are necessary for
risk management of IT-Networks incorporating medical devices to address safety,
effectiveness and data and systems security."
IEC 80001-1 is a voluntary standard that describes the procedures that healthcare
organizations, such as hospitals, physicians' offices, clinics, and labs should
follow when they put medical devices on their IT networks.
References:
[1] Mankovich, Nick and Trout, Leslie, Medical Devices & Cyber Security
Protection (Powerpoint presentation), Philips Healthcare. June 2, 2011.
http://icc.ite.gmu.edu/csga2011/Mankovich_Trout.ppt, retrieved October 25, 2014
[2] Scharff, Jack, IEC 80001-1 impacts hospitals, CEs, and BMETs: Due diligence
with medical devices on IT networks, The Trace Journal, Issue 31, September 2011,
http://thetracejournal.com/u/Philips/6NXlawFnuhRKTahiP6Mp/592075/IEC-80001-1-
impacts-hospitals-CEs-and-BMETs.htm, retrieved October 25, 2014
Q813EXPL
Three concepts of information security include confidentiality, integrity and
availability. These are referred to as the CIA triad.
Confidentiality refers to keeping data safe from unintended disclosure and

breaches of privacy. Integrity refers to keeping data from being changed or
modified in an unauthorized or undesirable manner. Integrity is maintained by the
use of relational databases and systems that will allow changes to be backed out
or reversed. Availability refers to the ability to access the data when needed.
Risk analysis is the process of evaluating potential and likelihood of threats.
Risk management refers to the process of taking steps to reduce the likelihood or
severity of threats.
References:
[1] Chia, Terry, Confidentiality, Integrity, Availability: The three components
of the CIA Triad, IT Security Community Blog website,
http://security.blogoverflow.com/2012/08/confidentiality-integrity-availability-
the-three-components-of-the-cia-triad, retrieved October 29, 2014
[2] Herzig, Terrell W., Walsh, Tom, and Gallagher, Lisa A., Implementing
Information Security in Healthcare: Building a Security Program, Healthcare
Information Management Systems Society (HIMSS), Chicago, 2013, pages 4-6, 27
Q843EXPL
The Safe Medical Devices Act (SMDA) of 1990 requires that hospitals and other
medical device users report device-related deaths to the FDA and the
manufacturer. Device user facilities must also report device-related serious
injuries to the manufacturer.
While adverse patient events, near miss events and other device-related events do
not need to be reported under SMDA regulations, it is generally considered good
practice to report these types of events to the manufacturer. In addition, the
FDA encourages device users to submit these kinds of voluntary reports through
its MedWatch program.
References:
[1] Lipschultz, Alan, Adverse Patient Events Involving Medical Devices,
pages 152-156
[2] Medical Device Reporting (MDR), FDA website,
http://www.fda.gov/MedicalDevices/Safety/ReportaProblem/default.htm, retrieved
November 9, 2014
Q845EXPL
When a medical device-related adverse patient event (APE) involves serious
injury, the hospital should make sure to preserve evidence, sequester the
equipment, contact the Risk Management Department or Committee (as appropriate in
the hospital), and flag the computer records associated with maintenance of any
equipment involved in the incident. Meticulous notes and pictures should be taken
without disturbing the scene or devices involved. All the information collected
should be provided to Risk Management. Once evidence has been disturbed, it may
be very difficult to determine the status of the device at the time of the
incident.
A device involved in a serious injury should not be sent to the manufacturer,

unless this is explicitly approved by Risk Management. In addition, the
hospital’s own personnel should not attempt to repair the equipment until the
incident has been fully analyzed and this action is approved by Risk Management.
In many cases, equipment will need to be removed from service indefinitely, until
the legal process fully runs its course, a process which may take several years.
References:
[1] Lipschultz, Alan, Adverse Patient Events Involving Medical Devices,
pages 152-156
Q854EXPL
DICOM stands for Digital Imaging and Communications in Medicine. It is a standard
that defines how medical images are transmitted from where they are recorded to
the locations where they are stored and later viewed, as well as the requirements
for image storage. The DICOM standard defines both the file format and the
network communications protocol that are used for medical images.
A PACS (picture archiving and communications system) is the hardware and software
actually used to store and transmit medical images, while the DICOM standards
identify how different components within the PACS will communicate with each
other.
A laboratory information system (LIS) is usually used by a clinical laboratory to

store the results of medical tests done by the laboratory.
A physiological monitoring system (PMS) is the hardware and software generally

used to capture physiological data, such as heart rate, blood pressure,
respiration rate, and temperature, from a patient and then present it to the
clinical staff on a real-time basis. Most physiological monitoring systems store
data for a relatively short amount of time. Their focus is on real-time data
acquisition and presentation. A PMS also allows a clinician to set appropriate
alarms to detect conditions, such as an episode of arrhythmia or apnea, that may
require immediate intervention.
An electronic medical record (EMR) is a system used to permanently document the

treatment given to a patient.
Reference:
[1] DICOM, Wikipedia, http://en.wikipedia.org/wiki/DICOM, retrieved November 9,
2014
Q873EXPL
Standards are documents that establish a minimum level of performance or
standardize items such as test methods, specifications, properties, definitions,
or practices. In general, compliance with standards is voluntary, unless a duly-
constituted government agency has mandated their acceptance. Only in that case
does a standard have the force of law. Standards are sometimes confused with
regulations. Regulations are mandates issued by an appropriate government body
that do have the power of law.
The International Electrotechnical Commission (IEC) is a European-based

organization whose standards are international in scope. IEC standards include
those for medical device design and ongoing quality assurance including
electrical safety, electromagnetic compatibility, alarms, human factors design,
communications between devices and the network and other device-related areas.
The U.S. Food and Drug Administration (FDA) has adopted a number of IEC
standards.
The full title of IEC 80001-1 is "Application of risk management for IT-networks
incorporating medical devices - Part 1: Roles, responsibilities and activities."
The Abstract of this standard notes that this document’s purpose is: "Recognizing
that medical devices are incorporated into IT-networks to achieve desirable
benefits (for example, interoperability), defines the roles, responsibilities and
activities that are necessary for risk management of IT-networks incorporating
medical devices to address safety, effectiveness and data and system security
(the key properties). IEC 80001-1:2010 does not specify acceptable risk levels.
IEC 80001-1:2010 applies after a medical device has been acquired by a
responsible organization and is a candidate for incorporation into an IT-
network."
This standard applies throughout the life cycle of IT-networks incorporating

medical devices.
DICOM standards apply to medical images and related information. These standards
are part of document ISO 12052, Health informatics - Digital imaging and
communication in medicine (DICOM) including workflow and data management. It
defines the formats for medical images that can be exchanged with the data and
quality necessary for clinical use.
The exchange, integration, sharing, and retrieval of electronic health

information that supports clinical practice and the management, delivery and
evaluation of health services is described in the Health Level Seven (HL7)
standard. Founded in 1987, Health Level Seven International (HL7) is a not-for-
profit, ANSI-accredited standards developing organization dedicated to providing
a comprehensive framework and related standards. The HL7 standard is the primary
standard for patient health information interchange and is the messaging standard
for the electronic health record.
IEC standard 60601-1, which is entitled: "Medical electrical equipment - Part 1:

General requirements for basic safety and essential performance," describes the
basic safety and essential performance requirements that are generally applicable
to medical electrical equipment.
References:
[1] IEC 80001-1:2010, Application of risk management for IT-networks
incorporating medical devices -- Part 1: Roles, responsibilities and activities,
ISO website, http://www.iso.org/iso/catalogue_detail.htm?csnumber=44863,
[2] 10 Questions About IEC 80001-1, ECRI Institute, Health Devices, May 2010,
https://www.ecri.org/Documents/HIT/10_Questions_about_IEC%2080001-
1(Health_Devices_Journal).pdf, retrieved November 18, 2014
[3] Digital Imaging and Communications in Medicine (DICOM), National Electrical
Manufacturers Association (NEMA) website, http://dicom.nema.org, retrieved
November 18, 2014
[4] Introduction to HL7 Standards, Health Level Seven International website,
http://www.hl7.org/implement/standards/index.cfm?ref=nav, retrieved November 18,
2014
[5] IEC 60601, Wikipedia, http://en.wikipedia.org/wiki/IEC_60601, retrieved
November 18, 2014
Q908EXPL
The IEC 80001 standard focuses on the measures that a healthcare facility should
undertake when connecting medical devices to the hospital IT network. The
standard addresses safety, effectiveness, and data and system security. The
rationale behind this standard is that securing a medical device system and its
data is essential for delivering safe and effective healthcare. This standard’s
requirement is that the risk management process address the entire life cycle of
the medical IT network starting from implementation, operation, modification, all
the way to discontinuation.
Reference:
[1] 10 Questions About IEC 80001-1, Health Devices, May 2010, ECRI Institute,
page 148, https://www.ecri.org/Documents/HIT/10_Questions_about_IEC%2080001-
1(Health_Devices_Journal).pdf, retrieved December 2, 2014
Q909EXPL
Overall responsibility for the implementation of the IEC 80001 medical IT network
standard falls on the management of the health care facility. That group should
establish and enforce the required risk management procedures for medical IT
networks within their facilities.
The standard also requires that medical device manufacturers and IT vendors of
all components in the medical IT network help with the implementation of the
standard by providing needed documentation and/or recommended configuration
settings to healthcare facilities so that the facility can safely connect the
devices, software, and middleware to their medical IT network. Successful
implementation cannot be achieved without all of them doing their respective
parts in the risk management process.
Reference:
[1] 10 Questions About IEC 80001-1, Health Devices, May 2010, ECRI Institute,
page 148, https://www.ecri.org/Documents/HIT/10_Questions_about_IEC%2080001-
1(Health_Devices_Journal).pdf, retrieved December 2, 2014
Q910EXPL
The IEC 80001 standard focuses on the measures that a healthcare facility should
undertake when connecting medical devices to the hospital IT network. The aim is
to preserve and balance safety, effectiveness, and data and system security. This
standard applies to medical device networks. With some exceptions, these are
defined as any IT network with at least one medical device.
In some cases, equipment made by a single manufacturer is connected to a
dedicated network used just for that manufacturer's equipment. These types of
networks, which support just a single manufacturer's equipment, are excluded from
the scope of this standard. However, if that dedicated network is connected to
one or more other networks that support other equipment, then that dedicated
network would fall within the scope of the IEC 80001 standard.
In general, this standard applies when there is no single manufacturer assuming

regulatory responsibility for the medical IT network. In that case, it is up to
the healthcare facility to assure that a network that supports equipment made by
more than one manufacturer, or that interfaces to other networks, complies with
the provisions of this standard.
The physical location of the network is of no relevance to the standard since a

healthcare facility might very well have a separate network that did not include
any medical devices. If that is the case, this network would not fall under the
scope of IEC 80001’s requirements. However, any network within the same facility
that did have medical devices attached to it would be expected to meet this
standard’s requirements.
Reference:
[1] Hampton, Rick, The New ISO/IEC 80001 Standard for Risk Management, Santa Rosa
Consulting, 2010, pages 10-12, http://www.santarosaconsulting.com/Documents/SRC-
StandardForRiskManagement-Webinar.pdf, retrieved December 2, 2014
Q914EXPL
IEC 80001-1 identifies safety, efficacy and security as the three properties that
an IT network that incorporates medical devices needs to manage.
Vendor documentation, the asset registry, and responsibility agreements/service

level agreements are entries in a risk management file.
Policy, resources, and risk management activities are responsibilities owned by

the role of the healthcare delivery organization (HDO) in the IEC 80001-1
standard.
Event management, change management, and monitoring are processes that are
described in a risk management policy.
Scope of activities, list of devices, and escalation times describe some of the
parts of a service level agreement or responsiblility agreement.
References:
[1] Grimes, Stephen L., Overview of ANSI/AAMI/IEC 80001-1 (2010) Application of
Risk Management for IT Networks Incorporating Medical Devices, CE-IT Community,
American College of Clinical Engineering, Association for the Advancement of
Medical Instrumentation, Healthcare Information and Management Systems, 2012,
http://ceitcollaboration.org/docs/VirtualTH4_TownHall.pdf, retrieved December 10,
2014
[2] Going Wireless: A Special Compilation of AAMI Wireless Articles and
Resources, Association for the Advancement of Medical Instrumentation, 2013,
http://www.aami.org/hottopics/wireless/AAMI/Going_Wireless_2013.pdf, retrieved
December 10, 2014
Q926EXPL
The AAMI water quality standard for dialysis lists allowable maximum levels for
about 25 contaminants sometimes found in drinking water, including metals (e.g.,
aluminum, lead, selenium), other compounds (e.g., nitrates, sulfates), bacteria
and endotoxins. The standard must be met by the product water. This is the water
that is the output of the reverse osmosis or other purification system that then
goes directly into the dialysis machine. The levels of contaminants in the city
water supply are not controlled by the standard.
Although the level of total dissolved solids (TDS) is measured in dialysis, it is

not an effective nor comprehensive measurement of water quality.
References:
2005, page 11, http://www.nwrenalnetwork.org/watermanual.pdf, retrieved December
13, 2014
[2] Payne, Glenda M., A Surveyor’s Perspective: Water Quality for Hemodialysis,
Hemodialysis Horizons, A supplement to Biomedical Instrumentation & Technology,
Association for the Advancement of Medical Instrumentation, pages 51-53,
http://www.aami.org/publications/hh/Water.quality.Payne.pdf
[3] ANSI/AAMI 13959:2014 Water for hemodialysis and related therapies,
Association for the Advancement of Medical Instrumentation, 2014
Q931EXPL
In order to receive funding under either the Medicare or Medicaid programs, a
hospital must meet requirements established by CMS (Centers for Medicare and
Medicaid Services). CMS requires that a hospital have an equipment maintenance
program in place to assure that equipment remains safe and operational.
While the default requirements of this program are that hospitals follow
manufacturer's requirements, CMS does allow an Alternate Equipment Maintenance
(AEM) program to be established under some circumstances. However, lasers are one
of the equipment types that may not be included in an AEM. CMS requires that the
manufacturer interval and procedure be followed when inspecting a laser. Although
there is no discretion in changing the manufacturer recommended interval for
lasers, CMS does allow equivalent test equipment to be used. Therefore, since the
manufacturer requires inspections every 6 months, your hospital must inspect this
laser every 6 months, following the procedures specified by the manufacturer.
However, you can use the existing laser power output meter, if you are able to
show that it is an equivalent device.
While purchasing a service contract would be an acceptable alternative solution,

this would not be the most cost effective solution, since you already have the
equipment and training needed to accomplish the inspection. Given the budget
constraints, this would not be the best alternative.
Reference:
[1] Hospital Equipment Maintenance Requirements, Centers for Medicare and
Medicaid Services, December 20, 2014, pages 1, 3, 12,
http://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-14-
07.pdf, retrieved December 14, 2014
Q946EXPL
The Digital Millennium Copyright Act of 1998, or DMCA, criminalizes the
production and dissemination of technology, devices, or services intended to
circumvent measures that control access to copyrighted works. In particular, the
DMCA makes it illegal to remove copy protection from digital works, such as
movies and music distributed as digital copies, for example, on a DVD or CD.
HIPAA, the Health Insurance Portability and Accountability Act of 1996, contains
provisions related to requirements for employee health insurance. Title II of
this act provides the basis for regulations that establish rules related to the
privacy of health information.
SMDA is the Safe Medical Devices Act of 1990. It requires the reporting of
medical device-related serious injuries or death to the manufacturer and, under
some circumstances, to the US Food and Drug Administration (FDA).
ERISA is the Employee Retirement Income Security Act of 1974. It contains

