Pilbeams Mechanical Ventilation

Physiological and Clinical Applications

6th Edition Cairo Test Bank
Go to download the full and correct content document:
https://testbankfan.com/product/pilbeams-mechanical-ventilation-physiological-and-cli
nical-applications-6th-edition-cairo-test-bank/
More products digital (pdf, epub, mobi) instant
download maybe you interests ...

Pilbeams Mechanical Ventilation Physiological and

Clinical Applications 5th Edition Cairo Test Bank

https://testbankfan.com/product/pilbeams-mechanical-ventilation-
physiological-and-clinical-applications-5th-edition-cairo-test-
bank/

Mechanical Vibrations Theory and Applications 1st

Edition Kelly Solutions Manual

https://testbankfan.com/product/mechanical-vibrations-theory-and-
applications-1st-edition-kelly-solutions-manual/

Nutritional Foundations and Clinical Applications A

Nursing Approach 6th Edition Grodner Test Bank

https://testbankfan.com/product/nutritional-foundations-and-
clinical-applications-a-nursing-approach-6th-edition-grodner-
test-bank/

Nutritional Foundations and Clinical Applications 5th

Edition Grodner Test Bank

https://testbankfan.com/product/nutritional-foundations-and-
clinical-applications-5th-edition-grodner-test-bank/
Mechanical Vibrations 6th Edition Rao Solutions Manual

https://testbankfan.com/product/mechanical-vibrations-6th-
edition-rao-solutions-manual/

Rodaks Hematology Clinical Principles and Applications

5th Edition Keohane Test Bank

https://testbankfan.com/product/rodaks-hematology-clinical-
principles-and-applications-5th-edition-keohane-test-bank/

Molecular Diagnostics Fundamentals Methods and Clinical

Applications 2nd Edition Buckingham Test Bank

https://testbankfan.com/product/molecular-diagnostics-
fundamentals-methods-and-clinical-applications-2nd-edition-
buckingham-test-bank/

Clinical Kinesiology and Anatomy 6th Edition Lippert

Test Bank

https://testbankfan.com/product/clinical-kinesiology-and-
anatomy-6th-edition-lippert-test-bank/

Nursing Interventions and Clinical Skills 6th Edition

Perry Test Bank

https://testbankfan.com/product/nursing-interventions-and-
clinical-skills-6th-edition-perry-test-bank/
Chapter 10: Assessment of Respiratory Function
Cairo: Evolve Resources for Pilbeam’s Mechanical Ventilation: Physiological and
Clinical Applications, 6th Edition

MULTIPLE CHOICE

1. A pulse oximeter differentiates oxyhemoglobin from deoxygenated hemoglobin by which of

the following methods?
a. Relating cyclical changes in light transmission through the sampling site.
b. Shining and comparing two wavelengths of light through the sampling site.
c. Direct measurement by a heated polarographic electrode applied to the skin.
d. Using a color sensing device that absorbs one wavelength of light through the skin.
ANS: B
A pulse oximeter uses spectrophotometry to differentiate between oxyhemoglobin and
deoxygenated hemoglobin. Two wavelengths of light (660 and 940 nm) are shined through a
sample site. Oxyhemoglobin absorbs more light at 940 nm (infrared [IR] light) than does
deoxygenated hemoglobin. Deoxyhemoglobin absorbs more light at 660 nm. The use of
cyclical changes in light transmission measured at the sampling site is the method to
determine the pulse rate with a pulse oximeter. A heated polarographic electrode is used for
transcutaneous partial pressure of oxygen (PtcO2) measurements. A color sensing device is
used to detect the amount of carbon dioxide in exhaled gas.

REF: pg. 161 | pg. 162

2. An arterial blood gas should be done to confirm pulse oximetry findings less than a minimum
of _____________.
a. 60%
b. 70%
c. 80%
d. 90%
ANS: C
When a patient’s oxygen saturation measured by pulse oximeter (SpO2) is less than 80% an
arterial blood gas should be drawn to confirm the patient’s oxygenation status because a pulse
oximeter is generally accurate for oxygen saturations greater than 80%.

REF: pg. 162

3. A pulse oximeter reading will be most accurate when used with a patient in which of the
following situations?
a. An intensive care unit patient with hyperbilirubinemia
b. A hypotensive patient receiving peripheral vasoconstrictors
c. An emergency department patient with evidence of smoke inhalation
d. An open heart patient receiving extracorporeal membrane oxygenation
ANS: A
 Hyperbilirubinemia does not appear to affect pulse oximetry measurements as do low
perfusion states, which are caused by the use of peripheral vasoconstrictors or extracorporeal
membrane oxygenation (ECMO). Carbon monoxide poisoning will lead to an overestimation
of oxygen saturation measured by pulse oximeter (SpO2).

REF: pg. 164

4. A patient arrives in the emergency department via ambulance following rescue from a house
fire. The instrument that would be most appropriate to assist the respiratory therapist in
assessing this patient’s oxygenation status is which of the following?
a. Capnograph
b. Pulse oximeter
c. Calorimeter
d. CO-oximeter
ANS: D
Laboratory CO-oximeters measure four types of hemoglobin: oxyhemoglobin (O2Hb),
deoxygenated hemoglobin (HHb), carboxyhemoglobin (COHb), and methemoglobin
(MetHb). This is beneficial for patients who are suffering from smoke inhalation. The
CO-oximeter provides the actual O2Hb and the COHb. Carbon monoxide produces an
erroneously high oxygen saturation measured by pulse oximeter (SpO2). Therefore, if smoke
inhalation is suspected, a CO-oximeter should be used to evaluate the oxygen saturation.
Capnography is the measurement of carbon dioxide concentrations in exhaled gases and is
used to assess proper airway placement. Calorimetry allows the clinician to estimate energy
expenditure from measurements of oxygen consumption (O2) and carbon dioxide production
(CO2). This measurement may be useful when weaning a patient from mechanical ventilation.

REF: pg. 163

5. While trying to use a finger probe to assess a patient’s oxygenation status, the respiratory
therapist finds that the pulse rate and the ECG monitor heart rate are not consistent and the
oxygen saturation measured by pulse oximeter (SpO2) reading is blank. The patient is awake,
alert, and in no obvious respiratory distress. The respiratory therapist should first take which
of the following actions?
1. Change the probe site.
2. Draw an arterial blood gas.
3. Adjust the probe position on the finger.
4. Remove the probe, and perform a capillary refill test.
a. 1 and 2 only
b. 2 and 3 only
c. 3 and 4 only
d. 1 and 4 only
ANS: C
 The fact that the patient is awake, alert, and in no respiratory distress decreases the likelihood
that the problem is with the patient. Therefore, the first action in this case should not be to
draw an arterial blood gas (ABG). In cases where the pulse oximeter cannot identify a
pulsatile signal, the oxygen saturation measured by pulse oximeter (SpO2) reading may not be
present. This could be alleviated by adjusting the probe position on the finger. Absent SpO2
readings could also be due to low perfusion states. Performing a capillary refill test on the
finger being used for the probe would show whether or not the finger has adequate blood
flow. If this is true, the next step would be to change the site.

REF: pg. 163

6. Pulse oximetry is most useful in which of the following situations?

a. Determining when to extubate an adult
b. Prescribing oxygen therapy for neonates
c. Monitoring patients undergoing chest physical therapy
d. Establishing initial oxygen necessity for home care patients
ANS: C
The oxygen status of a patient being considered for extubation needs to be assessed by an
arterial blood gas, not by pulse oximetry, because not only does the patient’s oxygen status
need assessment, but the acid-base balance does as well. Pulse oximetry is not used as a basis
for prescribing oxygen therapy in neonates. Neonatologists prefer to base oxygen therapy
decisions on arterial partial pressure of oxygen (PaO2) rather than oxygen saturation. Pulse
oximetry is useful for monitoring the oxygen status of patients undergoing chest physical
therapy because it gives immediate results and is used for continuous monitoring. Pulse
oximetry may not be as useful in prescribing oxygen therapy for home care patients.