provisions designed to protect employee pension plans.
References:
[2] Digital Millenium Copyright Act, Wikipedia,
http://en.wikipedia.org/wiki/Digital_Millennium_Copyright_Act, retrieved November
29, 2014
Q947EXPL
The FDA (U.S. Food and Drug Administration) is responsible for the regulation of
medical device data systems (MDDSs). An MDDS is a hardware or software product
that transfers, stores, converts formats, and displays medical device data. An
MDDS does not modify the data or modify the display of the data, and it does not
by itself control the functions or parameters of any other medical devices. An
MDDS is not intended to be used for active patient monitoring. An MDDS is simply
a conduit for sending and receiving medical device data to and from medical
devices.
The FDA had classified MDDSs as Class I devices subject to general controls.
These controls include registering with the FDA, listing the MDDS products,
reporting adverse events, and complying with FDA's Quality Systems regulation, a
basic system of manufacturing and design controls that ensure manufacturers test
their products before marketing them.
However, on February 9, 2015, the FDA released the document: "Medical Device Data
Systems, Medical Image Storage Devices, and Medical Image Communications Devices:
Guidance for Industry and Food and Drug Administration Staff." This document
explained that the FDA has determined that MDDSs pose a low risk to the public,
so the FDA decided to modify its regulatory approach to these products. While the
FDA did not formally revoke the classification of Class I as the assignment of
MDDSs, it did announce that it does not intend to enforce compliance with the
regulatory controls that would normally apply to these products. So, effectively,
the FDA has decided to no longer impose any regulatory controls on MDDSs.
Note the device class number is in ascending order of safety risk to the patient
in case of device failure. Class I devices (examples include bandages, medical
tape, tongue depressors, and gloves) are subject to general controls, which
include labeling, registration, reporting and tracking, and adherence to general
quality control requirements. Class II devices (examples include thermometers, IV
pumps, etc.) are subject to special controls, which include clinical trials and
performance requirements. Class III devices (such as pacemakers, knee
replacements, etc.) are subject to the same special controls as Class II devices,
with the additional requirement that these devices must receive premarket
approval (PMA) from the FDA before being allowed to be sold. To obtain that
approval, the FDA requires the company to submit clinical studies, which the FDA
then reviews to verify that the proposed device is safe and effective.
AAMI (the Association for the Advancement of Medical Instrumentation) is not a

government agency. AAMI administers committees that write voluntary standards
that address a wide variety of safety issues associated with medical devices.
AAMI then publishes those standards once they are completed.
OSHA (the Occupational Safety and Health Administration) is a government agency

charged with assuring the safety of workers. It regularly inspects workplaces to
verify that those workplaces meet applicable OSHA regulations.
CLIA are the Clinical Laboratory Improvement Amendments. This is legislation that
provides the regulatory framework for the inspection of clinical laboratories
that process samples from humans. In general, CLIA regulations are enforced by
the U.S. Centers for Medicare & Medicaid Services (CMS).
References:
[1] From the FDA: Overview of Medical Device Data System Rule, Biomedical
Instrumentation & Technology: Managing Medical Devices on the IT Network, volume
45, number s2, pages 15-18
[3] Medical Device Data Systems, Medical Image Storage Devices, and Medical Image
Communications Devices: Guidance for Industry and Food and Drug Administration
Staff, Food and Drug Administration, February 9, 2015,
http://www.fda.gov/downloads/medicaldevices/deviceregulationandguidance/guidanced
ocuments/ucm401996.pdf, retrieved March 12, 2015
Q975EXPL
The Digital Millennium Copyright Act (DMCA) is a United States copyright law
passed in 1998 that criminalizes the production and dissemination of technology,
devices, or services intended to circumvent measures put in place to control
access to copyrighted works whether or not there is actual infringement of
copyright itself. As part of the act, the copyright infringement penalties were
increased.
There are some exemptions to this act in specific areas. These promote alignment
with other laws and include exemptions for internet service providers,
educational uses, and boat hull designs.
Of significance to medical technology support organizations is Title III:

Computer Maintenance Competition Assurance Act. This allows those repairing
computer to make certain temporary, limited copies while repairing a computer.
Support organizations should have a clear understanding of this exemption if
making software copies is required for repair.
All of the other choices indicated are included as part of the DMCA. It includes
requirements that an online service provider (for example, Youtube) remove any
copyrighted material if the copyright holder files an infringement claim.
Material protected by an access control measure, such as the anti-copying
technology found on a movie DVD, may not be copied by circumventing the access
control measure. This is generally referred to as digital rights management
(DRM). Under certain circumstances, the Librarian of Congress is authorized to
issue exemptions to the DMCA’s anti-circumvention provisions, if the Librarian
finds that those provisions have a substantial adverse effect on the ability of
people to make non-infringing uses of copyrighted material.
References:
[1] Digital Millennium Copyright Act, Wikipedia,
http://en.wikipedia.org/wiki/Digital_Millennium_Copyright_Act, retrieved December
31, 2014
[2] Digital Millennium Copyright Act of 1998, U.S. Copyright Office Summary,
http://www.copyright.gov/legislation/dmca.pdf, retrieved December 31, 2014
[3] Digital Millennium Copyright Act Guide, American Library Association,
http://www.ala.org/advocacy/copyright/dmca/guidance, retrieved December 31, 2014
Q1017EXPL
There is no regulation that requires hospital-based BMETs to use only parts
supplied by the manufacturer of the equipment. APPROPRIATE repair part
substitutions may be made.
Of course, any parts substitution should be properly evaluated and tested, and a
risk assessment should be performed and documented. It is also very appropriate
to do a cost/benefit analysis in a case such as this. Depending upon the
hospital's policies, a substitution such as the one discussed in this question
may need to be reviewed by others in the hospital's leadership structure, for
example, the Director of Clinical Engineering, the Safety Committee, the Risk
Management department, or perhaps others. Before making any parts substitutions,
you should be aware of your own hospital's policies so that you can stay in
compliance with them.
In a case of cost savings as dramatic as the one described in this question, it

is certainly appropriate to let others know about the value of your department's
services.
Reference:
None
Q1018EXPL
How your hospital handles patient-owned equipment is dependent upon your
hospital's particular policies. In this case, you need to make a judgment call,
and the final decision may need to be elevated within your hospital's
adminstrative team for a final determination. However, in general, dirty
equipment should not be used in the hospital, regardless of ownership, because of
the dangers it poses both to the patient using it, as well as the risk it poses
to the staff and other patients.
References:
None
Q2001EXPL
Bloodborne pathogens are infectious microorganisms in human blood that can cause
disease in humans, including hepatitis B virus (HBV), hepatitis C virus (HCV),
and human immunodeficiency virus (HIV). OSHA's mandate is to promote safety for
employees of nearly all types of organizations, including healthcare
organizations. Its bloodborne pathogen regulations are intended to protect
employees from exposure to these pathogens. The primary objective of requiring
the use of appropriate bloodborne-pathogen PPE (personal protective equipment) is
to keep employees from contact with blood. This type of PPE includes equipment
such as gloves, gowns, eye protection, and masks.
The other types of equipment included as choices are also PPE, but, they do not
protect against bloodborne pathogens. Lead aprons protect against radiation
hazards, and would typically be used to prevent exposure to x-rays. A face mask
and a respirator would be used to prevent the inhalation of airborne infectious
agents, such as the influenza virus or tuberculosis bacteria. Earplugs would be
used to protect hearing in areas where loud noises might be found, such as inside
an MRI scanner. Steel-toe boots are used in areas where a heavy object, such as
handtools, might be dropped.
Reference:
[1] OSHA's Bloodborne Pathogens Standard,

https://www.osha.gov/OshDoc/data_BloodborneFacts/bbfact01.pdf, retrieved July 6,
2018
Q2002EXPL
While for most electrically powered devices, grounding is the primary method used
to protect against shock, double-insulated appliances use a different technique.
Double-insulated appliances are electrically-powered devices "where the primary
means of protection against electrical shock is by the use of combinations of
insulation and separation spacings in accordance with an approved standard." The
power cord of a double-insulated device may have a ground conductor; however,
this is not required. The power cords of most double-insulated devices do not
have a ground conductor.
It is important to distinguish devices that are formally listed or labeled as

double-insulated from typical consumer-grade devices that simply have two-wire
power cords. Genuine double-insulated devices have special design and
manufacturing features that allow them to be used safely in the patient care
vicinity. In order to identify double-insulated devices, the symbol below is
generally found on the device.
"Hospital-grade" is a term that is in use both to refer to electrical receptacles

and electrical equipment. Specifications of a hospital grade receptacle are
defined by the Underwriters Laboratories Standard for Attachment Plugs and
Receptacles, UL498. Specific requirements for a hospital-grade receptacle
include: (1) the blades must be solid instead of folded brass, (2) the blades are
usually nickel-plated, (3) the plug includes an internal cable retention device
or strain relief to prevent any stress to the plug's internal connections, and
(4) NEMA plug and receptacle are marked "Hospital-grade" and with a green dot.
When hospital-grade refers to equipment, that term is considered a marketing term
by the FDA, and has no regulatory definition.
Defibrillation-proof refers to equipment that will not be harmed during normal

operation, if it is connected to a patient while the patient is being
defibrillated. Defibrillation-proof characteristics are defined by IEC 60601-1,
Medical Electrical Equipment, Part 1: General Requirements for basic safety and
essential performance. There are three defibrillation-proof classes defined in
the IEC standards (type B, BF and CF, where type B has a non-conductive
attachment to the patient's skin, type BF has a conductive attachment to the
patient's skin, and type CF provides conductive contact to the patient's heart.
The symbols for defibrillation-proof equipment are shown below:
Electrically isolated refers to the isolation between electrical components in a

circuit and either other electrical parts in a device, or between the electrical
circuit and conductive parts of the case that a user might touch. It is used to
prevent unintended current flows which might injure a user or damage circuit
components. Generally, electrical isolation is provided by a combination of
electrical insulators, such as plastics, and spacing. Electrical isolation is
also referred to as galvanic isolation.
Reference:
[1] NFPA 99 (2012) Health Care Facilities Code, paragraph 3.3.41, Direct
Electrical Pathway to the Heart, National Fire Protection Association, Quincy,
Massachusetts.
[2] Baretich, Matthew, Electrical Safety Manual 2015, Association for the
Advancement of Medical Instrumentation, 2015.
[3] Hospital-Grade Standards for Power Cords and Other Power System Components
for Global Markets, Medical Design Briefs, January 1 2015,
https://www.medicaldesignbriefs.com/component/content/article/mdb/features/21330,
[4] What is a Hospital-Grade Breast Pump?,

https://www.hygeiahealth.com/blog/hospital-grade-breast-pump/, retrieved July 1,
2018.
[5] IEC 60601-1:2005+A1:2012(E), Medical Electrical Equipment â€“ Part 1: General

Requirements for Basic Safety and Essential Performance.
[6] Applied Part: Type B, BF or CF,

http://www.601help.com/Basic_Concepts/b__bf_or_cf.html, retrieved July 1, 2018.
[7] Galvanic Isolation, https://en.wikipedia.org/wiki/Galvanic_isolation,

Q2003EXPL
In order for a hospital to receive funding from Medicare and/or Medicaid, that
hospital must meet regulatory requirements established by the Centers for
Medicare and Medicaid Services (CMS). One way to demonstrate compliance with
those regulations is by earning accreditation from a "deeming authority." CMS
recognizes several groups under this program, including The Joint Commission
(TJC), the Healthcare Facilities Accreditation Program (HFAP), and DNV GL (formed
by the merger of Det Norske Veritas of Norway and Germanischer Lloyd of Germany).
What differentiates the DNV GL accreditation standards from those promulgated by

the other groups is that DNV GL Healthcare incorporates the principles of the ISO
9001 Quality Management Program. ISO 9001 is applicable to any organization that
provides products or services and is not specific to healthcare organizations.
However, the DNV GL Healthcare accreditation program applies the ISO 9001
principles to specific aspects of healthcare services. One example for medical
technology management are "metrology" requirements to have NIST-traceable
(National Institute of Standards and Technology) calibration of test equipment
and to identify on each work order the specific test equipment used for
inspection, maintenance, or repair.
Reference:
[1] DNV-GL Healthcare Hospital Accreditation,
http://www.dnvglhealthcare.com/accreditations/hospital-accreditation, retrieved
July 1, 2018.
[2] Survey & Certification General Information, Centers for Medicare and Medicaid
Services, https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertificationGenInfo/Accreditation.html, retrieved July 1,
2018.
Q2004EXPL
The Centers for Medicare and Medicaid Services (CMS) is a federal agency that is
responsible for administering Medicare (primarily serving the elderly population)
and Medicaid (primarily serving the low-income population) programs. For a
healthcare facility to receive Medicare or Medicaid payments from CMS (which
represent a substantial proportion of revenues for most hospitals), the facility
must comply with Conditions of Participation (COPs). Compliance with the COPs can
be demonstrated through survey by CMS (typically subcontracted to state
departments of health) or through survey by Accrediting Organizations (AOs) that
have been granted "deeming authority" by CMS. For example, a hospital that
achieves Joint Commission accreditation is deemed by CMS to be in compliance with
its COPs.
Reference:
Certification/SurveyCertificationGenInfo/Accreditation.html, retrieved July 1,
2018.
Q1012EXPL
The US Congress passed a law (ARRA - The American Recovery and Reinvestment Act)
in 2009 that included the Health Information Technology for Economic and Clinical
Health (HITECH) Act. The HITECH act contained incentives designed to accelerate
the adoption of health information technology, including the Electronic Health
Record (EHR).
To implement the provisions of the HITECH Act, CMS (The Centers for Medicare and
Medicaid Services) adopted "meaningful use" regulations, designed to spur the
adoption of EHRs. These meaningful use regulations are designed to encourage
hospitals to adopt EHRs by providing incentive payments to those hospitals
meeting goals incorporated into these regulations. The goals and amount of
incentive payments available vary over time. The regulations allow a healthcare
organization to phase in an EHR system over several years so that the
requirements to receive certain levels of payments are known several years in
advance. The goal is to have healthcare providers demonstrate that they are using
"certified EHR technology in ways that can be measured significantly in quality
and in quantity."
CMS's meaningful use regulations incorporate three stages. For example, for stage
2 (2015-2017), one of the measures is to use computerized provider order entry
(CPOE) for medication, laboratory, and radiology orders. The HITECH Act also
addresses the privacy and security concerns associated with the electronic
transmission of health information by strengthening the enforcement of the HIPAA
rules.
Regulations related to x-ray dose management come from The Joint Commission and
other standards organizations, and not from the HITECH Act.
Standards related to endoscope cleaning come from the device manufacturers, AAMI,
and other standards-development organizations and not from HITECH. The FDA also
has regulations related to endoscope cleaning.
There is no regulation mandating that patient monitors in ICUs be networked and

connected to the Electronic Health Record for automated charting. However, it is
a best practice and much more efficient than having clinicians manually enter
patient vital signs data into the EHR.
References:
[1] HITECH Act Enforcement Interim Final Rule, https://www.hhs.gov/hipaa/for-
professionals/special-topics/hitech-act-enforcement-interim-final-
rule/index.html, retrieved July 13, 2018.
[2] EHR Incentive Programs: 2015 through 2017 (Modified Stage 2) Overview,
https://www.cms.gov/Regulations-and-
Guidance/Legislation/EHRIncentivePrograms/Downloads/2015_EHR2015_2017.pdf,
Q1013EXPL
An MDS2 document (the Manufacturer Disclosure Statement for Medical Device
Security) is provided by a device manufacturer and contains specific information
about the device's connection to a network, and how the device handles security,
including whether or not the device stores and communicates ePHI. The MDS 2 form
provides medical device manufacturers with a standardized means for disclosing
the security-related features of the medical devices they manufacture to
healthcare providers. The MDS2 can be used as a tool in an organization's risk
assessment process by providing healthcare entities with information to assess
the vulnerabilities and risks associated with protecting the health information
created, received, transmitted or maintained by medical devices.
When evaluating medical systems for purchase, the answers contained in the MDS 2
form allow a healthcare organization to easily compare the security features of
different manufacturers' products.
IFUs (Instructions for Use) are important documents from the device manufacturer,
but not part of MDS2.
Healthcare Delivery Organizations (HDOs) assign IP addresses, not the device

manufacturer, so the actual IP address could not be included in the MDS 2. This is
because the IP address will be dependent upon the particular way that a
healthcare organization has decided to configure its network.
There are penalties under the HIPAA regulations associated with accidentally or
intentionally disclosing ePHI without a "need to know;" however that is not part
of MDS2.
Reference:
[1] Manufacturer Disclosure Statement for Medical Device Security (MDS2),
https://www.himss.org/resourcelibrary/MDS2, retrieved July 15, 2018
Q1018EXPL
While all of the options cited can be used as part of an infection control
strategy, the only barrier method included as a choice is the use of personal
protective equipment (PPE). PPE places a physical barrier, such as gloves, gowns,
and masks between the employee and the potentially infectious agent. When used
properly, PPE acts as a barrier between infectious materials such as viral and
bacterial contaminants and the employee's skin, mouth, nose, or eyes (mucous
membranes).
When working in a hospital environment, all body fluids and tissues should be
considered as hazardous materials. In addition, one should assume that all
equipment is contaminated. Personal protective equipment (PPE) refers to
protective clothing, helmets, gloves, face shields, goggles, facemasks and/or
respirators or other equipment designed to protect the wearer from injury or the
spread of infection or illness. When used properly, PPE acts as a barrier between
infectious materials such as viral and bacterial contaminants and the employee's
skin, mouth, nose, or eyes (mucous membranes). The barrier has the potential to
block transmission of contaminants from blood, body fluids, or respiratory
secretions. PPE may also protect patients who are at high risk for contracting
infections through a surgical procedure or who have a medical condition, such as
an immunodeficiency disease, from being exposed to substances or potentially
infectious material brought in by visitors and healthcare workers. When used
properly and in conjunction with other infection control practices such as
handwashing, using alcohol-based hand sanitizers, and covering coughs and
sneezes, it minimizes the spread of infection from one person to another.
Effective use of PPE includes properly removing and disposing of contaminated PPE
to prevent exposing both the wearer and other people to infection. Hand hygiene
should be performed immediately after removing PPE. If one's hands become visibly
contaminated during PPE removal, one should wash hands before continuing to
remove PPE.
References:
[1] Personal Protective Equipment for Infection Control, U.S. Food and Drug
Administration,
https://www.fda.gov/medicaldevices/productsandmedicalprocedures/generalhospitalde
vicesandsupplies/personalprotectiveequipment/default.htm, retrieved August 9,
2018.
[2] Hill, Jonathan Hill, Safety: Protecting Yourself Should Be Your #1 Priority,
Biomedical Instrumentation & Technology, January 2009, vol. 43, no. 1, pages 41-
42.
Q1019EXPL
When an infection outbreak affects a broad population in the U.S., the Centers
for Disease Control and Prevention (CDC), is responsible for making specific
recommendations for infection control measures in different circumstances and
settings.
The Food and Drug Administration (FDA) is responsible for assuring the safety of
food, drugs, and medical equipment.
The Occupational Safety and Health Administration (OSHA) is responsible for

assuring that employees have a safe environment in which to work.
The US Department of Agriculture (USDA) is responsible for providing a wide

variety of services on behalf of farmers. In addition, along with the FDA, it is
responsible for inspecting some types of food. For example, the USDA inspects
meat, poultry and eggs, while the FDA is responsible for the inspection of all
processed foods, produce, dairy and seafood. In addition, the FDA is responsible
for regulating the Nutrition Facts labels placed on processed foods.
The Centers for Medicare and Medicaid Services (CMS) establishes and enforces the
regulations that a healthcare facility must meet in order to receive
reimbursement for providing services to patients enrolled in either the Medicare
or Medicaid programs.
References:
[1] Personal Protective Equipment for Infection Control, U.S. Food and Drug
Administration,
https://www.fda.gov/medicaldevices/productsandmedicalprocedures/generalhospitalde
vicesandsupplies/personalprotectiveequipment/default.htm, retrieved August 9,
2018.
[2] Infection Control, Centers for Disease Control and Prevention,

https://www.cdc.gov/infectioncontrol/, retrieved August 9, 2018
[3] CDC Responds to Disease Outbreaks 24-7, Centers for Disease Control and
Prevention, https://www.cdc.gov/about/facts/cdcfastfacts/diseaseresponse.html,
Q2026EXPL
According to CMS requirements, there are four general types of medical equipment
that hospitals cannot put into an AEM program:
- Equipment, regardless of type, that either federal or state law require be
maintained strictly in accordance with manufacturers' recommendations. For
example, there is a separate federal regulation that requires alcohol-based hand-
rub dispensers to be maintained in compliance with the manufacturer's guidelines.
- Medical laser devices
- Imaging and radiologic equipment (whether used for diagnostic or therapeutic
purposes)
- New medical equipment with insufficient maintenance history to support the use
of an AEM strategy
It is important to note that even critical or high-risk medical equipment, like

defibrillators, can be put into a hospital's AEM program as long as there is good
reason to believe that this can be done safely, and all other AEM-related
requirements are satisfied.
References:
[1] Centers for Medicare & Medicaid Services. State Operations Manual, Appendix
Aâ€”Survey Protocol, Regulations and Interpretive Guidelines for Hospitals, rev.
176, 12-29-17, pages 392-398, https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf, retrieved September
3, 2018.
[2] Baretich MF, AEM Program Guide: Alternative PM for Patient Safety, AAMI,
2018.
Q2027EXPL
Hospitals that wish to receive payments under the Medicare and Medicaid programs
must comply with the CMS Conditions of Participation. Compliance may be
demonstrated by successful completion of a CMS survey. However, most hospitals
instead choose to be surveyed by an Accrediting Organization (AO) that has been
granted "deeming authority" by CMS. If a hospital is accredited by one of these
AOs, CMS deems that hospital to be in compliance with CMS Conditions of
Participation, and thus eligible to receive Medicare and Medicaid payments.
Among the AOs that have CMS-granted deeming authority for hospitals are:
- The Joint Commission
- Healthcare Facilities Accreditation Program (HFAP)
- DNV-GL Healthcare
- Center for Improvement in Healthcare Quality (CIHQ)
The National Fire Protection Association (NFPA) is not a CMS-approved AO.

According to its website, NFPA is a "global nonprofit organization, established
in 1896, devoted to eliminating death, injury, property and economic loss due to
fire, electrical and related hazards." NFPA develops voluntary, consensus
standards that may be adopted and enforced by various AHJs (Authorities Having
Jurisdiction). For example, CMS and The Joint Commission have adopted the 2012
editions of NFPA 101 Life Safety Code and NFPA 99 Health Care Facilities Code as
part of their requirements for hospitals.
References:
Certification/SurveyCertificationGenInfo/Accreditation.html, retrieved September
3, 2018.
[2] CMS-Approved Accrediting Organization Contacts for Prospective Clients,

https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertificationGenInfo/Downloads/Accrediting-Organization-
Contacts-for-Prospective-Clients-.pdf, retrieved September 3, 2018.
[3] About NFPA, https://www.nfpa.org/About-NFPA, retrieved September 3, 2018.

[4] Joint Commission surveys to 2012 NFPA 101: Life Safety Code, aligning with
CMS adoption,
https://www.jointcommission.org/issues/article.aspx?Article=fiMHsg3VOS4e%2FDLsw4d
RLTUyS8disoRsx%2FRyhLPuhEQ%3D, retrieved September 3, 2018.
Q2055EXPL
Companies that do business with hospitals need to have formal agreements on how
they handle protected healthcare information (PHI). These agreements are called
business associates agreements (BAAs).
Regulations published by the US Department of Health and Human Services specify

how PHI may be disclosed both within the healthcare organization, and to those
outside the organization. These regulations fall under the general umbrella of
regulations that were established by the Health Insurance Portability and
Accountability Act of 1996, also known as HIPAA.
Hospitals may disclose protected health information to its business associates

only to help the hospital carry out its health care functions, but not for the
business associate's independent use or purposes. A repair of a computerized
medical device like a pulmonary function system is in the best interest of the
hospital and therefore, allowable as long as there is a formal BAA. The business
associate can only access and use the protected healthcare information for the
purpose of repairing the system, not for any other reason.
Reference:
[1] Business Associate Contracts, https://www.hhs.gov/hipaa/for-
professionals/covered-entities/sample-business-associate-agreement-
provisions/index.html, retrieved October 7, 2018.
[2] Summary of the HIPAA Security Rule, https://www.hhs.gov/hipaa/for-

professionals/security/laws-regulations/index.html, retrieved October 7, 2018.
Q2058EXPL
The symbol shown below indicates the presence of a chemical associated with a
variety of health hazards, such as the presence of a carcinogen, mutagenicity,
reproductive toxicity, respiratory sensitizer, target organ toxicity, and
aspiration toxicity.
Related OSHA symbols that use the same red diamond but with different black
figures include the following:
- Exclamation Mark: Irritant (skin and eye), skin sensitizer, acute toxicity
(harmful), narcotic effects, respiratory tract irritant, or hazardous to ozone
layer (non-mandatory).
- Flame: Flammables, pyrophorics, self-heating, emits flammable gas, self-

reactives, organic peroxides.
- Flame Over Circle: Oxidizers.
- Skull and Crossbones: Acute toxicity (fatal or toxic).
The diagram below shows the various symbols specified by OSHA related to various
chemical hazards:
Reference:
[1] OSHA Brief 2626: Hazard Communication Standard: Lables and Pictograms,
https://www.osha.gov/Publications/OSHA3636.pdf, retrieved October 7, 2018.
Q2064EXPL
The Manufacturer Disclosure Statement for Medical Device Security (MDS 2) is the
most likely document to contain ePHI-related information. Some manufacturers will
also include similar information in some of the other documents listed, such as
the Instructions for Use (IFU), User manual (sometimes referred to as the
Operator Manual), and Service manual.
An MDS2 document is provided by a device manufacturer and contains specific

information about the device's connection to a network, and how the device
handles security, including whether or not the device stores and communicates
ePHI. The MDS2 form provides medical device manufacturers with a standardized
means for disclosing the security-related features of the medical devices they
manufacture to healthcare providers. The MDS 2 can be used as a tool in an
organization's risk assessment process by providing healthcare entities with
information to assess the vulnerabilities and risks associated with protecting
the health information created, received, transmitted or maintained by medical
devices. When evaluating medical systems for purchase, the answers contained in
the MDS2 form allow a healthcare organization to easily compare the security
features of different manufacturers' products.
The MDS2 was developed through a collaboration between HIMSS (Healthcare

Information and Management Systems Society), ACCE (American College of Clinical
Engineering), and NEMA (National Electrical Manufacturers Association).
The IFU (Instructions for Use) is also an important document from the device
manufacturer, but it is not part of MDS2.
The Material Safety Data Sheet (MSDS) is a document that relates to chemical
safety. Generally, the MSDS will include the instructions for the safe use of a
particular material or product. It will also describe the hazards that might be
associated with that product, and how they might be mitigated.
References:
[1] Manufacturer Disclosure Statement for Medical Device Security (MDS2),
https://www.himss.org/resourcelibrary/MDS2, retrieved October 14, 2018.
[2] Manufacturer Disclosure Statement for Medical Device Security, a blank copy
of the MDS2 form can be downloaded from this page,
https://www.nema.org/Standards/Pages/Manufacturer-Disclosure-Statement-for-
Medical-Device-Security.aspx, retrieved October 14, 2018.
[3] Sample GE Ultrasound MDS2, https://www.gehealthcare.com/-

/media/1294aa8558ba4180849b155d25b580c8.pdf?la=en&hash=CC6866134272A919FEF1A63400
0946FFD4ACD7C7, retrieved October 14, 2018.
Q2077EXPL
While human hearing is typically specified as being in the range of 20 Hz to
20,000 Hz, typical hearing tests are done between the range of 125 Hz and 8,000
Hz, or, alternately, between 250 Hz and 8,000 Hz. The standard that identifies
the requirement for audiology testing is ANSI S3.1-1999 (R2008), Maximum
Permissible Ambient Noise Levels (MPANL) for Audiometric Test Rooms. Throughout
this standard, the maximum frequency range identified as being measured is from
125 Hz to 8,000 Hz. For example, section 1.3 of the standard says: "This Standard
specifies that ambient noise in an audiometric test room shall be measured at
octave or one-third octave band intervals within the inclusive range from 125 to
8000 Hz ..."
ANSI S3-1-1999 is intended to be used for conducting hearing tests to ensure that
ambient noise in an audiometric test room will not have a masking effect or
influence on the hearing measurements being taken. This standard includes the
specification and measurement of MPANLs in an audiometric test room.
ANSI S3-1-1999 is also used by distributors, installers, designers, maintainers

and manufacturers so that they can plan, construct and test appropriate
acoustical treatments intended to reduce the ambient noise in audiometric test
rooms so that the results recorded are within an acceptable level of accuracy.
Generally, human hearing is most sensitive to the frequency range between 2,000
Hz and 5,000 Hz, as this is the range used to understand speech. For most adults,
the hearing threshold drops off significantly above a frequency of 15,000 Hz. For
these reasons, hearing tests do not use the broader range of 50 Hz to 20,000 Hz.
The other frequency ranges listed in the possible answers are for dogs (67 Hz to
45,000 Hz), bats (15,000 Hz to 90,000 Hz) and beluga whales (1,000 Hz to 120,000
Hz). Note that some researchers have reported results for whale hearing that go
down to much lower frequency ranges.
Reference:
[1] ANSI S3.1-1999, Maximum Permissible Ambient Noise Levels for Audiometric Test
Rooms, https://www.whisperroom.com/pdf/ANSI-ASA-S3.1-1999-R2008.pdf, retrieved
January 21, 2019.
[2] Hearing Test, https://en.wikipedia.org/wiki/Hearing_test, retrieved January

21, 2019.
[3] Hearing Range, https://en.wikipedia.org/wiki/Hearing_range, retrieved January

21, 2019.
[4] The human hearing range - what can you hear?,

https://global.widex.com/en/blog/human-hearing-range-what-can-you-hear, retrieved
January 21, 2019.
Q2078EXPL
The standard that identifies the requirements for an audiology testing booth is
ANSI S3.1-1999 (R2008), Maximum Permissible Ambient Noise Levels (MPANL) for
Audiometric Test Rooms.
When designing an audiology test room, the goal is to have a room that is quiet
enough so that no noise from a source other than the tones being generated by the
test equipment masks or interferes with the hearing measurements being taken.
That low level of ambient noise is satisfied when the noise level is less than or
equal to 2 dB of pure tones presented at reference equivalent threshold levels as
specified in ANSI S3.6-1996, American National Standard Specifications for
Audiometers.
Although 0 dB is the lowest level that a good human ear can hear, the
specification is for <= 2dB, allowing only a very small amount of "noise" to be
heard through the booth.
65 dB is associated with a normal speaking voice, 85 db corresponds to the noise

inside a jet plane cabin while at cruising altitude, and 120 dB corresponds to
the sound level typically associated with a rock band.
Reference:
[1] ANSI S3.1-1999, Maximum Permissible Ambient Noise Levels for Audiometric Test
Rooms, https://www.whisperroom.com/pdf/ANSI-ASA-S3.1-1999-R2008.pdf, retreived
January 21, 2019.
Q2088EXPL
A heated water bath is often an ideal environment for the growth of algae,
bacteria and other microbial life. In order to prevent the growth of algae, the
water used in a heated water bath should be as sterile as possible. Of the
choices included, distilled water is considered the most sterile, and so it is
the preferred choice for filling a heated water bath.
Tap water is not necessarily sterile and even if it is, algae, bacteria and other
forms of microbial life can enter the system.
Filtered water is generally preferred to tap water, but airborne microbes may
enter the system.
The processes that produce deionized water may filter out some microbial life but
do not kill the microbes, resulting in water that is not sterile.
Reverse osmosis water may not be sterile even though it is less likely to cause
algae or other bio-fouling than deionized water.
References:
[1] Pratt, Scott, Proper fluid selection and maintenance for heat transfer
applications, page 10,
https://tools.thermofisher.com/content/sfs/brochures/Proper-fluid-selection-
maintenance-for-heat-transfer-TNTCFLUIDS.pdf, retrieved January 27, 2019.
[2] Laboratory water bath, https://en.wikipedia.org/wiki/Laboratory_water_bath,