REF: pg. 164

7. During which phase of a capnograph does alveolar gas containing carbon dioxide (CO2) mix
with gas from the anatomical airways and the CO2 concentration rises?
a. Phase 1
b. Phase 2
c. Phase 3
d. Phase 4
ANS: B
In phase 1, the initial gas exhaled is from the conducting airways, which contain low levels of
carbon dioxide (CO2) from inspired air. During phase 2, alveolar gas containing CO2 mixes
with gas from the anatomical airways and the CO2 concentration rises. In phase 3, the curve
plateaus as alveolar gas is exhaled. In phase 4, the concentration falls to zero.

REF: pg. 167 | pg. 168

8. During which phase of a capnogram does inhalation occur?

a. Phase 1
b. Phase 2
c. Phase 3
d. Phase 4
ANS: D
 During inhalation the capnogram will have a zero reading because there is no exhalation of
carbon dioxide (CO2). As soon as the exhalation phase begins there is rise of the waveform. In
phase 1, the initial gas exhaled is from the conducting airways, which contain low levels of
CO2 from inspired air. During phase 2, alveolar gas containing CO2 mixes with gas from the
anatomical airways and the CO2 concentration rises. In phase 3, the curve plateaus as alveolar
gas is exhaled. In phase 4, the concentration falls to zero because inspiration is occurring.

REF: pg. 167 | pg. 168

9. The respiratory therapist has just stopped postural drainage for a 24-year-old patient with
cystic fibrosis because of shortness of breath and slight cyanosis in the “head-down” position.
The respiratory therapist should recommend which of the following adjustments to therapy?
a. Continue postural drainage and monitor patient with capnography.
b. Use only upright or flat postural drainage positions and draw an arterial blood gas
(ABG).
c. Administer oxygen via nasal cannula and monitor with pulse oximetry.
d. Use a transcutaneous partial pressure of oxygen (PtcO2) monitor to assess the
extent of hypoxemia.
ANS: C
The presence of slight cyanosis and shortness of breath in the “head-down” position is
indicative of hypoxemia. The respiratory therapist should administer supplemental oxygen via
nasal cannula (possibly 1-2 L/min) and monitor the patient with a continuous pulse oximetry.
Capnography is not useful in detecting hypoxemia. Using flat postural drainage positions
where the head is not lower than the shoulders has not been proven to be effective.

REF: pg. 164

10. A patient receiving mechanical ventilation is being continuously monitored for oxygen
saturation measured by pulse oximeter (SpO2) for the past 48 hours. When initially applied,
the SpO2 and the arterial oxygen saturation (SaO2), as well as the pulse on the pulse oximeter,
ECG, and manual pulse, were consistent. During clinical rounds, the respiratory therapist
notices that although the probe is appropriately placed and capillary refill is normal, the SpO2
reading is down to 90% from 95%. The most appropriate immediate action is to do which of
the following?
a. Replace the probe.
b. Reposition the patient.
c. Draw an arterial blood gas.
d. Move the probe to a different site.
ANS: C
The oxygen saturation measured by pulse oximeter (SpO2) has dropped from 95% to 90%.
Since the SpO2 and arterial oxygen saturation (SaO2) previously correlated, this situation could
mean that the patient is becoming hypoxemic. The probe is appropriately placed, so changing
sites is not appropriate. The patient has already been checked for and has adequate circulation
to the site of the probe, so moving the probe to a site with more perfusion is not appropriate.
Therefore, the patient needs to have an arterial blood gas to ascertain the SaO2 and partial
pressure of oxygen (PaO2).

REF: pg. 162

11. The partial pressure of end-tidal carbon dioxide (PetCO2) reading is taken at what point in the
figure?

a. Point A
b. Point B
c. Point C
d. Point D
ANS: C
Point C shows the concentration of carbon dioxide (CO2) at the end of the alveolar phase, just
before inspiration begins. This occurs in phase 3 of the four phases of a capnogram. Point A
depicts phase 1, which is the initial gas exhaled from the conducting airways. As a person
exhales, the amount of CO2 in the exhaled gas increases. The amount of CO2 exhaled levels
off at point B. This coincides with phase 4 or the alveolar plateau. Point D is showing the fall
in CO2 that occurs during inspiration.

REF: pg. 167 | pg. 168

12. A patient in the intensive care unit is receiving mechanical ventilation, has a pulmonary artery
catheter in place, and is being monitored continuously with a capnometer. The patient’s
arterial partial pressure of carbon dioxide (PaCO2) is 41 mm Hg and the partial pressure of
end-tidal carbon dioxide (PetCO2) is 36 mm Hg. There is a sudden decrease in the PetCO2 to
18 mm Hg causing an alarm to sound. The most likely cause of this development is which of
the following?
a. Hypovolemia
b. Apneic episode
c. Pulmonary embolism
d. Increased cardiac output
ANS: C
Pulmonary embolism will cause a decrease in blood flow to the lungs. This increases alveolar
dead space and leads to a decrease in the partial pressure of end-tidal carbon dioxide (PetCO2).
Hypovolemia would also cause a decrease in the PetCO2, but it would not occur as suddenly as
it did in this situation. The fact that the patient has an indwelling pulmonary artery catheter
increases the risk of developing a pulmonary embolism, which often will have a quick onset.
An apneic episode would have increased the PetCO2. An increased cardiac output would
increase the PetCO2 because increases in cardiac output result in better perfusion of the alveoli
and a rise in PetCO2.

REF: pg. 170

13. The capnogram in the figure is indicative of which of the following conditions?

a. Chronic obstructive pulmonary disease (COPD)

b. Cardiac arrest
c. Hyperventilation
d. Pulmonary embolism
ANS: A
Phase 3 becomes indistinguishable when physiological dead space increases, as in chronic
obstructive pulmonary disease (COPD), and causes the capnogram to appear as it does in the
figure. A cardiac arrest would lower the graph line to zero. Hyperventilation will decrease the
alveolar plateau, but its shape would remain the same as a normal capnogram. A pulmonary
embolism would also cause a drop in the alveolar plateau.

REF: pg. 168

14. For a given minute ventilation, partial pressure of end-tidal carbon dioxide (PetCO2) is a
function of which of the following?
1. Metabolic rate
2. Cardiac output
3. Alveolar dead space
4. Physiologic shunt
a. 1 and 3 only
b. 1, 2, and 3 only
c. 2, 3, and 4 only
d. 1, 2, 3, and 4
ANS: B
Changes in metabolic rate cause changes in partial pressure of end-tidal carbon dioxide
(PetCO2). For instance, fever and shivering increase the metabolism and increase the PetCO2.
A change in cardiac output will change PetCO2 because the heart transports the blood that
carries the carbon dioxide (CO2) to the lungs for elimination. Increases in cardiac output will
increase PetCO2. A change in dead space ventilation will also cause changes in the PetCO2.
Increasing dead space will decrease the PetCO2.

REF: pg. 168

15. The normal range for arterial-to-end-tidal partial pressure of carbon dioxide [P(a-et)CO2] is
which of the following?
a. 2-4 mm Hg
b. 4-6 mm Hg
c. 6 -8 mm Hg
 d. 8-10 mm Hg
ANS: B
The arterial-to-end-tidal partial pressure of carbon dioxide [P(a-et)CO2] for tidal breathing
should be approximately 4-6 mm Hg.

REF: pg. 167

16. During shift report, the day shift respiratory therapist informs the night shift respiratory
therapist about a freshly postoperative patient who is receiving full support via mechanical
ventilation. At the time of the last patient-ventilator system check the patient had not awaken
from anesthesia. During first round on the day shift the respiratory therapist notes the
capnography shown in the figure. The most appropriate action to take would be to do which of
the following?

a. Administer a bronchodilator.
b. Begin the weaning process.
c. Fix the leak in the sampling line.
d. Reinflate the ET tube cuff.
ANS: B
The figure shows a patient whose capnography is demonstrating spontaneous respiratory
efforts during mechanical ventilation. This corresponds to the patient’s waking up from
anesthesia. With all else stable, the next step would be to begin the weaning process.

REF: pg. 171 | pg. 177

17. The area under the curve of a single-breath carbon dioxide (SBCO2) curve represents which of
the following?
a. Tidal volume
b. Alveolar dead space
c. Physiologic dead space
d. Effective alveolar ventilation
ANS: D
The area under the single-breath carbon dioxide (SBCO2) curve represents alveolar volume.
This is known as phase 3 on the SBCO2 curve. Phase 1 is the anatomical dead space volume.
Phase 2 is a transitional phase between anatomical dead space and alveolar volume.