Q2094EXPL
DNV GL Healthcare is a risk management company that was founded in Norway in
1864. In 2008, its accreditation program for acute care and critical access
hospital received approval from CMS (the Centers for Medicare and Medicaid
Services) to be considered a deemed status organization. This means that
hospitals accredited by DNV are also accepted as meeting CMS requirements for
participation in the Medicare and Medicaid programs. That is, hospitals are
deemed to comply with CMS's Conditions of Participation (CoPs) for hospitals.
In many ways, DNV GL's accreditation process and standards are similar to those
of The Joint Commission (TJC), which also has deemed status. However, one
important distinction is that DNV's standards and survey process incorporate ISO
9001:2015 quality management system surveys, while TJC surveys only against its
own standards. The ISO 9001 quality management standards have been used by U.S.
manufacturers for several decades, and have also been used by some overseas
healthcare systems in recent years.
Another difference between DNV GL and TJC is that DNV surveys its member
hospitals annually, while TJC surveys its hospitals on an 18-month to three-year
cycle.
Other aspects of DNV GL's survey process are similar to the surveys performed by
CMS, TJC, and other deemed status accrediting organizations. All of the surveys
use tracer methodology, along with staff and patient interviews, and a review of
medical records. However, while surveying the hospital for evidence of compliance
with the CMS CoPs, DNV GL surveyors also ensure that hospitals are compliant with
the ISO 9001:2015 standards throughout clinical and non-clinical areas.
For the smallest hospitals, DNV GL sends either a nurse or physician surveyor
along with a physical environment surveyor. This survey team may be complemented
by a generalist and/or additional clinical or physical environment surveyors,
depending upon the size of the institution.
References:
[1] Accreditation options: Understanding DNV GL - healthcare's national
integrated accreditation for healthcare organizations program,
https://www.beckershospitalreview.com/hospital-management-
administration/accreditation-options-understanding-dnv-gl-healthcare-s-national-
integrated-accreditation-for-healthcare-organizations-program.html, retrieved
January 30, 2019.
[2] DNV attracts attention from health care organizations,

https://www.hfmmagazine.com/articles/494-dnv-attracts-attention-from-health-care-
organizations, retrieved January 30, 2019.
[3] DNV-GL International Healthcare Accreditation,