REF: pg. 170 | pg. 171

18. The change in the single-breath carbon dioxide (CO2) curve from “A” to “B” shown in the
figure may be a result of which of the following?

a. Hypervolemia
b. Decreased positive end-expiratory pressure (PEEP)
c. Increased mean airway pressure
d. Excessive bronchodilator administration
ANS: C
The change in the figure shows an increase in phase 1 and a decrease in phase 2 of the
single-breath carbon dioxide (SBCO2) curve. An increase in phase 1 may be caused by an
increase in anatomical dead space. This is possible as a result of increased airway obstruction
or excessive positive end-expiratory pressure (PEEP). Therefore, answers “B” and “D” cannot
be correct. A decrease in phase 2 means there is a decrease in venous return or an increase in
intrathoracic pressure. This could be caused by hypovolemia or an increased intrathoracic
pressure as seen with increased mean airway pressures. Therefore, answer “A” cannot be
correct. Answer “C” is a measure of increased intrathoracic pressure and is the correct answer.

REF: pg. 170 | pg. 171

19. Which of the following situations will cause an increase in the single-breath carbon dioxide
(SBCO2) curve?
a. Decreased metabolic rate and decreased ventilation
b. Decreased metabolic rate and increased ventilation
c. Increased metabolic rate and increased ventilation
d. Increased metabolic rate and decreased ventilation
ANS: D
The same cause for an increase in arterial partial pressure of carbon dioxide (PaCO2) will
increase the single-breath carbon dioxide (SBCO2) curve. An increase in metabolic rate will
increase the carbon dioxide (CO2) production in the body. This, accompanied by either no
change in ventilation or a decrease in ventilation, will cause the amount of CO2 in the body to
increase and thus cause the amount of CO2 exhaled to increase. The only combination that will
do this is “D,” increased metabolic rate and decreased ventilation.

REF: pg. 170 | pg. 171

20. The area represented by the letter “Y” in the figure is which of the following?
 a. End-tidal carbon dioxide (EtCO2)
b. Alveolar ventilation
c. Alveolar dead space
d. Airway dead space
ANS: C
The end-tidal carbon dioxide (EtCO2) is represented by the very end of the waveform. The
alveolar ventilation is represented by the area under the curve, which is “X.” The alveolar
dead space is represented by the difference between the arterial partial pressure of carbon
dioxide (PaCO2) and the EtCO2 line, which is “Y.” The airway dead space is represented by
“Z.”

REF: pg. 171

21. A patient is receiving mechanical ventilation with a fractional inspired oxygen (FIO2) of 0.85
and a positive end-expiratory pressure (PEEP) of 5 cm H2O. His arterial partial pressure of
oxygen (PaO2) is 68 mm Hg, arterial oxygen saturation (SaO2) is 88%, and partial pressure of
end-tidal carbon dioxide (PetCO2) is 32 mm Hg. Over the next few minutes his PEEP is
titrated resulting in the following data:
Time FIO2 PEEP (cm SpO2 (%) PetCO2 (mm Hg)
H2O)
0600 0.85 5 88 30
0630 0.85 8 88 30
0650 0.85 10 90 32
0720 0.80 12 93 34
0740 0.80 15 90 25
At 0740 the single-breath carbon dioxide (SBCO2) curve shifted to the right. What action
should the respiratory therapist take at this time?
a. Increase the FIO2 to 0.90.
b. Reduce the set tidal volume.
c. Continue to increase the PEEP.
d. Reduce the PEEP to 12 cm H2O.
ANS: D
 The increase in positive end-expiratory pressure (PEEP) to 15 cm H2O seems to have
decreased pulmonary perfusion because of overinflation of the alveoli. This is evident by the
decrease in the partial pressure of end-tidal carbon dioxide (PetCO2) to 25 mm Hg and the
right shift in the single-breath carbon dioxide (SBCO2) curve. Increasing the fractional
inspired oxygen (FIO2) will not address this problem. Reducing the set tidal volume will
increase the PetCO2 but will not improve the pulmonary circulation. Continuing to increase the
PEEP will further reduce pulmonary perfusion and cause more dead space. Reducing the
PEEP back to 12 cm H2O will optimize the PEEP and reduce overinflation.

REF: pg. 170 | pg. 171

22. Exhaled nitric oxide is used to monitor the effectiveness of which drug used in the treatment
of asthma?
a. Anticholinergic bronchodilators
b. Beta adrenergic bronchodilators
c. Inhaled corticosteroids
d. Leukotriene inhibitors
ANS: C
Exhaled nitric oxide (NO) is currently used as a marker for airway inflammation associated
with asthma. Monitoring the level of exhaled NO can also be used to monitor the
effectiveness of inhaled corticosteroid in the treatment of asthmatic patients.

REF: pg. 172

23. The condition that is associated with a reduction in exhaled nitric oxide is which of the
following?
a. Alveolitis
b. Cystic fibrosis
c. Chronic bronchitis
d. Airway viral infection
ANS: B
See Box 10-3 in the text for a list of conditions that reduce and elevate levels of exhaled nitric
oxide.

REF: pg. 172

24. What type of electrode is used by a transcutaneous partial pressure of oxygen (PtcO2) device?
a. Galvanic
b. Polarographic
c. Paramagnetic
d. Stow-Severinghaus
ANS: B
A heated Clark or polarographic electrode is used to monitor the transcutaneous partial
pressure of oxygen. The Stow-Severinghaus electrode is used in the measurement of
transcutaneous carbon dioxide (CO2) partial pressure. Polarographic and Galvanic electrodes
are types of oxygen analyzers that use chemical reactions to measure oxygen concentrations in
gas mixtures.
 REF: pg. 172

25. To properly operate, the transcutaneous partial pressure of oxygen electrode needs to be at
what temperature range?
a. 32-35° C
b. 36-39° C
c. 42-45° C
d. 46-49° C
ANS: C
The transcutaneous partial pressure of carbon dioxide (PtcO2) electrode is heated to between
42° C and 45° C to produce capillary vasodilation below the surface of the electrode. This
will improve diffusion of gases across the skin. If the PtcO2 temperature is lower than this
range, the results will not be reliable. A temperature higher than this range will produce skin
burns.

REF: pg. 173

26. A transcutaneous partial pressure of oxygen (PtcO2) reading is reliable in which of the
following situations?
a. Hypothermia
b. Septic shock
c. Infant respiratory distress syndrome
d. Elevated peripheral (cutaneous) resistance
ANS: C
A reduction in cutaneous circulation will dramatically affect the measurement of
transcutaneous partial pressure of oxygen (PtcO2). This situation is caused by hypothermia,
septic shock, and elevated peripheral resistance. PtcO2 measurements have been shown to be
reliable for neonates.

REF: pg. 174

27. What type of electrode is used by a transcutaneous partial pressure of carbon dioxide (PtcCO2)
device?
a. Galvanic
b. Polarographic
c. Paramagnetic
d. Stow-Severinghaus
ANS: D
The Stow-Severinghaus electrode is used in the measurement of transcutaneous carbon
dioxide partial pressure. A Clark or polarographic electrode is used to monitor the
transcutaneous partial pressure of oxygen. Polarographic and Galvanic electrodes are types of
oxygen analyzers that use chemical reactions to measure oxygen concentrations in gas
mixtures.

REF: pg. 174

28. During calibration of a transcutaneous monitor the respiratory therapist notices a signal drift.
The respiratory therapist should do which of the following?
 a. Increase the probe temperature.
b. Replace the monitor and call for repair.
c. Add more electrolyte gel to the patient’s skin.
d. Change the electrolyte and sensor’s membrane.
ANS: D
A signal drift on a transcutaneous monitor should be addressed by changing the electrode and
sensor’s membrane. The electrode and the sensor’s membrane should be changed weekly due
to the evaporation of the electrolyte solution caused by the heating of the electrode. Increasing
the probe temperature may cause patient burns if it is over 45° C. The signal drift does not
necessarily mean that the monitor itself needs to be taken out of service. Adding more gel to
the patient’s skin will help with gas diffusion during measurement only.

REF: pg. 174

29. How often should the respiratory therapist reposition the sensor of a transcutaneous monitor?
a. 30 minutes to 1 hour
b. 1-3 hours
c. 4-6 hours
d. 7-9 hours
ANS: C
Burns can occur because the site of measurement needs to be heated to between 42° C and 45°
C. Repositioning the sensor every 4-6 hours will help avoid this problem.

REF: pg. 174

30. The clinical data that should be recorded when making transcutaneous measurements include
which of the following?
1. Electrode temperature
2. Skin temperature
3. Probe placement
4. Fractional inspired oxygen (FIO2)
a. 1 and 3 only
b. 1 and 2 only
c. 2, 3, and 4 only
d. 1, 2, 3, and 4
ANS: D
The electrode temperature must be documented to ensure that the temperature stays within the
range of 42-45° C. The skin temperature should be noted to assess the patient’s peripheral
perfusion. The probe placement should be noted to ensure that the probe is being moved to
different sites every 4-6 hours. The fractional inspired oxygen (FIO2) should be documented to
determine the need for an increase or decrease in the amount of supplemental oxygen the
patient is receiving.

REF: pg. 174

31. Components of an indirect calorimeter may include which of the following?

1. Pressure manometer
2. Pneumotachometer
 3. Pressure-sensitive transducer
4. Oxygen and carbon dioxide analyzers
a. 1 and 2 only
b. 2 and 4 only
c. 2, 3, and 4 only
d. 1, 2, 3, and 4
ANS: B
Indirect calorimeters contain analyzers for measuring the concentration of inspired and
expired gases, oxygen (O2) and carbon dioxide (CO2), pneumotachometers, turbine
flowmeters, or ultrasonic vortex flowmeters to measure volume and flow,
temperature-sensitive, solid-state transducers to measure barometric pressure and exhaled gas
temperatures.

REF: pg. 174 | pg. 175

32. An energy expenditure (EE) of 60 kcal/hr/m2 for an adult is indicative of which of the
following conditions?
a. Burns
b. Sedation
c. Starvation
d. Hypothermia
ANS: A
An energy expenditure (EE) of 30-40 kcal/hr/m2 is normal for an adult. The EE of 60
kcal/hr/m2 is greater than 120% of predicted and is considered a hypermetabolic state. Burns
create a hypermetabolic state. Starvation, sedation, and hypothermia create hypometabolic
states.

REF: pg. 177

33. An energy expenditure (EE) of 20 kcal/hr/m2 for an adult is indicative of which of the
following conditions?
a. Pregnancy
b. Starvation
c. Hyperthyroidism
d. Stimulant drugs
ANS: B
An energy expenditure (EE) of 30-40 kcal/hr/m2 is normal for an adult. The EE of 20
kcal/hr/m2 is less than 80% of predicted and is considered a hypometabolic state. Starvation
creates a hypometabolic state. Pregnancy, hyperthyroidism, and stimulant drugs create
hypermetabolic states.

REF: pgs. 175-177

34. The respiratory quotient (RQ) value associated with substrate utilization patterns in normal,
healthy individuals is which of the following?
a. 0.7
b. 0.8
c. 0.9
 d. 1.0
ANS: B
A healthy adult consuming a typical American diet will have a respiratory quotient (RQ)
range from 0.80-0.85. An RQ of 0.7 is indicative of lipid metabolism as seen in prolonged
starvation or severe sepsis. The RQ for the metabolism of pure carbohydrates is 1.0. An RQ of
0.9 would mean that the individual is consuming a higher amount of carbohydrates than a
normal diet.

REF: pg. 175

35. A patient whose carbon dioxide (CO2) production is 390 mL/min and oxygen (O2)
consumption is 375 mL/min is most likely experiencing which of the following?
a. Ketosis
b. Severe sepsis
c. Hyperventilation
d. Too much carbohydrate intake
ANS: C
The respiratory quotient (RQ) is the ratio of carbon dioxide (CO2) production to oxygen (O2)
consumption. This patient has an RQ (390/375) of 1.04. Ketosis causes the RQ to be less than
0.7. Severe sepsis is associated with RQ levels of approximately 0.7. Hyperventilation is
associated with RQ levels greater than 1.0. Pure carbohydrate RQ is 1.0.

REF: pgs. 175-177

36. A mechanically ventilated patient with chronic obstructive pulmonary disease is in the process
of being weaned from mechanical ventilation. A diet containing which of the following will
be most beneficial to this process?
a. High protein, low fats, and carbohydrates
b. Low fats and proteins, high carbohydrates
c. Low carbohydrate with increased fats and proteins
d. Equal amounts of carbohydrates, fats, and proteins
ANS: C
Diets with a high percentage of carbohydrates will raise the amount of carbon dioxide (CO2) a
patient produces. This will overburden a patient with limited ventilatory reserves, as with
chronic obstructive pulmonary disease (COPD). The added CO2 is greater than the patient’s
ventilatory capacity, and when attempting to maintain spontaneous breathing the patient will
fail to wean.

REF: pgs. 175-177

37. The newest types of mechanical ventilators use which of the following devices to measure
airway pressures?
a. Barometers
b. Aneroid manometers
c. Electromechanical transducers
d. Variable orifice pneumotachometers
ANS: C
 Barometers are used to measure atmospheric (barometric) pressure. Older ventilators
incorporated an aneroid manometer into the ventilator circuit. Variable orifice
pneumotachometers are used to measure flow. The devices that are used in the current
ventilators today are the electromechanical transducers, which include piezoelectric
transducers, variable capacitance transducers, and strain gauge transducers.

REF: pgs. 175-177

38. Which of the following actions is indicated when a disparity exists between SpO2, SaO2, and
the clinical presentation of a patient?
a. Move the probe to an alternate site to check for SpO2.
b. Replace the pulse oximeter probe.
c. Measure arterial oxygen saturation by CO-oximetry.
d. Disregarding the SaO2.
ANS: C
Laboratory CO-oximeters measure all four types of hemoglobin by using separate
wavelengths of light to identify each species, whereas pulse oximeters use only two
wavelengths to quantify the amount of O2HB and HHB present.

REF: pg. 163

39. To measure plateau pressure, inspiration should be held for how many seconds?
a. 1-2
b. 2-3
c. 3-4
d. 4-5
ANS: A
Plateau pressure requires the establishment of a period of no-flow for 1-2 seconds to allow
pressure equilibration by the redistribution of the tidal volume and stress relaxation. This
maneuver increases inspiratory time and if held longer than 2 seconds may cause barotrauma.

REF: pg. 178

40. Select the ventilator flowmeter that will read accurately when used with heliox.
a. Turbine
b. Vortex ultrasonic
c. Variable capacitance
d. Variable orifice pneumotachometer
ANS: B
Vortex ultrasonic flowmeters are not affected by the viscosity, density, or temperature of the
gas being measured. The turbine and variable orifice pneumotachometer will not be accurate
when using heliox because of its decreased density. A variable capacitance device is a
transducer used to measure airway pressure.

REF: pg. 178

41. Bidirectional flow can be measured by which of the following devices?

a. Turbine flowmeter
b. Piezoelectric transducer
 c. Ultrasonic vortex flowmeter
d. Variable orifice pneumotachometer
ANS: D
The turbine and ultrasonic flowmeters are inaccurate with bidirectional flows. The
piezoelectric transducer measures airway pressures. The variable orifice pneumotachometer is
a bidirectional flow measuring device.

REF: pg. 178

42. During the application of positive end-expiratory pressure (PEEP), the monitoring of which
pressure will alert the respiratory therapist specifically to alveolar overdistention?
a. Peak inspiratory pressure (PIP)
b. Plateau pressure (Pplateau)
c. Mean airway pressure
d. Transairway pressure (PTA)
ANS: B
The plateau pressure (Pplateau) is the pressure required to overcome only elastance. When
positive end-expiratory pressure (PEEP) is applied, the alveolar pressure will rise. This will
result in a higher Pplateau. If overdistention occurs the Pplateau will rise immediately. Peak
inspiratory pressure (PIP) reflects the total force that must be applied to overcome both
elastance and airway resistance offered by the patient-ventilator system. The mean airway
pressure represents the average pressure recorded during the entire respiratory cycle. It is
influenced by PIP, PEEP, inspiratory time, and total cycle time. The mean airway pressure is
not a specific monitor for optimizing PEEP. The PIP will increase in the face of alveolar
overdistention, but it is not specific enough to rely on as the sole measurement to identify
overdistention. The transairway pressure is the difference between the PIP and the Pplateau and
represents the amount of pressure needed to overcome airway resistance (all frictional forces).
The transairway pressure will not reflect alveolar overdistention because when alveolar
overdistention happens both the PIP and the Pplateau will rise, and the difference between the
two will remain constant unless there is an unrelated change in airway resistance.