https://www.dnvgl.com/services/international-healthcare-accreditation-7516,
retrieved February 2, 2019.
Information technology
Q304EXPL
The first thing to note here is that among the possible answers, only two relate to the network: PING and TRACERT. The
other two: IPCONFIG and MSCONFIG, relate to a particular computer (which may or may not be a node on a network).
PING is a basic Internet program that lets you verify that a particular IP address exists and can accept requests. The verb
PING means the act of using the PING utility or command. PING is used diagnostically to ensure that a host computer
you are trying to reach is actually operating. If, for example, a user can not PING a host, then the user will be unable to
interact with that host. Using PING, you can learn the number form of the IP address from the symbolic domain name.
Loosely, PING means "to get the attention of" or "to check for the presence of" another party online. PING operates by
sending a packet to a designated address and waiting for a response. The computer acronym (for Packet Internet or Inter-
Network Groper) was contrived to match the submariners' term for the sound of a returned sonar pulse.
The TRACERT utility is a diagnostic utility that determines the route taken to a destination (node to node) by sending
ICMP packets with varying time-to-live (TTL) values to the destination. Each router along the path is required to
decrement the TTL on a packet by at least 1 before forwarding it, so the TTL is effectively a hop count. When the TTL on
a packet reaches 0, the router is supposed to send back an ICMP Time Exceeded message to the source system.
IPCONFIG is a utility on a computer (for Windows systems) that can be used to show current TCP/IP information,
including address, DNS server addresses, adapter type and so on. This is most useful if using DHCP (a method to
automatically assign TCP/IP information needed by a computer). Because the TCP/IP information, including the address,
is assigned when the computer is booted, it is not known until boot time. IPCONFIG will show that information at any
time.
MSCONFIG, or the "Microsoft System Configuration Utility," is built into Windows 98, 98SE, ME, XP, Vista, 7, 8 and
10. It is designed to help you troubleshoot problems with your computer by helping you diagnose system configuration
issues. The utility allows you to reset or change the configuration settings in Windows to include preferences for such
files and settings as the System.ini file, the Win.ini file, the Boot.ini file, and programs that are set to load during the
startup process (these programs are specified in the Startup folder and in the registry).
References:
[1] http://en.wikibooks.org/wiki/Computer_Networks/Ping
[2] http://technet.microsoft.com/en-us/library/cc757819%28WS.10%29.aspx#BKMK_tcpip_tro_using_tracert
[3] Dean, T., Network + Guide to Networks, 5th edition, Thomson Course Technology, Boston, MA, 2009, pages 193–
194 and 591-593
[4] http://netsquirrel.com/msconfig/index.html
Q313EXPL
On a client/server network, the server typically provides services such as file and printer access, as well as application and
communication access, to the intelligent workstations connected to it. Because the workstations (clients) perform the
majority of the processing, this is considered a distributed processing network (i.e., processing is shared across a number
of network components). Distributed processing generally provides more flexibility, as workstations can be easily
customized to meet the specific needs of their operator and their applications. The central server can be optimized to
provide common access to critical resources.
Reference: Dean, Tamara, Network+ Guide to Networks, 5th edition, Thomson Course Technology, Boston, MA, 2009,
pages 4 - 6
Q330EXPL
A VLAN (Virtual Local Area Network), which is a subcategory of a VPN (Virtual Private Network), makes it possible to
relocate computers geographically while still maintaining connections and resources like shared printers and drives. It can
also be used to group certain computers in one local network into smaller networks for various functional and security
reasons.
Subnetting requires that all devices be connected to the same switch and that switch must be connected to a port on the
same router. A VLAN can group computers not connected to the same router or switch and make them act like they are
connected.
References:
[1] http://www.differencebetween.net/technology/difference-between-vlan-and-vpn
[2] http://www.petri.co.il/csc_setup_a_vlan_on_a_cisco_switch.htm
Q331EXPL
A network switch is an Ethernet device that forwards broadcasts, allowing data packets to move on to specific segments
based on MAC addresses.
A router filters broadcast transmissions, directing individual data packets to specific destinations based on the packet’s
logical (IP) addressing information. The device will route packets between different networks, determining the shortest
path available.
References:
[1] http://wiki.answers.com/Q/Why_dont_routers_forward_broadcast
[2] http://www.laneye.com/network/how-network-works/network-switches-and-broadcast-packets.htm
[3] Dean, T, Network + Guide to Networks, 5th edition, Thomson Course Technology, Boston, MA, 2009, page 256
Q332EXPL
All computers on the network must be running the most current virus protection patches; otherwise, a virus can attack the
unprotected computers and affect the network. If the monitoring system manufacturer will not install the patches, the
monitoring system should be isolated from the main network.
According to Stanford University: "Security patches help to remove vulnerabilities from a given computer, such as open
backdoor ports or other bugs in the operating system. If you do not patch the computer, a virus can exploit one or more of
those vulnerabilities to use your computer to spread viruses, send out spam, illegally serve up copyrighted material,
launch denial of service (DOS) attacks against Internet servers, etc."
References:
[2] http://acomp.stanford.edu/info/security
Q333EXPL
All computers on the network must be running the most current virus protection patches; otherwise, a virus can attack the
unprotected computers and affect the network. If the monitoring system manufacturer will not install the patches, the
monitoring system should be isolated from the main network.
According to Stanford University: "Security patches help to remove vulnerabilities from a given computer, such as open
backdoor ports or other bugs in the operating system. If you do not patch the computer, a virus can exploit one or more of
those vulnerabilities to use your computer to spread viruses, send out spam, illegally serve up copyrighted material,
launch denial of service (DOS) attacks against Internet servers, etc."
References:
[2] http://acomp.stanford.edu/info/security
Q335EXPL
The better the traffic on a network is controlled, the more reliable the network remains (with regard to speed, data volume
and integrity, security, etc.). This is especially true when mixing patient data in with enterprise network traffic. As
network bandwidth increases, traffic concerns may decrease.
The data transmission characteristic most frequently discussed by networking professionals is bandwidth – a measure of
how much data is transmitted during a given period of time. Though technically, the term "bandwidth" has a different
meaning (and relates to analog signals), networking professionals use it to indicate "throughput" – the quantity of bits
transmitted per second. The various types of physical media (cabling and fiber) are rated this way, as are networks
themselves.
When we say the bandwidth of an ECG monitor is 0.05 to 100 Hz, we mean that the analog frequencies of the
physiological waveform within that range are amplified while those outside the range are not. Bandwidth is actually a
measure of the difference between the highest and lowest frequencies that are processed. The ECG monitor’s bandpass is
about 100 Hz (100 - 0.05 Hz).
UDP (User Datagram Protocol) is a faster, but less reliable (connectionless) routine for file transfer. TCP (Transmission
Control Protocol) is a connection-oriented network routine for data transfer (greater reliability, but slower). UDP might be
desirable for time-sensitive, real-time data transfer; however, patient data acquired with an electrocardiograph likely does
not fall into this category.
References:
[1] Kabachinski J, "Managing Patient Monitoring Network Traffic," Biomedical Instrumentation and Technology, AAMI,
Arlington, VA., Sept 2005, pages 372-374
[2] Dean, T, Network + Guide to Networks, 5th edition, Thomson Course Technology, Boston, MA, 2009, page 87 - 88
Q336EXPL
Fiber-optic cable is a high-speed alternative to copper wire. It uses glass or plastic filaments to move data and provides
greater bandwidth as well as longer cable runs. Because it uses light to transfer data, it is not susceptible to tapping
(stealing data off the line). Therefore, fiber provides a more secure environment.
Reference: Habracken J, Absolute Beginner's Guide to Networking, 4th edition, Que, Indianapolis, IN, 2004, pages 73-74
Q337EXPL
Though the range varies somewhat with the manufacturer of the wireless access point device, 300 feet is a typical
maximum. While radio reception does not depend per se on data throughput, it is closely related. In general, you can
define the connectivity range boundary to be the point where user devices can connect to the access point at a specified
data rate.
Reference:
[1] http://www.wi-fiplanet.com/tutorials/article.php/2212591
[2] Dean, T, Network + Guide to Networks, 5th edition, Thomson Course Technology, Boston, MA, 2009, pages 129 -
135
[3] Habracken J, Absolute Beginner's Guide to Networking, 4th edition, Que, Indianapolis, IN, 2004, pages 73 - 74
Q338EXPL
A router acts as a very simplistic firewall. While routers can be programmed to block or pass datagrams based on IP
address and type of service session, they are easily defeated and tunneled through. Simple routers can not perform content
filtering and represent a single hardware point of failure. Firewalls for the most part are software systems that can provide
extensive authentication, encryption, filtering, and blocking of processes.
Reference: Pardoe TD and Snyder GF, Network Security, Delmar Cengage Learning; first edition, 2004, page 299
Q339EXPL
Access points act at Layer 2 (of the OSI model) as translational bridges, allowing and controlling network access to
wireless devices. They contain at least two physical interfaces and can learn the MAC addresses associated with either.
The Data Link layer is responsible for framing of data packets and the movement of data across the physical link.
OSI (Open Systems Interconnection) refers to the conceptual model for network communications developed by the ISO
(International Standards Organization). It describes network communications as a series of seven layers. These are
(ranging from one to seven): Physical, Data Link, Network, Transport, Session, Presentation, and Application. Each layer
is responsible for a different part of the process that takes place when two computers on a network establish a connection
and move data between them.
HL7 (Health Level 7) is a standard for information exchange between medical applications. HL7 does not describe how
data gets from one place to another on a network – that is up to other protocols at the lower levels.
References:
[1] CWNA Wireless LAN Administration, Planet3 Wireless, Inc. Atlanta, GA, 2006, p. 04.
[3] Kabachinski J, "What is Health Level 7?" Biomedical Instrumentation and Technology, AAMI, Arlington, VA.,
Q340EXPL
RSN is a protocol for establishing secure communications over an 802.11 wireless network. "Robust Security Network" is
an element of the IEEE's (2004) 802.11i wireless security standard, which utilizes more sophisticated authentication
services between Wireless Application Protocol (WAPs) and wireless clients. It is also known as WPA2 (Wi-Fi Protected
Access, version 2), a name given to RSN by the Wi-Fi Alliance.
References:
[1] http://www.tech-faq.com/rsn-robust-secure-network.html
[2] http://www.windowsecurity.com/articles/80211i-wpa-rsn-wi-fi-security.html
Q341EXPL
In order to utilize the data provided by computerized patient monitoring and diagnostic equipment, other devices must be
able to access the data over a network - hence the movement from private to enterprise networks. Medical device
manufacturers are transitioning from physically separate private networks to creating logically private networks (using
network switches and routers).
Answers A and C are actually advantages of private networks. If devices are isolated from the enterprise network, there is
no need to update any software or hardware to ensure compatibility with anything on the enterprise network.
Reference: http://medicalconnectivity.com/2008/12/18/medical-device-networks-trouble-industry
Q342EXPL
HL 7 is not a software package, but a standard for information exchange between medical applications. It is a
specification for describing, formatting, encoding, and sharing clinical and administrative data in healthcare. At Layer 7,
the "Application" layer of the OSI model, we find application services for file transfers, e-mail, and other network
software services.
While one can assume that HL7 standards incorporate HIPAA guidelines, they do not actually ensure compliance. HIPAA
(Health Insurance Portability and Accountability Act of 1996) is focused on the confidentiality of patients' medical
records.
Founded in 1987, Health Level Seven International (HL7) is a not-for-profit, ANSI-accredited standards developing
organization dedicated to providing a comprehensive framework and related standards for the exchange, integration,
sharing, and retrieval of electronic health information that supports clinical practice and the management, delivery, and
evaluation of health services.
TCP/IP is not the name of any of the seven layers – it operates at the Transport and Network Layers.
References:
[1] Kabachinski J, "What is Health Level 7?" Biomedical Instrumentation and Technology, AAMI, Arlington, VA.,
[2] http://www.hl7.org/about/index.cfm
[3]http://www.corepointhealth.com/sites/default/files/whitepapers/hl7-hipaa-requirements.pdf
Q343EXPL
The MAC address refers to a computing device's physical, not logical, address on a network. It is burned into a ROM chip
on the device's NIC (Network Interface Card). A device's logical address refers to a (changeable) IP address (in the case of
TCP/IP). Logical addresses must be resolved to the NIC's hardware address before data can actually be received.
A MAC address is 48 bits long and is represented as a hexadecimal number. The standard (IEEE 802) format for printing
MAC addresses in human-friendly form is six groups of two hexadecimal digits, separated by hyphens (-) or colons (:), in
transmission order (e.g. 01-23-45-67-89-ab or 01:23:45:67:89:ab). The MAC address can be changed if the device’s NIC
is changed.
References:
[1] Habracken J, Absolute Beginner's Guide to Networking, 4th edition, Que, Indianapolis, IN, 2004, pages 41 and 89.
[2] http://www.sccs.swarthmore.edu/users/08/ajb/tmve/wiki100k/docs/MAC_address.html
[3] http://computernetworkingnotes.com/n_plus_certifications/tcp_ip_stack.html
Q344EXPL
"Dynamic" addressing implies the use of DHCP, or Dynamic Host Configuration Protocol. In this situation, the DHCP
client (medical device) requests a new IP address from a server running DHCP every time the device boots up. A common
policy, such as the one found at Columbia University, is that all devices, except servers and printers, are configured to use
DHCP, and the DHCP server assigns (or "leases") an IP address to the device for a time determined by the settings on the
DHCP server.
If the device will be stationary, it would seem to make sense that the IP address could be static (always stays the same),
but this may not be in keeping with your network administrator's rules.
HIPAA-compliance and whether the network is connected to the Internet are irrelevant to the question at hand.
References:
[1] http://www.cumc.columbia.edu/it/getting_started/policy.html
[2] Habracken J, Absolute Beginner's Guide to Networking, 4th edition, Que, Indianapolis, IN, 2004, pages 41 and 89
Q345EXPL
Routers simply read the Network Layer destination address of transmitted WAN packets to determine whether or not to
pass them along to another WAN. They do not ensure data integrity; they connect WANs (Wide Area Networks) based on
destination addressing and routing tables.
Repeating traffic to all ports is the job of a hub, which operates at the OSI's Physical Layer.
Reference: Kabachinski J, "Translating the Concepts Behind Gateways," Biomedical Instrumentation and Technology,
AAMI, Arlington, VA., May/June 2006, pages 201 - 204
Q346EXPL
127.0.0.1 is the standard IP address used for a loopback network connection. This means that when you try to connect to
127.0.0.1, you are looped back to your own machine.
Network software and utilities can use 127.0.0.1 to access a local computer's TCP/IP network resources. Messages sent to
loopback IP addresses like 127.0.0.1 do not reach outside to the local area network (LAN), but instead are automatically
re-routed by the computer's own network adapter back to the receiving end of the TCP/IP stack.
A loopback interface has several uses. PINGing the loopback interface is a basic test of the functionality of the IP stack in
the operating system. A successful ping request to 127.0.0.1 will verify that a computer's network interface card, its
drivers, and the operating system's TCP/IP implementation are all functioning correctly.
References:
[1] http://compnetworking.about.com/od/workingwithipaddresses/g/127_0_0_1_def.htm
[2] http://what-is-what.com/what_is/127.0.0.1.html
[3] http://www.networkpcworld.com/2012/01/what-is-localhost-loopback-and-127000.html
[4] http://technet.microsoft.com/en-us/library/cc737478%28WS.10%29.aspx
Q347EXPL
Category 6 cable, commonly referred to as Cat 6, is a cable standard for Gigabit Ethernet and other network physical
layers that is backward compatible with the Category 5/5e and Category 3 cable standards. Compared with Cat 5 and Cat
5e, Cat 6 features more stringent specifications for crosstalk and system noise. Most Category 5 cables are unshielded,
relying on the twisted pair design and differential signaling for noise rejection. Cat 6 has more shielding.
Cat 5 and Cat 6 cable are both available in stranded and solid conductor forms. Both use an RJ45-style connector, and to
avoid signal loss, both specify a maximum cable length of 100 meters (however, when used for 10GBASE-T, Cat 6
cable's maximum length is only 55 meters).
References:
[1] http://www.tech-faq.com/cat-6.html
[2] http://www.lvpcrepair.net/pages/tips-tricks/networkcable.pdf
Q348EXPL
Faster and farther. Cat 6 twisted pair copper cable achieves a maximum throughput of 1,000 Mbps, but is limited to cable
runs of 100 meters (however, when used for 10GBASE-T, Cat 6 cable's maximum length is only 55 meters). Fiber can
handle data rates in excess of 10 Gbps (10,000 Mbps) at distances measured in kilometers – but not at light speed.
A main drawback of fiber is that it can not be bent in a 45-degree angle and you can not have kinks in it. It is fragile,
which is why copper is still preferred in many situations. While the price of fiber-optic cable has come down in recent
years, making fiber a viable alternative for LAN usage, it is still more expensive than Cat 6 cable.
References:
[1] http://www.lvpcrepair.net/pages/tips-tricks/networkcable.pdf
[2] Habracken J, Absolute Beginner's Guide to Networking, 4th edition, Que, Indianapolis, IN, 2004, page 73
Q349EXPL
Twisted pair wire (AWG 22-26 gauge) for networking applications comes in two styles - shielded and unshielded (STP
and UTP). The main difference is that STP wires are encased in a foil wrap that protects them from interference.
UTP is the most commonly used network wiring. It is inexpensive, flexible, and light, making it very easy to work with.
UDP stands for User Datagram Protocol, a routine for file transfer similar to TCP (Transmission Control Protocol). SPX
stands for Sequenced Packet Exchange and is part of IPX/SPX, the primary protocol of Novell NetWare. Internetwork
Packet Exchange/Sequenced Packet Exchange (IPX and SPX) protocols provide services similar to those offered by IP
and TCP.
Reference:
[1] Habracken J, Absolute Beginner's Guide to Networking, 4th edition, Que, Indianapolis, IN, 2004, page 73
[2] http://computernetworkingnotes.com/n_plus_certifications/tcp_ip_stack.html
[3] http://searchsoa.techtarget.com/definition/UDP
Q350EXPL
Generically, an SQL server is any database management system (DBMS) that can respond to queries from client machines
formatted in Structured Query Language. The term "SQL server" does not necessarily refer to a device – it is software that
runs on a computer. This server (developed by Microsoft) is of the relational database type.
SQL is actually the name of a specific interactive programming language for storing, retrieving, and modifying relational
databases.
A database is similar to a spreadsheet – a collection of data organized in some fashion so as to allow quick access. An
example is a typical biomedical equipment control database. The term relational means that the database is organized
according to relationships between data fields (for example, the control number of a piece of equipment in the biomedical
inventory and its historical record).
References:
[1] http://www.webopedia.com/TERM/S/SQL_Server.htm
[2] http://www.easeus.com/resource/sql-server.htm
[3] http://www.sqlcoding.com
[4] Kabachinski J, "Databases, Tuples, and SQL," Biomedical Instrumentation and Technology, AAMI, Arlington, VA.,
Sept/Oct 2008, pages 385-387
[5] Basic Database Tutorial: http://www.quackit.com/database/tutorial
[6] http://office.microsoft.com/en-us/access-help/database-design-basics-HA001224247.aspx
Q351EXPL
Two insulated copper wires running parallel to each other will electrically interfere with each other. By twisting the wires
together, the interference (or crosstalk) is minimized. Twisted pair cabling (the predominant choice in network data
cabling) is a type of wiring in which two conductors (the forward and return conductors of a single circuit) are twisted
together for the purposes of canceling out electromagnetic interference (EMI) from other twisted pairs in the same cable
or from external sources. Twisted pair cable is very flexible compared to solid wire cable.
References:
[2] http://www.linfo.org/twisted_pair.html
Q352EXPL
MMF stands for "Multimode Fiber" and 100Base-FX is one of several commonly used standard fiber-optic cables.
100Base-FX refers to a network capable of 100Mbps throughput that uses baseband transmission and fiber-optic cabling.
Fast Ethernet is designated as 100Base-T, and uses twisted pair wiring, not fiber.
A media converter is a device that allows networks or segments running on different media (copper and fiber, for
instance) to interconnect and exchange signals.
Reference: Dean, T, Network + Guide to Networks, 5th edition, Thomson Course Technology, Boston, MA, 2009, pages
94 - 112
Q353EXPL
The data transmission characteristic most frequently discussed by networking professionals is bandwidth – a measure of
how much data is transmitted during a given period of time. Though technically the term "bandwidth" has a different
meaning (and relates to analog signals), networking professionals use the term to indicate "throughput" – the quantity of
bits transmitted per second. The various types of physical media (cabling and fiber) are rated this way, as are networks
themselves.
When we say the bandwidth of an ECG monitor is 0.05 to 100 Hz, we mean that the analog frequencies of the
physiological waveform within that range are amplified while those outside the range are not. Bandwidth is actually a
measure of the difference between the highest and lowest frequencies that are processed. The ECG monitor's bandpass is
about 100 Hz (100 - 0.05 Hz).
Baseband means that data flows in a stream in a single signal. Broadband is a type of transmission that carries multiple
channels of information.
Reference: Dean, T, Network+ Guide to Networks, 5th edition, Thomson Course Technology, Boston, MA, 2009, page 87
- 88.
Q354EXPL
Ethernet, Fast Ethernet, and Gigabit Ethernet are designated by three-part names, such as 10BASE-T. The first part of the
name (10 or 100) designates transmission speed. In this case, the 10 indicates 10Mbps.
The second part of the name, BASE, is the same for all types of Ethernet. It specifies that the Ethernet signal is a
Baseband signal (data flows in a stream in a single signal), as opposed to Broadband (which carries multiple channels of
information).
The final part of the Ethernet-type name 10BASE-T designates the kind of cable used. In this case, the T refers to twisted-
pair cable.
Thinnet, designated 10BASE-2, is an IEEE Physical Layer standard for achieving 10Mbps throughput over coaxial copper
cable. A 10Gbps transmission speed would be written as 10GBASE-xx.
References:
[2] Dean, T, Network + Guide to Networks, 5th edition, Thomson Course Technology, Boston, MA, 2009, page 135 - 145
Q355EXPL
A topology is a network's virtual shape or structure. This virtual shape does not necessarily relate to the physical layout of
the devices on the network. For example, the computers on a star LAN do not have to be physically arranged around the
central hub like rays radiating from the center.
Advantages of the star topology include easy expandability of computers on the network, as well as greater reliability than
can be provided by either bus or token ring topologies. With a star topology, if one computer ceases to communicate on
the network, it does not prevent other computers on the network from communicating with each other. Of course if the
central hub fails, the network ceases to function.
A bus topology is essentially several computers in series, along a passive communications bus. Though simpler than other
topologies, the bus topology is prone to problems. If a connector becomes loose or broken, all network communication
can cease. A token ring topology, though technologically more sophisticated, can have the same problem. In this
topology, computers are again connected in series, but in a circular fashion. Again, if a computer node becomes physically
disconnected from the network, all communication stops. The term "token" refers to a data packet that facilitates
communication between computers on such a network.
Complex topologies such as mesh and tree have been developed to expand upon the advantages of the basic models, while
improving reliability. Though the basic network topologies have a theoretical purpose, there are very few instances of
them in actual use. The fact is that most enterprise networks are a mix of various types of topologies.
Ethernet is not a topology. It is a network architecture standard that specifies how devices communicate on a given
network.
References:
[1] http://compnetworking.about.com/od/networkdesign/a/topologies.htm
[2] Habracken J, Absolute Beginner's Guide to Networking, 4th edition, Que, Indianapolis, IN, 2004, pages 31 – 35
[3] http://www.webopedia.com/DidYouKnow/Hardware_Software/Networking/mesh_topology.html
Q356EXPL
Computer circuitry and operation is based on the binary number system. Computer memory is also dependent on the
binary number system.
The power of 2 closest to 1,000,000,000 is referred to as a gigabyte (abbreviated GB). 2 raised to the 30th power is
referred to as 1 GB (1,073,741,824). 8 GB is equal to 8192 MB.
For convenience, the power of 2 closest to 1,000 is called a kilobyte (abbreviated KB). It turns out that 2 raised to the 10th
power is equal to 1,024. Therefore, 1,024 is 1 KB.
Similarly, the power of 2 closest to 1,000,000 is referred to as a megabyte (abbreviated MB). When 2 is raised to the 20th
power, the result is 1,048,576. Therefore, 1,048,576 is 1 MB.
References:
[1] Digital Electronics A Practical Approach, 8th Ed, William Kleitz, Pearson Prentice Hall, 2008, Chapter 16
[2] http://en.wikipedia.org/wiki/Gigabyte
Q395EXPL
A hub is a common connection point for devices on a network that takes an incoming signal and repeats it on all other
ports. Hubs operate at the physical layer. They are AC-powered and can lose power in a variety of ways.
If your username expired, you could potentially lose the ability for your computer to communicate with the server, but the
question implies a more global problem.
A gateway is essentially a computer, a network point that acts as an entrance to another network. i.e. through an internet
service provider (ISP). A Gateway is a router, a type of node that can connect a small network to the Internet. On the
Internet, a node or stopping point can be either a gateway node or a host (end-point) node. The computers that control
traffic within your company’s network or at your local ISP are gateway nodes. With reference to a peer-to-peer mode, the
gateway is probably acting in some VoIP (Voice over IP, or Internet telephony) configuration.
A firewall is a set of related programs, located at a network gateway server, that protects the resources of a private
network from users from other networks. (The term also implies the security policy that is used with the programs.) An
enterprise with an intranet that allows its workers access to the wider Internet installs a firewall to prevent outsiders from
accessing its own private data resources and for controlling what outside resources its own users have access to. While
this is a possible answer, it is less likely than D.
Reference:
http://www.ihets.org/progserv/video/vidconf/glossary.html; http://largebande.gc.ca/pub/technologies/bbdictionary.html
Q402EXPL
Let's use some basic troubleshooting skills here and not let the computer jargon scare us. The network connection between
node 2 and the reader station has been lost. Because the rest of the nodes still interact with the reader station, the problem
must be between node 2 and the reader station.
Now, to troubleshoot this, we DO need to have some networking skills. The rest of the nodes interact with the reader
station just fine, so the NIC (Network Interface Card) would not be the problem. Modems are not used to connect nodes
on a network, so choice A is out.
That leaves "C" and "D." PINGing means to use the PING utility or command on a networked computer to verify the
presence of another computer (or node) on the network). If a user can not PING a host, then the user will be unable to
interact with that host. Do we want to PING the known good computer (reader station) from the potentially bad computer
(that at node 2)? No, so then choice "D" is the best answer.
References: http://whatis.techtarget.com/; Kurose JF and Ross KW, Computer Networking, Addison-Wesley, 2003, pages
56 - 57
Q405EXPL
This makes the replacement PC compatible with that particular network node. Assuming there is not a problem with the
spare’s MAC address, this should work.
From a network management perspective, we would not want to assign a new IP address at that location (choice A).
Though it is not likely that the subnet mask of that portion of the network had changed (choice C), it is possible that the
Information Systems staff could have done this to address some network issue, without realizing the repercussions.
Reference:
[1] Englander I, The Architecture of Computer Hardware and Systems Software: An Information Technology Approach,
Wiley, 2002, pages 112 - 114
Q428EXPL
A latching alarm is one that requires human intervention to end it. Non-latching
refers to an alarm that can silence and reset automatically without human
intervention. A false positive is another way of saying a mistake, or a false
alarm.
Adding a delay can potentially reduce the number of nuisance alarms. For example,
allowing a monitor to ignore a momentary drop in SpO2 but requiring it to
acknowledge a more sustained drop can make the alarm system less susceptible to
patient movement artifact.
References:
[2] http://ajcc.aacnjournals.org/content/19/1/28.full.pdf
Q429EXPL
BIOS (Basic Input/Output System) refers to a group of firmware programs
(including startup routines) stored in a computer's ROM. You cannot change
information in the BIOS, so you need another device with memory that can be
changed easily to store things like time and date that can be read by BIOS. CMOS
chips store this information, but require a small voltage whether the computer is
turned on or not. Motherboards have a small on-board battery for this purpose.
The battery usually lasts several years. If the battery dies, CMOS errors or lost
time and date will occur. To prevent this nuisance problem, the pulmonary
function system could just be left powered up until the battery can be changed.
Power-on Self Test (POST) is a start-up program that checks out the system every
time the computer boots. The computer beeps if it finds something wrong with a
device e.g., the video card, processor, or memory.
Reference: Meyers, M., A+ Certification Exam Guide, 7th edition, McGraw-Hill

Osborne Media, Berkeley, CA, 2010, pages 218 - 240
Q430EXPL
Wireless networked medical devices have either an internal or external wireless
Ethernet card. They typically have a small antenna and otherwise operate like any
other NIC (Network Interface Card) using a transceiver. External cards can easily
become dislodged from their sockets or removed altogether.
Wireless radio LANs (Local Area Networks) require an access point to be placed on
the network for the devices that need to connect to the LAN. Being beyond the
range of an access point could prevent the cardiograph from transmitting data to
its server; being too close is not an issue.
Frequency-hopping is a technological strategy for keeping data secure on a

wireless network. It reduces the possibility of intercepting data by making the
transmitter and receiver switch (or hop) frequencies periodically.
Reference:
[1] Habracken J, Absolute Beginner's Guide to Networking, 4th edition, Que,
Indianapolis, IN, 2004, pages 75 - 76
Q435EXPL
Unfortunately, the answer is "C." Even if the drive was backed up, it was
probably done the previous night. In which case, data stored since the backup was
performed will be the only data lost. Drives will fail. The other part of this
scenario that works against the repair process is the fact that the system is
obsolete. It is very possible that even if the data is recoverable, a replacement
for the drive itself may be unavailable. While answer B is a possibility, such a
service is never guaranteed.
Not all servers have RAID drives. RAID (an acronym for redundant array of
independent disks), is a storage redundancy technology. RAID uses "shared,
multiple physical or logical hard disks to ensure data integrity and
availability."
References:
[1] Dean, T, Network + Guide to Networks, 5th edition, Thomson Course Technology,
Boston, MA, 2009, page 707
[2] Meyers, M.., A+ Certification Exam Guide, 7th edition, McGraw-Hill Osborne
Media, Berkeley, CA, 2010, pages 494 - 495
[3] http://bugclub.org/beginners/hardware/raid.html
Q438EXPL
Patient monitors need an HL7 interface to route clinical data to a hospital's EMR
(electronic medical record). This is necessary to link the patient's ID (and
other demographics) to the appropriate clinical data.
Hospitals use a variety of computer systems and computerized medical equipment.