REF: pg. 178

43. A patient-ventilator system check reveals the following information: peak inspiratory pressure
(PIP) 27 cm H2O, positive end-expiratory pressure (PEEP) 5 cm H2O, plateau pressure
(Pplateau) 14 cm H2O, inspiratory time (TI) 0.75 second, and set frequency 20/minute. Calculate
the mean airway pressure.
a. 6.75 cm H2O
b. 7.75 cm H2O
c. 11.75 cm H2O
d. 12.37 cm H2O
ANS: B
Total cycle time (TCT) = 60/frequency = 60/20 = 3 seconds. (P-macron)aw = [(PIP −
PEEP)  (TI/TCT)] + PEEP = [(27 − 5)  (0.75/3)] + 5 = (22  0.25) + 5 = 7.75 cm
H2O.

REF: pg. 178

44. A patient-ventilator system check reveals the following information: peak inspiratory pressure
(PIP) 32 cm H2O, positive end-expiratory pressure (PEEP) 12 cm H2O, plateau pressure
(Pplateau) 20 cm H2O, inspiratory time (TI) 1 second, and set frequency 12/min. Calculate the
mean airway pressure.
a. 4 cm H2O
b. 8 cm H2O
c. 12 cm H2O
d. 14 cm H2O
ANS: D
Total cycle time (TCT) = 60/frequency = 60/12 = 5. (P-macron)aw = [(PIP − PEEP) 
(TI/TCT)] + PEEP = [(32 − 12)  (1/5)] + 12 = (20  0.2) + 12 = 14 cm H2O.

REF: pg. 178

45. Calculate the dynamic compliance given the following clinical data: tidal volume 500 mL,
peak inspiratory time (PIP) 35 cm H2O, plateau pressure (Pplateau) 20 cm H2O, positive
end-expiratory pressure (PEEP) 5 cm H2O, and tubing compliance (CT) 2.5 mL/cm H2O.
a. 11.8 mL/cm H2O
b. 14.2 mL/cm H2O
c. 25 mL/cm H2O
d. 46.2 mL/cm H2O
ANS: B
Dynamic compliance = tidal volume (VT) − [(PIP − PEEP)  CT]/(PIP − PEEP) = 500 − [(35 −
5)  2.5]/(35 − 5) = 14.2 mL/cm H2O.

REF: pg. 180

46. Calculate dynamic compliance given the following clinical data: tidal volume 600 mL, peak
inspiratory pressure (PIP) 28 cm H2O, plateau pressure (Pplateau) 15 cm H2O, positive
end-expiratory pressure (PEEP) 10 cm H2O, and CT 2 mL/cm H2O.
a. 30.2 mL/cm H2O
b. 31.3 mL/cm H2O
c. 38 mL/cm H2O
d. 44.1 mL/cm H2O
ANS: B
Dynamic compliance = tidal volume (VT) − [(PIP − PEEP)  CT]/(PIP − PEEP) = 600 − [(28 −
10)  2]/(28 − 10) = (600 − 36)/18 = 31.3 mL/cm H2O.

REF: pg. 180

47. Calculate the static compliance given the following clinical data: tidal volume 500 mL, peak
inspiratory pressure (PIP) 35 cm H2O, plateau pressure (Pplateau) 25 cm H2O, positive
end-expiratory pressure (PEEP) 12 cm H2O, measured unintended positive end-expiratory
pressure (auto-PEEP) 3 cm H2O, and tubing compliance (CT) 2.5 mL/cm H2O.
a. 17.5 mL/cm H2O
b. 34 mL/cm H2O
 c. 36 mL/cm H2O
d. 47.5 mL/cm H2O
ANS: D
Static compliance = tidal volume (VT) − [(Pplateau − PEEP)  CT]/(Pplateau − PEEP) = 500 − [(25
− 15)  2.5]/25 − 15 = (500 − 25)/10 = 47.5 mL/cm H2O.

REF: pg. 180

48. Calculate the static compliance given the following clinical data: tidal volume 600 mL, peak
inspiratory pressure (PIP) 40 cm H2O, plateau pressure (Pplateau) 30 cm H2O, positive
end-expiratory pressure (PEEP) 15 cm H2O, and tubing compliance (CT) 2 mL/cm H2O.
a. 14.5 mL/cm H2O
b. 38 mL/cm H2O
c. 55 mL/cm H2O
d. 58 mL/cm H2O
ANS: B
Static compliance = tidal volume (VT) − [(Pplateau − PEEP)  CT]/(Pplateau − PEEP) = 600 − [(30
− 15)  2]/30 − 15 = 570/15 = 38 mL/cm H2O.

REF: pg. 180

49. Calculate the airway resistance given the following clinical data: flow rate 60 L/min, peak
inspiratory pressure (PIP) 42 cm H2O, plateau pressure (Pplateau) 15 cm H2O, and positive
end-expiratory pressure (PEEP) 5 cm H2O.
a. 10 cm H2O/L/sec
b. 30 cm H2O/L/sec
c. 37 cm H2O/L/sec
d. 42 cm H2O/L/sec
ANS: B
60 L/min = 1 L/sec. Raw = (PIP − Pplateau)/(L/sec) = (42 − 15)/1 = 30 cm H2O/L/sec.

REF: pg. 180

50. Calculate the airway resistance given the following clinical data: flow rate 60 L/min, PIP 28
cm H2O, Pplateau 21 cm H2O, and PEEP 8 cm H2O.
a. 7 cm H2O/L/sec
b. 13 cm H2O/L/sec
c. 20 cm H2O/L/sec
d. 28 cm H2O/L/sec
ANS: A
60 L/min = 1 L/sec. Raw = (PIP − Pplateau)/(L/sec) = (28 − 21)/1 = 7 cm H2O/L/sec.

REF: pg. 180

51. The energy required to move gas through the airways and expand the thorax is known as
which of the following?
a. Airway resistance
b. Dynamic compliance
 c. Intrinsic work of breathing
d. Extrinsic work of breathing
ANS: C
Intrinsic work of breathing is a result of work done to overcome normal elastic and resistive
forces and work to overcome a disease process affecting normal workloads in the lungs and
thorax. Airway resistance is the opposition to airflow from nonelastic forces of the lung.
Dynamic compliance is a measurement of the ease of movement of gas through the airways.
The work of breathing is a result of the airway resistance, dynamic compliance, and static
compliance.

REF: pg. 181

52. An increase in intrinsic work of breathing due to a decrease in static compliance is caused by
which of the following?
a. Emphysema
b. Bronchospasm
c. Pulmonary fibrosis
d. Airway inflammation
ANS: C
Static compliance is influenced by the elastic characteristics of the lungs and thorax. A
decrease in static compliance is due to either the lungs becoming stiffer or the thorax’s
inability to stretch to accommodate volume in the lungs. Pulmonary fibrosis is a
pathophysiologic condition that causes the alveoli to become stiffer due to scarring.
Therefore, pulmonary fibrosis will increase a patient’s work of breathing due to decreases in
the static compliance. Emphysema causes an increase in static compliance due to the loss of
elastic properties of the lungs and also an increase in airway resistance because of
bronchospasm, airway inflammation, and airway edema. Bronchospasm and airway
inflammation lead to increased airway resistance and decreased dynamic compliance.

REF: pg. 181

53. The best assessment of the function of the diaphragm during inspiration is obtained by
measuring which of the following?
a. Airway resistance
b. Pressure-time product
c. Pressure-volume curve
d. Maximum inspiratory pressure
ANS: B
The pressure-time product is a way of estimating the contributions of the diaphragm during
inspiration. It is probably a better indication of a patient’s effort to breathe than measurement
of work derived from pressure-volume curves. Airway resistance is a measure of how much
opposition there is to gas movement through the airways. An increase in airway resistance
will cause the diaphragm to work harder. However, airway resistance is not a direct way of
assessing the function of the diaphragm. Maximum inspiratory pressure provides nonspecific
information about the function of the respiratory muscles in general, not specifically the
diaphragm.

REF: pg. 181

54. At which point in the pressure-time curve of a spontaneous breath should the
transdiaphragmatic pressure be greatest?
a. Mid-inspiration
b. Mid-expiration
c. End of exhalation
d. Beginning of inspiration
ANS: A
The transdiaphragmatic pressure is the difference between the gastric and esophageal
pressures, as measured during the respiratory cycle. The greatest distance between these two
pressures during the respiratory cycle is at the middle of inspiration, when the esophageal
pressure is at its lowest point. At mid-expiration the gastric and esophageal pressure
difference is at its smallest point. See Figure 10-25.

REF: pg. 181

55. Which of these two parameters does a pulse oximeter measure?

1. O2Hb
2. Hb
3. COHb
4. MetHb
a. 1 and 2
b. 1 and 3
c. 2 and 3
d. 3 and 4
ANS: A
Pulse oximetry provides continuous, noninvasive measurements of arterial oxygen saturation.
A sensor is placed over a digit, an earlobe, the forehead or the bridge of the nose; this sensor
measures the absorption of selected wavelengths of light beamed through the tissue (Fig.
10-1). For example, oxyhemoglobin can be differentiated from deoxygenated hemoglobin by
shining two wavelengths of light (660 and 940 nm) through the sampling site. As Figure 10-2
illustrates, at a wavelength of 660 nm (red light), deoxygenated hemoglobin absorbs more
light than oxyhemoglobin. Conversely, oxyhemoglobin absorbs more light at 940 nm (infrared
light [IR]) than does deoxygenated hemoglobin.

REF: pg. 162

Another random document with
no related content on Scribd:
"Buy an horologue!" called one close to her ear. "The best sarcenet
sold here!" cried another. "Laces of all sorts can be had at the
Beehive!" bawled a third, thrusting himself in their way, and pointing
to his master's shop.

It was the seventeenth century method of advertising, and evidently

the 'prentice lads who were employed tried to get as much fun out of
it as possible, to the great annoyance of the passengers, who were
continually being pestered with the vociferating youths.

"Verily, I little wonder now that my mother liketh not the City," said
Audrey, who felt stunned and bewildered by the din of the shouting
'prentices.

Then there were the stalls where hot meat, sheep's feet, and other
such delicacies were sold, and a good many people still having their
dinner stood round the open tables placed along the edge of the
footpath.

"No, I don't like the City," concluded Audrey, as they walked up

Cheapside and began to look out for Soper Lane.

"The plague and the great fire hath made it a desolate place to
many, Mistress Audrey," said the nurse with a sigh, for she too had
sorrowful memories of that bitter time.

"My aunt lives close to the river, and not far from the garden of the
Dyers' Company," said Audrey, as they were looking down some of
the streets that had been recently rebuilt; for where they were
walking now the fire had raged and roared, sweeping down houses
and churches, so that all the place seemed uncomfortably new as
yet.

"I could never live in the City again, Mistress Audrey," said nurse.
"This is not like what it used to be in my young days; times are
altered, and not for the better either. The Lord-Protector ruled
England then—ruled it in righteousness; but the people were not
satisfied, they never are—and so they chose a godless king to rule
over them, and little wonder was it that God's judgment followed their
choice of King Charles."

"Hush, hush, nurse! They will say you are a Quaker or a Fifth
Monarchy woman," said Audrey in some alarm.

"They may say what they like. I care not who hears me, the fire and
plague were—" But to Audrey's relief a bustling 'prentice lad ran
against them at this moment, and nurse's anger was turned against
boys in general and London apprentices in particular. Before she had
done complaining of the change in manners since she was young,
Soper Lane was reached, and King Charles forgotten in their
eagerness to discover where Master Drayton lived.
 CHAPTER IV.

THE RIVER GARDEN.

IN the days of which we are writing, the River Thames was lined with
the gardens of the well-to-do citizens, while here and there was a
flight of steps leading from the bank for the accommodation of those
going by boat to various points. It was the great highway for traffic,
and rowing-boats, stately barges, handsomely decorated for parties
of pleasure, as well as others heavily laden with merchandise, were
constantly passing up and down the stream.

The wealthy London Companies also held gardens skirting the river
banks and kept swans, and to go and feed the swans in the Dyers'
Garden was a favourite pastime with Dame Drayton's children.
Master Drayton was a member of this Company, and therefore it was
a right he could claim that his children should be allowed to play or
walk about in this garden—a never-ending delight to them. It was not
far from Soper Lane, and so Deborah, or Dame Drayton herself,
generally took the children to the garden when the day's work was
over, that they might spend a few hours in the fresh air whenever it
was fine.

Dame Drayton was at the door with her children and the Westlands,
just going into the Dyers' Garden, when Audrey Lowe and her nurse
came down the Lane. The nurse knew the lady at once, for she had
been servant in the family many years, and Dame Drayton greeted
her cordially, but looked at Audrey, in doubt for a minute who she
could be, until the nurse said,—

"I have brought Mistress Audrey."

"Dear child, I had forgotten you," said Dame Drayton, kissing her
niece warmly, without waiting to hear the errand they had come
upon, for that was what nurse was about to tell her, she supposed.
But nurse only said, "My mistress made me say I would call again at
four of the clock to take Mistress Audrey back."

"But you will come and rest after your long walk?" said Dame
Drayton; "or you might come with us to the Garden and see the
swans."

Nurse shook her head.

"My brother lives in Honey Lane, and I would fain see him while I
wait," she replied.

"Would you like to go in, or will you come with us to the Garden,
Audrey?" asked her aunt. "There are seats upon which we can rest,"
added the lady.

"I should like to go to the Garden, an I may," replied Audrey.

Somehow she felt as though she would like to nestle up to this new-
found aunt, and tell her how anxious and sad her mother often
looked; for although there was no outer trouble at the vicarage now,
there always seemed an undertone of sadness, a sort of suppressed
sorrow, that Audrey in her great love for her mother and father could
not help feeling, though she would never give expression to her
thoughts about it. Now, all at once, she felt that she would like to
take this aunt into her confidence, and tell her of the vague
undefined sorrow that seemed to pervade her home.

"I am very pleased to see thee, Audrey. Tell thy mother I am so glad
that she hath sent thee on this errand—whatever it may be." And as
she spoke the lady looked at her niece, for she felt sure she had
something to say to her that could scarcely be trusted even to nurse.
"We shall be able to have a quiet talk to ourselves, and thee shall tell
me all that is in thine heart, in a few minutes."

"This is Bessie Westland, who hath come with her sisters to tarry for
a time with us," said Dame Drayton, drawing the girl forward after
Audrey had spoken to her cousins.
"We have come because my father and mother are sent to prison for
being Quakers," said Bessie, as if she feared this fact might be
forgotten if it was not instantly avowed.

"Hush, Bessie! Do not speak so loudly of these matters. People may

hear thy words, and—"

"Martha Drayton, I must speak the truth at all times and in all
places," said Bessie; "for I would not have this worldling think I am
anything but a Quaker." And as she spoke, Bessie looked scornfully
at Audrey's fashionable dress of silk brocade, and then at her own
coarse homely frock.

Dame Drayton looked distressed, and Audrey shocked and amazed

to hear her aunt addressed by this girl as "Martha." No wonder her
mother feared that trouble would come upon them if this was the way
Quakers behaved. The lady saw the look in her niece's face, and
said to Bessie—

"Will you take care of the children for me, that I may talk to my niece
while she rests in the Garden? For we have not seen each other for
some years."

"Yea, verily. I will do all that I call to keep them from the sight and
sound of evil, for this garden is but a worldly place, I trow," said
Bessie, for they had reached the gate by this time, and could see the
people walking about on the promenade facing the river, where there
was always something going on to amuse and interest the visitors.

Dame Drayton had found a quiet corner that was generally

unoccupied by the more fashionable citizens, and she led her little
party thither, nodding to friends and acquaintances as she passed,
but not stopping to speak to anyone to-day, for fear Bessie should
feel it her duty to announce that she was a Quaker, which would be
pretty sure to draw the attention of the authorities to them.