Many types of diagnostic equipment, for instance, need to communicate with each
other, and potentially with billing and patient tracking systems. The
technologies therefore need to communicate with each other. HL7 specifies data
standards that are designed to allow medical computing systems to easily share
clinical information. In so doing, it becomes possible for different healthcare
organizations to similarly share this information.
Having all your monitors at the same software revision level does not necessarily
allow them to communicate with any EMR.
A CAN-bus is a communications protocol, and "flat file" refers to a database

record in which fields of plain text make up one record per line (certainly too
detailed a question to ask at this point).
Chances are, your hospital EMR system accepts the ADT (admission / discharge /
transfer) message format. ADT messages carry patient demographic information for
HL7 communications and are among the most widely used of all message types.
References:
[1] http://www.orionhealth.com/glossary/f-j/health-level-7-hl7
[2] http://www.hl7standards.com/blog/2006/10/05/what-is-an-adt-message
[3] http://en.wikipedia.org/wiki/Flat_file_database
[4] http://kb.iu.edu/data/ahrp.html
[5] http://www.corepointhealth.com/resource-center/hl7-resources/hl7-adt
Q492EXPL
Microprocessors depend upon very fast, digital signals for proper operation. If
something causes interference that results in the distortion of those digital
signals, errors can result, and the microprocessor may malfunction.
Induced voltages, which may distort the digital signals, can be caused by any
strong electromagnetic signal. In the presence of these signals, if the device
that contains the microprocessor is not adequately shielded, the circuitry inside
the device will act as an antenna, causing induced voltages to appear in the
circuitry.
Electromagnetic waves can take many forms, including x-rays, radio waves (at
radio frequencies), and microwaves, for example.
Reference: None
Q551EXPL
The Wireless Medical Telemetry Service (WMTS) is regulated by the Federal
Communications Commission. Prior to establishing the Wireless Medical Telemetry
Service (WMTS), medical telemetry devices operated on an unlicensed basis on
vacant television channels 7-13 (174-216 MHz) and 14-46 (470-668 MHz) or on a
licensed but secondary basis to private land mobile devices in the 450-470 MHz
band. This meant that wireless telemetry devices had to accept interference from
the television broadcasters and private land mobile licensees.
As part of the transition from analog to digital broadcast television, the FCC
established the Wireless Medical Telemetry Service (WMTS) in 2002 by allocating
14 MHz of spectrum for wireless medical telemetry. The Wireless Medical Telemetry
Service (WMTS) is in the 608 – 614, 1395 – 1400, and 1427 – 1432 MHz range.
Wireless medical telemetry systems include devices to measure patients' vital
signs and other important health parameters (e.g., pulse and respiration rates)
and devices that transport the data via a radio link to a remote location, such
as a nurses' station equipped with a specialized radio receiver. For example,
wireless cardiac monitors are often used to monitor patients following surgery
and these use the WMTS spectrum.
Reference: http://www.fcc.gov/encyclopedia/wireless-medical-telemetry-service-
wmts
Q552EXPL
The Wireless Medical Telemetry Service (WMTS) is in the 608 – 614, 1395 – 1400,
and 1427 – 1432 MHz range. WMTS spectrum is used for remote monitoring of a
patient's health. Wireless medical telemetry systems include devices to measure
patients' vital signs and other important health parameters (e.g., pulse and
respiration rates) and devices that transport the data via a radio link to a
remote location, such as a nurses' station, equipped with a specialized radio
receiver. For example, wireless cardiac monitors are often used to monitor
patients following surgery.
wmts
Q553EXPL
Only authorized health care providers are eligible to operate Wireless Medical
Telemetry Service (WMTS) devices and WMTS devices may be used only within a
health care facility. WMTS devices must be registered with the FCC's designated
frequency coordinator, the American Society for Healthcare Engineering of the
American Hospital Association (ASHE/AHA).
wmts
Q586EXPL
Pump communication requires a pervasive and reliable wireless network. A quick
way to check the wireless network’s quality and availability is to use a VOIP
phone. As noted in the reference cited below: “One rough method of quickly
assessing wireless coverage is through the support and use of voice over internet
protocol (VOIP) communication devices. If patient care areas in the facility have
been shown to offer adequate coverage and uptime for VOIP use, it is likely that
they will offer sufficient support for infusion pump integration.”
Reference:
[1] AAMI Foundation Healthcare Technology Safety Institute, Best Practices for
Infusion Pump—Information Network Exchange, 2012, page 4, online access available
at http://www.aami.org/htsi/SI_Series/Infusion_Pump_White_Paper.pdf
Q651EXPL
Modern TCP/IP networks (such as the Internet) can carry almost any type of data
traffic. Examples of the kind of data include video (such as Youtube videos),
voice (for example, VOIP, voice over internet protocol systems carry telephone
calls outside of the traditional telephone network), and data (pretty much
everything on the Internet is some form of data).
Reference:
[1] TCP/IP abc's, Your Dictionary website, http://www.yourdictionary.com/tcp-ip-
abc-s, retrieved September 21, 2014
Q652EXPL
By international agreement, 10.x.y.z addresses are “private” and therefore not
routable on the Internet. The result is that the exact same address can be used
in different locations. That is not true for the other two addresses listed which
are public and Internet-routable.
The following address groups are reserved for private addresses:

10.0.0.0 through 10.255.255.255
172.16.0.0 through 172.31.255.255
192.168.0.0 through 192.168.255.255
Reference:
[1] IP Address, Wikipedia,
http://en.wikipedia.org/wiki/IP_address#IPv4_private_addresses, retrieved
September 21, 2014
Q653EXPL
Although TCP (Transmission Control Protocol) is the most common protocol used on
the Internet and is used by many operating systems including the Windows, Linux
and Apple operating systems, UDP (User Datagram Protocol) is used for
applications where real-time transmission is more important than 100% accuracy.
For example, voice (Voice over Internet Protocol; VOIP) and some real-time
medical applications that transmit real-time video information use the UDP
protocol.
A major difference between the TCP protocol and the UDP protocol is that TCP uses
handshaking, where the receiver confirms that it has received all of the bits
sent by the transmitter, while UDP sends data between the transmitter and
receiver with no handshaking, so there is no assurance that the receiver has
actually received everything that was sent. With handshaking, if the transmitter
does not receive the required confirmation receipt from the receiver, it will
again send the data packets. This process will be repeated several times before
the transmitter gives up (times out).
Time-sensitive applications often use UDP because dropping packets is preferable

to waiting for delayed packets.
Reference:
[1] User Datagram Protocol, Wikipedia,
http://en.wikipedia.org/wiki/User_Datagram_Protocol, retrieved September 20, 2014
Q654EXPL
Active IP addresses on one subnet must be unique. AE Titles are used in DICOM and
have nothing directly to do with IP addresses.
References:
[1] Troubleshooting Duplicate IP Addresses, Professor Messer website,
http://www.professormesser.com/n10-005/troubleshooting-duplicate-ip-addresses/,
[2] Public and Private Addresses, Microsoft Technet,
http://technet.microsoft.com/en-us/library/cc958825.aspx, retrieved September 21,
2014
Q655EXPL
A valid IP address, subnet mask and gateway address are all required. The IP
address identifies the computer to its local area network. In most cases, the IP
address of a single computer will be selected from the range of private addresses
available on that network, such as an address in the 10.x.x.x or 192.168.x.x
range. The subnet mask identifies the range of computer addresses visible to the
particular computer, and so allows the computer to communicate with other
computers on the same subnet. For example, if the subnet mask 255.255.255.0 is
used, then a computer with the IP address of 10.1.1.200 could communicate with
other computers assigned addresses that begin with 10.1.1, but not computers that
have an address that starts with 10.1.2.
Finally, the gateway address provides the information that the computer needs to
find the router that has a direct physical connection to the Internet.
In many cases, computers will use DHCP (Dynamic Host Configuration Protocol) to
automatically obtain these three pieces of information from the network
controller.
Regardless of whether the IP address, subnet mask and gateway address are fixed
or are obtained through DHCP, all three pieces of information are required in
order for the computer to talk to other computers on the Internet; i.e.,
computers that are not part of its particular local area network.
References:
[1] Understanding TCP/IP addressing and subnetting basics, Microsoft,
http://support.microsoft.com/kb/164015, retrieved September 21, 2014
[2] IP Address, Wikipedia,
http://en.wikipedia.org/wiki/IP_address#IPv4_private_addresses, retrieved
September 21, 2014
[3] Dynamic Host Configuration Protocol, Wikipedia,
http://en.wikipedia.org/wiki/Dynamic_Host_Configuration_Protocol, retrieved
September 21, 2014
Q656EXPL
DHCP (Dynamic Host Configuration Protocol) dynamically provides network IP
addresses to a client, such as a computer or printer. This reduces network
administrator workload and allows IP addresses to be later re-used by a different
device. DHCP does not speed up the network, nor does it make the network more
secure.
References:
[1] DHCP Addressing Overview, Professor Messer website,
http://www.professormesser.com/n10-005/dhcp-addressing-overview, retrieved
September 21, 2014
[2] Dynamic Host Control Protocol, Wikipedia,
http://en.wikipedia.org/wiki/Dynamic_Host_Configuration_Protocol, retrieved
September 21, 2014
Q657EXPL
Subnet masks are contiguous strings of ones followed by a contiguous
string of zeroes. That is, the binary representation of a subnet mask must
start with at least one 1. That 1 may be followed by a 1 or a 0, but if it
is followed by a 0, then all subsequent values must be 0. For example, the
number 255 (decimal) is represented as 11111111 in binary. This would be a
valid value for a portion (known as an octet) of the subnet mask.
It turns out that the only valid values for an octet are:
Decimal Binary
255 11111111
254 11111110
252 11111100
248 11111000
240 11110000
224 11100000
192 11000000
128 10000000
0 00000000
Therefore, the last octet in answer D (103) is not valid since the binary
equivalent of 103 (decimal) is a mix of ones and zeros that are not
contiguous (1100111).
References:
[1] Subnet Masks, Connected: An Internet Encyclopedia website,
http://www.freesoft.org/CIE/Course/Subnet/6.htm
[2] Subnets and Subnet Masks, Microsoft, http://technet.microsoft.com/en-
us/library/cc958832.aspx
[3] Subnetting, Professor Messer website,
http://www.professormesser.com/n10-005/subnetting
Q658EXPL
In general, computerized medical devices are vulnerable to the same types of
attacks as any other computerized devices, so the same kinds of techniques should
be employed to prevent malware, such as computer viruses, from attacking these
devices.
Virus protection software, network design and security patches all have a role in
protecting computerized medical devices from malware. As newer devices come to
market, they are often designed to allow virus scanning and patching. Special
network security design is used for those systems that cannot be patched
automatically as well as for other network “segregation” purposes.
References:
[1] Guide to Malware Incident Prevention and Handling, National Institute of
Standards and Technology, http://csrc.nist.gov/publications/nistpubs/800-
83/SP800-83.pdf, pages 3-1 to 3-2, retrieved September 20, 2014
[2] Virus and Worm Attacks, Professor Messer website,
http://www.professormesser.com/n10-005/virus-and-worm-attacks, retrieved
September 20, 2014
Q659EXPL
Wireless medical devices use a variety of frequencies on a shared basis. The
allocation of frequencies depends upon the geographic area where the operation is
taking place. The WMTS (Wireless Medical Telemetry Services) uses three frequency
bands: 608 – 614 MHz, which is shared with radio astronomy; 1395 – 1400 MHz,
which is exclusively authorized for medical applications; and 1427 – 1432 MHz,
which is shared by WMTS devices and non-WMTS devices such as utility telemetry
devices.
Microwave ovens use 2.45 GHz and can interfere with 802.11b (and 802.11g) radios.
802.11 radios are NOT licensed. 802.11 radios are typically used for wifi
communications, allowing computers to wirelessly connect to networks.
References:
[1] Wireless Medical Telemetry Service (WMTS), Federal Communications Commission
website, http://www.fcc.gov/encyclopedia/wireless-medical-telemetry-service-wmts,
[2] ISM Band, Wikipedia, http://en.wikipedia.org/wiki/ISM_band, retrieved
September 22, 2014
[3] IEEE 802.11, Wikipedia, http://en.wikipedia.org/wiki/IEEE_802.11, retrieved
September 22, 2014
Q660EXPL
802.11a uses the 5.0 GHz band. 802.11b and 802.11g radios use the 2.4 GHz band.
802.11n uses both the 2.4 and 5.0 GHz bands.
Reference:
September 22, 2014
Q661EXPL
802.11b and 802.11g radios use the 2.4 GHz band. 802.11a uses the 5.0 GHz band.
802.11n uses both the 2.4 and 5.0 GHz bands.
Reference:
September 22, 2014
Q662EXPL
1920 x 1080 has an aspect ratio of 1920/1080 = 16/9. This is a 16 by 9 aspect
ratio.
Reference:
[1] Aspect Ratio, Wikipedia, http://en.wikipedia.org/wiki/Display_aspect_ratio,
Q663EXPL
A MAC address is a unique hardware address of a Network Interface Card (NIC)
typically written as 6 groups of 2 hexadecimal numbers each (e.g.
01:23:45:67:89:AB). Answer C is an IP address, not a MAC address.
Reference:
[1] MAC Address, Wikipedia,
http://en.wikipedia.org/wiki/MAC_address#Notational_conventions, retrieved
September 22, 2014
Q664EXPL
HL7 is a framework and set of standards used for the transmission and exchange of
text and numeric medical information. Essentially, HL7 is designed to send text
strings between various medical systems. Images are sent using the DICOM (Digital
Imaging and Communications in Medicine) standards.
References:
[1] HL7, Wikipedia, http://en.wikipedia.org/wiki/HL7, retrieved September 22,
2014
2014
[3] Standards Watch - DICOM & HL7: Friend or Foe?, Health Imaging,
http://www.healthimaging.com/topics/standards-watch-6, retrieved September 22,
2014
Q665EXPL
DICOM is a set of standards primarily used for the transmission and exchange of
medical images. HL7 identifies standards that are used primarily to transmit
text, numeric and demographic information.
References:
[1] HL7, Wikipedia, http://en.wikipedia.org/wiki/HL7, retrieved September 22,
2014
2014
[3] Standards Watch - DICOM & HL7: Friend or Foe?, Health Imaging,
http://www.healthimaging.com/topics/standards-watch-6, retrieved September 22,
2014
Q735EXPL
Wi-Fi is the generic name for wireless local area network (WLAN) communication
technology. Wi-Fi is based on the IEEE 802.11 series of wireless networking
standards. The standard first became popular with 802.11b, introduced in 1999.
802.11b supports a bandwidth of up to 11 Mbps using unregulated 2.4 GHz frequency
spectrum.
The 802.11a standard was actually established after the 802.11b standard. The
802.11a standard supports bandwidth up to 54 Mbps and uses a regulated frequency
spectrum around 5 GHz. This higher frequency shortens the range of 802.11a
networks, as compared to 802.11b networks. Due to its higher data throughput of
54 Mbps, 802.11a was adopted for business networks whereas 802.11b better serves
the home market, because of its lower cost. Because 802.11a and 802.11b utilize
different frequencies, the two technologies are incompatible.
The 802.11g standard emerged in 2002 in an attempt to combine the best of both
802.11a and 802.11b. It is backward compatible with the 802.11b standard. 802.11g
supports bandwidth up to 54 Mbps, and it uses the 2.4 GHz frequency for greater
range. The 802.11n was developed in 2009 as an improvement to 802.11g in the
amount of bandwidth supported by utilizing multiple wireless signals and antennas
(called MIMO technology) instead of one. The standard provides up to 300 Mbps of
network bandwidth and offers somewhat better range over earlier Wi-Fi standards
due to its increased signal intensity. It is backward-compatible with 802.11b/g
gear.
The 802.11ac standard was approved in 2014. It utilizes dual band wireless
technology, supporting simultaneous connections on both the 2.4 GHz and 5 GHz Wi-
Fi bands. 802.11ac is rated up to 1300 Mbps on the 5 GHz band plus up to 450 Mbps
on 2.4 GHz.
References:
[1] Mitchell, Bradley, Wireless Standards - 802.11a, 802.11b/g/n, and 802.11ac:
The 802.11 family explained, About.com website,
http://compnetworking.about.com/cs/wireless80211/a/aa80211standard.htm, retrieved
August 28, 2014
[2] Cisco Systems Inc., Cisco Networking Academy Program: Second-Year Companion
Guide, 2nd edition, Cisco Press, Indianapolis, 2001, pages 553-554
Q737EXPL
Crosstalk is the condition when electrical noise on the wire in a cable
originates from signals on other wires in the cable. When two wires are near each
other and untwisted, energy from one wire can induce signals in an adjacent wire.
This can result in noise at both ends of a terminated cable. Twisting together
the pair of wires carrying a signal (a twisted pair) can help reduce the
crosstalk between those wires and the other wires in the cable carrying different
signals.
When a signal is being sent along a transmission medium, such as a copper cable
or an optical fiber, some of the signal power may be reflected back to its origin
rather than being carried all the way along the cable to the far end. This can
happen because of impedance mismatches between segments of the cable or other
changes in the cable characteristics.
Attenuation is the gradual loss of the intensity of a signal as it travels