So she made her way as quickly as she could to a quiet alley, where
the children could play at ball between the shrubs, and Bessie would
be shielded from the sight of the ladies' gay dresses. There was a
seat, too, close at hand, and here Dame Drayton and Audrey could
sit and talk; and they made their way to it, leaving Bessie in charge
of the little ones and their play.

"Now, dear child, tell me of thy mother and father. It is so long since I
heard aught concerning thee that I have grown hungry for news.
Thou dost look well, Audrey," she added.

"I am well, dear aunt; but my mother is more troubled than usual, for
the Widow Tompkins came to see her this morning concerning
something her son had told her. He is one of thy 'prentice lads, my
mother bade me say, and told his mother a strange story concerning
the Quakers and his master's dealings with them."

"What did he say, Audrey?" asked her aunt, rather anxiously.

"Nay, I did not see the woman myself; but this lad is her only son,
and it may be she is over careful concerning him, seeing she lost her
other children in the plague; but I wot she hath frightened my mother
sorely concerning thee, so that she thought it better that I should
come and tell thee it will soon be the town's talk that thou dost
harbour Quakers within thy household. This girl who doth so sorely
despise me is one of the children Sim Tompkins spoke of, I trow."

"Poor Bessie! Her whole love is given to her father, who hath
suffered so sorely for his faith," said Dame Drayton with a sigh.

"Then they are Quakers," said Audrey, a little shocked that her aunt
could live on familiar terms with such people.

"Yea, verily; Bessie Westland glories in that which thou dost think is
a name of reproach. If thou couldest know her, too, thou wouldest
learn that she is a worthy, trusty maid, careful and loving to her little
sisters, who are too young to take care of themselves."

"But—but what are you going to do with them, aunt?" asked Audrey.
"Do with them? Nay, until God opens some other refuge for them
they must abide in the house, and share with my own children in my
care," said her aunt.

"But there is danger in this, and that is why my mother sent me to

you," said Audrey.

"It was kind of Annie to think of me, and kinder still to let me see you
once more; but you must tell her, Audrey, that I could not do less
than offer these children the shelter of my home, since they are
worse than orphaned, with father and mother in prison for being
Quakers."

"Yea, but why should they be Quakers, and rebel against the king?
Perhaps things were better for religion under the Lord-Protector,—
nurse says they were,—and my father thinks so too, I know; but now
the king has come to his own again we ought to obey him, my
mother says."

"Truly, we should; and the Quakers seek not to disobey the law,
except in the matter of taking oaths and some small matters in the
addressing of people, which was the reason why Bessie called me
'Martha' just now."

"It is not seemly, aunt, that a wench like this Bessie Westland should
speak to thee in that fashion," said Audrey, rather hotly.

"Nay, but, dear child, it was no disrespect for Bessie to do this. Her
principles as a Quaker forbid her the use of any title beyond that of
friend. Not for the king himself would a Quaker remove his hat, and
yet the king hath no more loyal subjects than the Quakers. They are
of all people the most peaceable, for, if wrongfully and cruelly
treated, they are forbidden to strike again, even in their own defence;
and if struck upon one cheek, they hold they must turn the other
also, an the smiter will have it so."

Audrey opened her eyes and looked at her aunt in amazement.

"I thought they were turbulent people, sowing sedition and disorder.
My mother said they might again bring civil war to England, if they
were allowed to do as they pleased."

Dame Drayton smiled and shook her head. "Nay, nay, it is not so,
believe me. I know what Quakers are, for I too am a Quaker; though
I hold it not binding upon my conscience to hold every rule it is
thought good by the Society to lay down for the guidance of its
members."

"Oh, my aunt!" said Audrey with a gasp; but instead of starting away
from her the girl drew closer, as if to protect her.

"Dear Audrey, it is a sweet and joyful thing to be a Quaker, as I

believe and strive to live up to my belief in that name. As sinners in
the sight of God we quake and tremble before Him; but we fear not
what man can do to us, so that we live under the guidance of that
divine voice that speaks to the heart of every child of God,—if they
will abide in such peace that this still small voice can yet rule and
guide them in everything they think and do."

"Is not this voice our conscience, aunt? And are we not taught to
obey it in all things?" asked Audrey.

"Yea, verily, dear child; but it is a truth that hath been well-nigh
forgotten, until Fox began to preach and teach that the inner voice
within the soul of man was the voice of God, which the soul is bound
to obey if it will live and grow. It is meat and drink, the very bread of
heaven by which alone we can live truly in this naughty world."

"But when my father speaks of obeying the voice of conscience he

means the same thing, aunt," said Audrey.

"Yes, I doubt not that, dear child; but people have talked and talked
about their conscience until it has come to mean little or nothing to
them, and God seeing this, hath sent His messenger, George Fox, to
declare once more to His people, that He hath not left them alone,
but speaks to the heart of each by His own still small voice. As
Quakers we prefer to call things plainly, for we are a plain people,
and so have thrown away that word 'conscience' as a worn-out and
broken mirror that does but hide instead of revealing more plainly the
truth it covers. Therefore, we say 'the voice of God' will guide us in
all things if we will but listen, and as little children obey it, even
though it should sometimes bid us to walk in a path that is not
pleasant to our feet."

"And is it this that makes thee so happy, aunt?" asked Audrey.

The simple form of 'thee' and 'thou' was still in vogue among close
friends, and so Audrey's use of it was not at all singular. The
exclusive use of it by Quakers later on was a survival of this feeling
that there was a closeness of friendship, a sincerity in these terms,
and so they rescued from oblivion this simple form of speech that
prevailed among all classes in England at that time. The same may
be said of their dress. They did but seek to evade observation at the
time of which we write, and desiring to be known only as a plain
God-fearing people. They dressed in simple, unostentatious colours;
but they have brought up through the generations the fashion of the
garments worn by their forefathers, and held to them while other and
very different fashions prevailed in the world.

So at this time, although Dame Drayton was a professed Quaker,

there was little to distinguish her from her neighbours around, in the
matter of dress and speech. The Society impressed upon its
members the duty of dressing plainly and simply, whatever their rank
in life might be, and that Dame Drayton chose to wear greys and
drabs in the place of crimsons or other brilliant colours was regarded
as a simple matter of taste by her neighbours. She had always been
known as a godly woman before she became a Quaker; but as she
had never felt called to preach, and went as often to the old parish
church she had attended from her girlhood, as she did to the Quaker
meeting-house in Gracechurch Street, few knew that she was a
Quaker.

As Audrey asked her question, she looked earnestly into her aunt's
face and nestled closer to her. "You seem very happy," she added;
"so much happier than my mother."

"Dear Audrey, I am very happy, for since I learned this truth from
George Fox, there hath come to me a peace that passeth all
understanding; for, following the guidance of this voice, the
distractions of the world cannot mar the quiet resting upon God, as
my Father, my Guide, my Friend, who will never fail nor forsake me.
It matters not whether thou art one who worships in a church or in a
meeting-house,—which is but a plain room fitted for a plain people
who meet together,—if haply the Spirit hath a word to speak by one
of them for the edification of all; and if there is no such word given
forth, still the Lord can and doth speak to each soul in the silence
that to many is better and more helpful even than the words of
prayer spoken by another, who cannot know the secret wants and
longings of any soul but his own."

"Then at these meetings there is silence all the time, aunt?" said
Audrey questioningly.

"Why should any speak if they feel not moved thereto by the inward
voice of the Spirit?" asked Dame Drayton. "It is this multiplying of
words without life or power that hath made preaching of none effect.
Now we know that when one speaketh he is moved thereto by the
Spirit of God working in him, and that he hath of a surety a message
for one or other or many of us. In some this power of the Spirit to
speak and warn and encourage is continually seeking to find
utterance, and then woe be to the man if he forbear to utter his
testimony for fear of what man shall do to him. Bessie's father was
such an one as this, and a brave honest man to boot; so, as he
would not be stayed from warning sinners to flee from the wrath to
come, whenever and wherever he could find opportunity, the soldiers
have haled him to prison, and his wife too, because she felt moved
to warn her godless neighbours, when her husband could no longer
do so. Bessie being the eldest was left in the cottage to take care of
the children, or do as she could, for none cared to befriend them, as
they were children of condemned Quakers. They had been
despoiled of all they possessed in fines for the same offence; but the
little they had left in the cottage was stolen or destroyed by the mob,
while Bessie and her sisters hid themselves in the cellar."