through a transmission medium, such as a cable.
Propagation delay refers to the time it takes for a signal to reach its intended
destination.
References:
[1] Cisco Systems Inc., Cisco Networking Academy Program: First-Year Companion
Guide, 2nd edition, Cisco Press, Indianapolis, 2001, page 141-142
[2] Signal Reflection, Wikipedia, http://en.wikipedia.org/wiki/Signal_reflection,
[3] Attenuation, Wikipedia, http://en.wikipedia.org/wiki/Attenuation, retrieved
October 24, 2014
[4] Propagation Delay, Wikipedia, http://en.wikipedia.org/wiki/Propagation_delay,
Q738EXPL
Wi-Fi (wireless local area networking) has several advantages over wired local
area networks (LANs). Wi-Fi provides mobility for professionals, business
executives, and the general population. Wi-Fi also generally provides flexibility
and cost savings compared to wired network configurations.
In general, Wi-Fi networks operate a lower speeds than wired networks. In

addition, because the signals are transmitted over-the-air, they can be
intercepted more easily, so security is a greater problem with wireless networks
as compared to wired networks. Connectivity is generally better in a wired
network compared to a wireless network. Interference from other users of the same
radio frequencies can disrupt the transmission of data being sent over the
wireless network. In addition, obstacles placed in the path of the radio signal,
such as walls or floors, tend to absorb radio waves making the reliability of
wireless connections lower than those of wired connections.
References:
Q739EXPL
A router is a networking device that forwards data packets between computer
networks. Routers perform "traffic directing" functions on the Internet. When a
data packet from one network comes into the router, the router reads the address
information in the packet to determine the final destination, and then directs
the packet to the next network on the data packet’s journey. The router examines
the packet, chooses the best path, and then switches the packet to the proper
outgoing port. This allows virtually any computer network to communicate with any
other computer network anywhere in the world.
References:
[2] Router (computing), Wikipedia,
http://en.wikipedia.org/wiki/Router_(computing), retrieved August 28, 2014
Q740EXPL
Reliable delivery guarantees that a stream of data sent from one machine will be
delivered through a data link to another machine without duplication or data
loss. Positive acknowledgment with retransmission is one technique that
guarantees reliable delivery of data.
Positive acknowledgment requires a recipient to communicate with the source,

sending back an acknowledgment message (ACK) when the recipient is satisfied that
the data is valid. Validity of data is typically confirmed by a stream of CRC
(cyclic redundancy code) check bits that are transmitted with the data packet.
The CRC check is an algorithm that uses the CRC check bits to validate the data.
If the receiver is not satisfied, the receiver transmits a negative acknowledge
(NAK). The sender keeps a record of each data packet (Transmission Control
Protocol or TCP segment) that it sends and that should receive a positive
acknowledgment. The sender starts a timer when it sends a segment. If the timer
expires before the acknowledgment arrives or if the sender receives a NAK, the
sender retransmits the segment.
TCP transmission, which relies on acknowledgment, differs from the UDP (User
Datagram Protocol) in that the receiver of a UDP transmission does not send back
an acknowledgment. UDP transmissions are used when real-time data transmission is
more important than error-free data transmission. For example, telephone or video
signals will typically be sent using the UDP protocol.
Reference:
Guide, 2nd edition, Cisco Press, Indianapolis, 2001, page 467
Q742EXPL
The Internet is vulnerable to a wide variety of security and identity
compromises. Defects in vendor software like web browsers, email programs, image
viewers, instant messaging software, and media players may allow malicious
websites, email messages, or files to infect or compromise a computer simply by
viewing a compromised website or opening a malware-infected file.
Applicable security solutions include: authentication, encryption, firewalls, and

software patches.
Authentication gives access to authorized users only. Encryption hides data

traffic from unauthorized or malicious individuals. Firewalls filter data traffic
to allow only valid traffic and services. Software patches apply fixes or
measures to stop the exploitation of known vulnerabilities.
References:
Guide, 2nd edition, Cisco Press, Indianapolis, 2001, page 805
[2] Software Patches and OS Updates, Massachusetts Institute of Technology
website, http://ist.mit.edu/security/patches, retrieved September 5, 2014
Q809EXPL
The SSID is a unique identifier that wireless networking devices use to establish
and maintain wireless connectivity. SSID stands for service set identifier and is
commonly referred to as the network name associated with a wireless network.
Multiple access points on a network or sub-network can use the same SSIDs.
SSIDs are similar to subnets; however, each new SSID takes a certain amount of
wireless overhead, including traffic management, and potential spectrum
congestion, leading to decreased wireless performance.
SSIDs are local and there is no "worldwide" impact. Also, SSIDs are not sold. A
user is free to establish any SSID that the user wants.
References:
[1] Improve Air Quality by Minimizing SSIDs: Using Role-Based Access to Increase
Wi-Fi Application Performance, Aruba Networks website, October 2010,
http://www.arubanetworks.com/pdf/technology/whitepapers/wp_Virtual-Access-
Points.pdf, pages 3-4, accessed on 10/26/2014
[2] Service set (802.11 network), Wikipedia,
http://en.wikipedia.org/wiki/Service_set_(802.11_network), accessed on 3/12/2015
Q828EXPL
Laptop computers typically have an external power supply (sometimes referred to
as a power brick) that converts standard AC mains voltage into the DC voltage
required by the computer. Typical computer power supplies produce a DC voltage of
about 20 volts.
Because these power supplies are usually connected by a flexible cable between
the power supply and the computer, these cables may be subject to bending, which
can eventually lead to an open wire in the connecting cord.
While the computer’s motherboard may actually use several different voltages in
different parts of its circuit, the output power provided by the power supply is
just a single voltage, which is typically about +20 V DC.
Many computer power supplies use a standard IEC power connector to make the power
cord connection. While IEC standards are typically thought of as European
standards, manufacturers will use this connector with a power cord appropriate
for the electrical power outlets found in the U.S.
Aging of the power supply should have no effect on its output impedance. Aging of
the batteries in the laptop will generally lead them to have a decreased capacity
as time goes on. However, the ability of a power supply to recharge the batteries
does not change over time.
Reference:
[1] Wolfe, Glen L., Is It Turned On? Troubleshooting Power Supplies, Biomedical
Instrumentation & Technology, January 2007, Volume 41, Number 1, pages 48-49
Q857EXPL
The goal of device integration is to send data produced by a medical device
directly into an electronic medical record on a real-time basis. Generally, what
the EMR tries to record are device settings (such as the oxygen percentage and
respiration rate delivered by a ventilator) and patient measurements (such as the
heart rate displayed on a bedside monitor).
Device integration involves two kinds of medical devices. Networked devices

generally include equipment such as bedside monitors that send their data to a
central station. The servers that support the collection of data for the central
station typically can also aggregate the data from all devices on that network,
and then send the results into the electronic medical record system (EMR).
On the other hand, standalone devices would be those that do not usually
communicate with a central station. If their data is to go to an EMR, it needs to
travel via a different path. Examples of these kinds of devices would be
ventilators used in a critical care unit and anesthesia machines used in an
operating room. In order to send data from these devices into the EMR, the data
generally needs to be processed by a computer at the bedside. That computer needs
to do some preliminary processing of the data and then send the data on to an
application server that collects all of the data from the various medical
devices. That server then converts the data received from each medical device
into the HL7 messages that the EMR is designed to handle.
One problem with standalone medical devices is that the data produced by them
usually does not identify the device creating the data; that is, the data stream
usually contains information about the current device settings and the patient
measurements taken by the device, but the stream does not uniquely identify the
device that produced the data. Depending upon the type of middleware selected to
handle device integration, the middleware approaches the identification problem
in different ways. Some systems use a special adapter (or dongle) that connects
to the cable coming out of the device and then adds an electronic signature to
the data stream, allowing the identity of the originating device to be
encapsulated in the data stream. Other systems add this identifying data into the
data stream using software incorporated into the bedside computer.
So, in general, the path followed by data transmission from a standalone device
is that the data is first sent by a serial cable into a bedside computer, then
the bedside computer sends data to the device integration application server,
which then converts the incoming messages into the HL7 format required by the
EMR. Depending upon the device integration solution adopted by the hospital,
there may need to be an appropriate dongle (data adapter) added to the cabling
between the medical device and the bedside computer to allow the association of
the data stream with a particular device.
802.11 is a wireless communication standard that identifies how data will be sent
over a wireless network. ICD-9 (Internatonal Classification of Dieases, 9th
edition) is used to identify diagnoses and procedures are part of a billing
process. It is not used as part of the data transmission process.
RS-232 is a type of communications port on the back of a piece of equipment that

produces a serial data stream. RS-232 messages cannot be used directly by an EMR.
The EMR will only accept HL7 messages.
DICOM is a standard that identifies how digital images will be sent and stored.
DICOM messages are sent to a PACS (picture archiving and communications system),
not to an EMR.
The messages coming out of a medical device cannot be sent directly to an EMR.
The format of those messages must be converted to an appropriate HL7 format in
order for the EMR to utilize the information.
Reference:
[1] Moorman, Bridget, Biomedical Device Interfacing to Clinical Information
Systems: A Primer, Biomedical Instrumentation and Technology, May/June 2008,
Volume 42, pages 205-208,
https://www.aami.org/cemc/resources/Biomedical%20Device%20Interfacing.pdf,
Q887EXPL
IP (Internet Protocol) addresses identify the location of computers on the
Internet. These addresses can range from 0.0.0.0 through 239.255.255.255.
While most addresses are public addresses, meaning that a computer identified
with that address can be reached by any other computer that is also on the
Internet, there are some reserved addresses that are used for private networks,
i.e., networks which cannot be reached directly from the Internet. Typically,
private addresses are used by computers within a certain location, so that they
can reach each other. When those computers need to reach other computers on the
Internet, they send requests through a gateway that translates their private
address into a public address that can be seen by other computers on the
Internet. Generally, many computers on a private network will share a single
public address.
Private addresses are in the following ranges:

10.0.0.0 through 10.255.255.255
172.16.0.0 through 172.31.255.255
192.168.0.0 through 192.168.255.255
In addition, certain IP addresses are reserved as multicast addresses. These are

addresses assigned to hosts on a computer network. The reserved range for
multicast addresses is 224.0.0.0 through 239.255.255.255.
All other allowable IP addresses are public addresses.
In this case, since the address 172.16.25.126 falls into the reserved range for
private addresses, this must be a private IP address.
CIDR refers to Classless Inter-Domain Routing. It is a method for both allocating

IP addresses and routing IP packets. It replaced the older class-based IP address
allocation model, where addresses were assigned in blocks known as Class A, B or
C types. By the early 1990s, it was clear that this old assignment model would
quickly lead to exhaustion of the available IP addresses, so the CIDR model
replaced it.
In the CIDR model, the information about the subnet mask is replaced by a single
forward slash, followed by a decimal number. This number identifies the number of
1s in the subnet mask, when the mask is written in binary notation.
The subnet mask 255.255.255.224 could be written in binary notation as

11111111.11111111.11111111.11100000, because 255 decimal is 11111111 in binary,
while 224 decimal is 11100000 in binary. Counting the number of 1s that appear in
the subnet mask, when written this way, we find that there are 27 ones.
Therefore, in CIDR notation, the IP address would be written as 172.16.25.126/27.
Therefore, this is a private IP address with a CIDR prefix of 27.
Reference:
[1] Networking 101: Understanding Subnets and CIDR, Enterprise Networking Planet
website,
http://www.enterprisenetworkingplanet.com/netsp/article.php/3566521/Networking-
101-Understanding-Subnets-and-CIDR.htm, retrieved November 29, 2014
[2] Address Classes, Microsoft TechNet website, http://technet.microsoft.com/en-
us/library/cc940018.aspx
Q907EXPL
Solid-state drives offer all of the advantages noted in the question including
local storage, high speed access, small size, low power consumption, high
reliability and durability when exposed to shock or vibration.
The focus of a RAID storage solution is on providing redundant storage of data in

a way that allows full recovery of the data even in the event of the failure of
some parts of the storage system. Typically, a RAID system will include multiple
hard drives that are connected together in a way that allows redundant storage of
data, so that if one hard drive fails, the data is still available on the other
drives in the system. A RAID system typically is relatively large because it
contains several hard drives.
Network-attached storage and cloud storage are not local storage solutions.
Generally, these provide data storage at a remote, usually centralized, location.
References:
[1] Drossel, Gary, Medical Design technology: Solid State Storage for Medical
Equipment Applications, Medical Design Technology, 2008,
http://www.mdtmag.com/articles/2008/02/solid-state-storage-medical-equipment-
applications, retrieved December 2, 2014
[2] Rouse, Margaret, Fast Guide to Storage Technologies, WhatIs.com website,
http://whatis.techtarget.com/reference/Fast-Guide-to-Storage-Technologies,
Q921EXPL
Latency is the time it takes for a packet of information to cross a network
connection, from a sender to a receiver. An increase in time for information to
travel from the source to its destination is indicative of a latency issue with
the network.
If there is a problem with the IP address, then the information would never
arrive at its intended destination.
If there was a drug library issue, then the drug library would either not be
updated with new information or may be updated incorrectly. This would not be
isolated to a single nursing unit. If the problem were affecting all nursing
units, then it might be explained by a server's inability to reach the drug
library, which could account for the delay. However, since the question makes
clear that this is only affecting a single unit, the drug library could not be to
blame.
A CPOE system is a clinical information system that enables a patient’s care

provider to enter an order for a medication, clinical laboratory, radiology test,
or procedure directly into a computer. If there were a CPOE system or pump server
issue, then the problem would not be isolated to a single unit.
If the pump server or the CPOE system are not communicating at all, then no
prescription would be sent.
References:
[1] AAMI Foundation HTSI Safety Innovations: Best Practice Recommendations for
Infusion Pump-Information Network Integration, Association for the Advancement of
Medical Instrumentation, 2012,
http://www.aami.org/htsi/SI_Series/Infusion_Pump_Network_Integration.pdf,
[2] Latency, Dictionary.com website,
http://dictionary.reference.com/browse/latency?s=t, retrieved December 10, 2014
[3] Gibbs, Mike, and Quillen, Howard, The Medical-Grade Network: Helping
Transform Healthcare, Cisco Internet Business Solutions Group, 2007,
http://www.cisco.com/web/strategy/docs/healthcare/07CS1034_HC_Whitepaper_r5.pdf,
[4] Pettus, Dan C., and Vanderveen, Tim, Worth the Effort? Closed-Loop Infusion
Pump Integration with the EMR, Biomedical Instrumentation & Technology, 47.6
(2013), pages 467-477
Q922EXPL
H.323 is a protocol used to transmit voice and video information over IP
networks. More and more operating room (OR) video equipment manufacturers are
designing equipment that sends signals over the hospital’s standard IP network,
so these companies are adopting standard communication protocols from the IT and
telecommunications industry to accomplish this transmission. Protocols like H.323
are used for communication between devices and subsystems within the OR and for
video conferencing outside of the OR.
Reference:
[1] H.323, Wikipedia, http://en.wikipedia.org/wiki/H.323, retrieved December 12,
2014
Q923EXPL
Since the physiological monitoring system communicates with the hospital’s
standard IT network, it is very likely that it can send any requested print jobs
to any printer already on the network. Assuming this is the case, then routing
the ECGs to the existing printer is the simplest, and most cost-effective answer,
since it will require no additional space and no additional funds, aside from the
expense associated with reconfiguring the monitoring system to send print jobs to
the existing printer. This expense is likely to be minimal.
Purchasing a new printer, whether to be stacked on top of the existing printer,

or to replace the existing printer with a larger, faster printer, would require
additional funds. In fact, the work required to program the larger, faster
printer to accept both the current print jobs now being handled by the current
printer, along with the ECGs from the physiological monitor, is virtually the
same as programming the existing printer to accept the ECGs.
Purchasing a print server would not provide any benefit. The job of a print
server is to allow a printer that is not connected directly to the network to
receive print jobs sent over the network. The existing printer is already a
network printer, so a print server is not needed.
Reference:
[1] Print server, Wikipedia, http://en.wikipedia.org/wiki/Print_server, retrieved
December 12, 2014
Q924EXPL
In order for data to cross from the physiological monitor into the electronic
health record (EHR) system, the data must have a label recognized by the EHR. If
the nurse has selected an incorrect label, the data either will not cross into
the patient’s record or will be put into the wrong row in the record.
For example, the monitor may allow the nurse to select from the labels ART or ABP
for the arterial blood pressure, but if the EHR is expecting to see the label ART
attached to arterial blood pressure values, and the nurse has selected ABP, the
EHR will reject the data. In general, the only symptom seen by the nurse will be
the failure to see the data where it is expected to be filed. In most cases, the
nurse will not see an error message.
Although the other answers are possible, it is very unlikely that the
physiological monitor, central station or EHR are malfunctioning in such a way to
cause only the blood pressure values to not show in the EHR. In general, if even
one physiological parameter is crossing over into the EHR from the physiological
monitor, then it is safe to assume that the monitor, central station, and EHR
system are all working properly when it comes to data production and flow.
Note that while many hospitals use the terminology electronic health record and
electronic medical record interchangeably, others refer to the overall system as
an EHR system, and to the individual patient's record that is replacing the older
paper charts as an EMR. Currently, the US federal Office of the National
Coordinator for Health Information Technology (ONC) prefers the term EHR to show
that it considers electronic health records as being a comprehensive repository
of health information about a patient designed to be shared with other healthcare
providers, not just the particular institution that originally collected the
data.
Reference:
[1] Garrett, Peter and Seidman, Joshua, EMR vs EHR - What is the Difference?,
Health IT Buzz, ONC, http://www.healthit.gov/buzz-blog/electronic-health-and-
medical-records/emr-vs-ehr-difference/, retrieved May 13, 2015
Q951EXPL
CAT 5 cable, and its successors, CAT 5e and CAT 6 cable, are used to connect
computers to Ethernet networks. These cables all have four pairs of twisted wires
in them, for a total of eight wires. The type of connector generally used to make
this connection is an RJ-45 connector. An RJ-45 connector is also known as an
8P8C (for 8 position, 8 connection) connector. RJ stands for "registered jack."
Although RJ-45 was first used to connect telephone hardware, today it is more
commonly used to connect computers. A hospital example would be connecting a
bedside patient monitor in an intensive care room to the central monitor system.
An RJ-11 jack is a 6P4C connector which is typically used in residential

telephone systems.
An RJ-12 jack is the same physical size as an RJ-11 jack, but it is a 6P6C
connector. It is typically used in a telephone system with multiple lines.
An RJ-31X jack is an 8P8C connector that is typically used in a residential

security system. The wiring in this jack allows a security system to seize the
telephone line when an alarm is generated, so that the system can communicate
with an alarm monitoring service. When this happens, the telephone line going to
the other telephones in the residence is cut off.
References:
[1] Falwell, Elizabeth, What Is the Meaning of RJ-45? eHow website,
http://www.ehow.com/info_8650321_meaning-rj45.html, retrieved November 29, 2014
[2] Noblitt, John, The CBET and Networking, 24X7, December 9, 2010,
http://www.24x7mag.com/2010/12/the-cbet-and-networking, retrieved November 29,
2014
Q1021EXPL
A RAID system is a method of using multiple disk drives to provide redundant
storage of data. While RAID 1 only provides for data redundancy, other RAID
levels (levels 2, 3, 4, 5 and 6) also can provide performance improvement,
depending upon how they are implemented. (Note that RAID 0 is a special case,
which provides performance improvement, but does not provide redundancy.) By
distributing data across several disk drives, it is possible to completely
prevent data loss in the case of a single drive failure, or, with some systems,
multiple drive failures.
RAID 1 achieves redundancy by using two disks that are mirror images of each
other. That way, if a single drive fails, the system will still keep operating
properly. When the drive that has failed is replaced, the RAID controller will
automatically rebuild the new drive that has been placed into service so that it
contains all of the data on the remaining drive.
A RAID 0 system is one that provides only performance improvement, but not
redundancy, so that a RAID 0 system will not continue to work in the case of the
failure of a single drive. To recover from the failure of a RAID 0 system, data
will need to be restored from an offline backup.
A RAID 5 system can provide for both performance improvement and reduncancy.
However, it requires a minimum of three disks.
Regardless of the level of RAID implemented in any mission-critical system, such

as a fetal monitoring system, any failures need to be quickly addressed,
generally by replacing any failed disk drives, so that there is continued
assurance against data loss.
Reference:
[1] Standard Raid Levels, Wikipedia,
http://en.wikipedia.org/wiki/Standard_RAID_levels#RAID_1, retrieved January 25,
2015
Q1014EXPL
Because so many modern medical devices incorporate computers in their internal
control systems, BMETs need to have a basic understanding of computer systems, IT
networking, cable installation, and troubleshooting in order to determine which
components and subsystems need to be installed or repaired. Various signal
modifiers are often required to move clinical data from the medical device to the
EHR (Electronic Health Record). For example, the medical device may output data
in a serial digital format that needs to be converted to the TCP/IP protocol used
by the hospital's ethernet network. Then another subsystem may be needed to
convert that TCP/IP data into an HL7 format so that the EHR can understand it.
BMETs typically would not be writing computer programs. Modifying FDA-approved

systems is almost never allowed by the healthcare delivery organization (HDO).
Equipment modifications generally require manufacturer quality control reviews
and approvals that fall under FDA quality management requirements.
Licensed medical personnel, not BMETs, interpret clinical data for patient care.
Typically, IT (information technology) staff, not BMETs, configure the switches

and routers that are part of the HDO's IT network.
Reference:
[1] Biomedical Device Interfacing to Clinical Information Systems: A Primer,
Moorman, Bridget, Biomedical Instrumention & Technology, May 2008, Vol. 42, No.
3, pages 205-208, http://aami-bit.org/doi/pdf/10.2345/0899-
8205%282008%2942%5B205%3ABDITCI%5D2.0.CO%3B2, access requires AAMI account,
retrieved June 27, 2018.
Q1015EXPL
When installing CAT6 cable, it should be tested for physical length, wiring
errors, end-to-end pin-to-pin errors, signal loss, crosstalk, impedance
mismatches and propagation delay.
Do not untwist twisted pair cable any more than necessary to terminate. The cable
is intentionally twisted to reduce noise and crosstalk. It should never be
untwisted more than one-half inch to maintain its specifications.
The maximum CAT6 cable length is 100 meters. When used in a 10GBase-T network,
the maximum allowable length for CAT6 cable is 55 meters. If a longer run is
needed, CAT6A can be used for a run of up to 100 meters and still meet the
10GBase-T network specifications.
References:
[1] Twisted Pair Definition, http://www.linfo.org/twisted_pair.html, retrieved
July 15, 2018
[2] Cat 6, http://www.tech-faq.com/cat-6.html, retrieved July 15, 2018.
[3] 10 Gigabit Ethernet,

https://en.wikipedia.org/wiki/10_Gigabit_Ethernet#10GBASE-T, retrieved July 15,
2018.
Q2032EXPL
Health Level-7 or HL7 refers to a set of international standards for the transfer
of clinical and administrative data between software applications used by various
healthcare providers. HL7 messages are constructed in a standard format to allow
the many different systems found in hospitals to exchange information. Examples
of systems that use HL7 messages include electronic medical record systems,
patient monitoring systems, and billing systems.
HL7 messages use different type of separators to identify each part of the
message.
Segment separator: carriage return
Field separator: vertical bar or pipe (|)
Component separator: caret (^)
Subcomponent separator: ampersand (&)
Truncation separator: hashtag (#)
References:
[1] HL7 Tutorial Part Two: Understanding HL7 Message Structure,
http://www.hl7soup.com/HL7TutorialUnderstandingHL7MessageStructure.html,
[2] HL7 Message Components, https://blog.interfaceware.com/components-of-an-hl7-

message, retrieved September 7, 2018.
[3] Health Level 7, https://en.wikipedia.org/wiki/Health_Level_7, retrieved

September 7, 2018.
Q2033EXPL
Health Level-7 or HL7 refers to a set of international standards for the transfer
of clinical and administrative data between software applications used by various
healthcare providers. HL7 messages are constructed in a standard format to allow
the many different systems found in hospitals to exchange information. Examples
of systems that use HL7 messages include electronic medical record systems,
patient monitoring systems, and billing systems.
The OBX segment is the part of an HL7 message that carries key clinical
observation results. This segment always starts with the letters OBX. A single
HL7 message can have as many OBX segments as needed to carry all of the
observations that the sending system is transmitting. One OBX segment can only
transmit a single observation.
An HL7 message always starts with the message header, which is indicated by the
prefix MSH. Therefore, the OBX segment can never be at the very beginning of an
HL7 message.
Some HL7 messages do not contain OBX segments.
References:
[1] HL7 OBX - Observation Segment, https://corepointhealth.com/resource-
center/hl7-resources/hl7-obx-segment, retrieved September 7, 2018.
[2] HL7 Tutorial Part Two: Understanding HL7 Message Structure,

http://www.hl7soup.com/HL7TutorialUnderstandingHL7MessageStructure.html,
[3] HL7 Message Components, https://blog.interfaceware.com/components-of-an-hl7-

message, retrieved September 7, 2018.
[4] Health Level 7, https://en.wikipedia.org/wiki/Health_Level_7, retrieved
September 7, 2018.

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Certified

Healthcare technology management professionals that desire a CBET certification

 Test and calibrate medical devices (preventive maintenance)

- The CBET exam is a three-hour closed book exam

Weight = 77 kg X 2.2 lb/kg

Meningitis is the inflammation of the meninges, a brain membrane.

Sepsis is a widespread infection of bacteria in the body, not specific to the

Sinusitis is the inflammation and congestion of the sinuses due to an infection.

Body temperature is primarily regulated by hormones that are secreted by the

The blood-brain barrier is not reliant on either a thick physical membrane, or

The gray matter is surrounded by white matter, which consists of groups of

It also serves as a primary storage location for essential nutrients, vitamins,

Blood glucose regulation is primarily the function of the pancreas. Glucose

Neurology is the study of the nervous system.

Pulmonology is a study of the respiratory system and especially the lungs.

The ovary is classified as an endocrine gland and as a female reproductive organ.

The reproductive system is affected by some of the hormones produced by some of

A urologist specializes in treating disorders of the male and female urinary

A pulmonologist specializes in disorders associated with the pulmonary system and

A cardiologist treats conditions associated with the heart.

The pancreas is a fish-shaped, digestive system organ that secretes pancreatic

Omega cells do not exist.

Each nephron contains a structure known as a Bowman’s capsule. Inside that

In later sections of the nephron (the peritubular capillaries), those chemicals

The pancreas is also an organ in the digestive system, as well as being an

[2] Human Skin, https://en.wikipedia.org/wiki/Human_skin, retrieved September 3,

[3] Integumentary System, https://en.wikipedia.org/wiki/Integumentary_system,

Hypodermic is an adjective that means below (hypo) the skin (dermis). A

Dermatitis is a noun that means inflammation (itis) of the skin (dermis).

Subcutaneous refers to something happening under the skin. A subcutaneous

During an eye examination (funduscopy), the ophthalmoscope is the instrument used

[2] Ophthalmoscope, https://www.britannica.com/technology/ophthalmoscope,

[3] Iris (anatomy), https://en.wikipedia.org/wiki/Iris_(anatomy), retrieved

{4} Cornea, https://en.wikipedia.org/wiki/Cornea, retrieved September 10, 2018.

[5] Lens (anatomy), https://en.wikipedia.org/wiki/Lens_(anatomy), retrieved

[6] Retina, https://en.wikipedia.org/wiki/Retina, retrieved September 10, 2018.

Cystometric studies are also called cystometrograms or CMGs.

[2] Cystometric Study, https://www.healthline.com/health/cystometric-study,

[3]Why Would I Need a Urodynamic Test?,

where A and B are the inputs to the gate.

The truth table for a NAND gate is:

The truth table for an Exclusive-OR gate is:

The logic equation for gate 1, a NAND gate, is:

Where A and B are the inputs to the gate.

In this case, the differential voltage gain, Ad is:

Similarly, the common-mode voltage gain, Acm is:

Acm = 1.0 volt / 10 volts

The common-mode rejection ratio, CMRR, is:

This could also be expressed as a common-mode rejection ratio of 20,000:1.

It is important to realize that reactions to current have been found to

Current Level Reaction

5 mA Maximum harmless current

10 - 20 mA "Can't let go" reaction

50 mA Pain, exhaustion, fainting

100 - 300 mA Ventricular fibrillation

6A Sustained myocardial contraction, burns

Reference: National Fire Protection Association, ANSI/NFPA 70:2011 - National

* reducing internal equipment leakage current;

* continuously monitoring the continuity of the ground wire, so that corrective

* adding an additional ground wire (a redundant ground) in parallel with the

* periodically inspecting the ground-connection integrity of equipment; and

Ohmic heating, caused by the intentional generation of heat, for example, in a

Undersized conductors in a wire can cause heating in a power cord, or in other

An additional control on the oscilloscope is the trigger control. This control