"Oh, aunt, would people really be so cruel?" said Audrey in a tone of

compassion, as she turned to look at the girl walking up and down
with the little ones, but rarely touching the ball herself even when it
fell close to her.

"I daresay there were some who felt sorry for them, and would
nathless have helped them if they could; but the baser sort, and
those whom Friend Westland had reproved for their sin and
wickedness, would be willing to break chairs and tables while they
shouted, 'Long live King Charles! Down with all Quakers and rebels!'
That was how it was done, Bessie says, while she sat cowering in
the cellar below, praying that God would keep them from following
her, for fear they should frighten the little ones to death."

"Oh, aunt, it was terrible! And she is not so old as I am, I should
think?"

"No, you are sixteen, and Bessie is not yet fourteen. But she is brave
and true, and whispered to her sisters not to cry out or make a noise,
and God would surely send deliverance to them by the hand of some
friend. We knew not to what straits the poor children were left, but as
Quakers, who called themselves brethren with him who was
suffering for the truth's sake, we were bound to seek the children
when we knew they had been left friendless and alone. Thee will tell
thy mother what I have told to thee, and then she will understand
how I was moved by the inward voice to offer a home and a refuge
to these little ones."

"Aunt, methinks the voice would have bidden me do likewise if I was

grown up and could have helped them," whispered Audrey, kissing
her tenderly, and feeling that she had found a friend in this aunt who
could understand her better than her mother could.
 CHAPTER V.
ONE SUNDAY MORNING.

THE exemplary punishment dealt out to the unfortunate martyr

Westland seemed to satisfy the authorities for some time, or it might
have been that their failure to silence Sir William Penn in spite of
fines and imprisonment, made them pause to consider before taking
up another crusade of persecution.

Sir William Penn was son of the Lord High Admiral of England, who
had recently died, leaving his son a considerable fortune, as well as
claims upon the government for money lent to them by the old
admiral.

But while a student at Oxford, Master William Penn, his son, had
embraced Quakerism, and been expelled for preaching and teaching
it. His father was very angry, and threatened to disown him for his
connection with such a disgraceful set of people, but afterwards sent
him to travel on the Continent, in the hope that he would forget what
the old admiral thought was the wildest vagary.

But after two years of travel young Penn came home a confirmed
Quaker, and very soon was sent to the Tower for writing a pamphlet
he called "The Sandy Foundation Shaken," which was specially
directed against the Church of England. During his eight months'
imprisonment, he wrote "No Cross No Crown," and several others,
which he published as soon as he was released.

Then he began preaching again, and was again arrested. But the
indomitable young Quaker had won for himself the regard of the
citizens of London, and the jury refused to convict him upon the
evidence brought forward, and were themselves fined for their
refusal.

Master Drayton had been one of these, and it had strained his
resources to make up this money; but he felt amply compensated by
the friendship that arose out of this between him and the ardent
young champion of their despised sect.

When Audrey Lowe had gone home, and the children had been put
to bed, Dame Drayton told her husband the errand her niece had
come upon.

"The 'prentice lads suspect we are Quakers, and Sim Tompkins has
told his mother about it. What wilt thou do, my husband?" she asked.

"Nay, what can we do but put our trust in the Lord?"

"But thou wilt be careful, Gilbert, for the children's sake?"

"Careful, dear heart? It is not to be feared that I shall publish abroad
that I am a Quaker; but, as thou sayest, too many suspect it, I fear,
and I have been pondering on a thought that came to me to-day
when thinking of Westland and his wife. He will doubtless be sent out
to the plantations of America by the next cargo of convicts, and when
he can save money enough to pay for the passage of his wife, she
will be allowed to join him in his exile. Now, our young champion, Sir
William Penn, is rich, and moreover the government is deeply
indebted to him for moneys lent by his father, and which he hath
small hope of regaining, for the king is too extravagant ever to pay
his debts. But if he hath little money to spare, he hath many waste
lands out in the plantations of America, and he might be induced to
sell some to our friend Penn in part payment of his debt. On this land
some of us might go and settle, even as the Independents did in the
reign of the first Charles, for America is wide and free, and there we
might serve God even as the divine voice should guide and direct us,
and none could make us afraid."

"That were a blessing indeed," said Dame Drayton, but with a sigh,
for the prospect of leaving her native land and her beloved London
was a painful thought to her. "Oh that we could have this blessed
freedom in England!" she said, clasping her hands, while the tears
slowly filled her eyes.

"Nay, nay, dame, thou hast naught to fret over, I trow," said her
husband, in some surprise to see his wife in tears.

"It was not of myself I was thinking, but of Annie Lowe, my sister.
Audrey hath let me know—without herself understanding—that the
way they thought would be soft to their feet hath been strewn with
thorns; none the less sharp are they, I trow, because they have to be
covered from the world."

"Now thou art speaking in parables, Martha. I thought the vicar was
well content to abide in the church that could nourish him."

"It may afford nourishment for the body, but to sign the Act of
Uniformity, whereby Parson Lowe and many another gave up the
right to serve and worship God as the inner voice would fain lead
them, could but be starvation for the soul. I felt sure it would come to
this with Annie and her husband, and that she would one day wish
she had been among those who were ejected for the truth's sake."

"But—but I thought Annie sent to warn thee of the danger thou wert
in through Sim chattering to his mother of what had been spoken
here?"

"Yea, she hath grown timid because she hath chosen the path of the
coward, until now she hath become timid at a shadow, for she fears
that if I walk not warily, men may even accuse her of being a Quaker.
Dear Annie! she hath always been feeble and timorous, and the
times are hard to endure for such. The child Audrey is different from
either mother or father, and so it is for her sake as well as Annie's I
long and pray that all in England may have freedom to worship God
even as they will, without let or hindrance from king or parliament."

But Master Drayton shook his head.

"That were a vain wish, dear heart; but a tract of country might surely
be granted in America, where Quakers could dwell in peace, and
another where Independents might rule themselves in matters of
religion, for it hath been proved that they cannot abide in peace
together. I will talk to Friend Penn of the thought that hath come to
me, and it may be he will have sonic light given to guide him in this
matter, for to provide a refuge for the Lord's persecuted people will
surely be a true way of devoting the wealth he hath inherited to the
service of the Lord, which he is fully purposed to do."

It was evident to Dame Drayton that her husband feared trouble was
thickening around them, or he would not have spoken in this way,
and it must be confessed that life was indeed hard, when each time
he went out she knew not whether he would return, or whether some
friend might not come to tell her he had been arrested and carried off
to Bridewell to await the meeting of the court where his case would
be heard.
But Master Drayton went in and out of Soper Lane without
interference, and for the next few weeks nothing was heard of the
Quakers being molested, so that at last the lady began to breathe
more freely again; other Quakers also took courage, and from
meeting in their own or at each other's houses for worship, ventured
to open once more the little meeting-house which was situated in an
alley in Gracechurch Street.

The closing of this had been a great deprivation to many, but Dame
Drayton had never wholly given up attending the church of All
Hallow's, close to her home, for it was here she first learned to know
God as her Father and Friend, and here she could still hold
communication with Him, even through the prayers which were such
a stumbling-block to many sincere and earnest souls at this time. To
her sister they were little else than chains and fetters, galling instead
of helping her soul to rise as upon the rungs of a ladder to the very
bosom of the Father. This was what the service of the Church of
England was to Dame Drayton; but sometimes there were other
seasons when nothing but the solemn silence of their own meeting-
house would satisfy her soul's need. Yet so that she was fed with the
bread of heaven, what did it matter whether it was words or the
absence of words, so long as the still small voice of God spoke in
her soul, and made itself heard above her fears or the clamour of the
world?

To Master Drayton, however, the church but ill supplied the quiet
meeting-house, and so he sat at home and read the Bible or some of
the pamphlets written by Barclay, Fox, or Penn, in defence of their
faith, and to him the opening of the meeting-house once more was a
source of great comfort and rejoicing.

He was the more glad, too, when he saw Sir William Penn among
the worshippers, for he doubted not the Spirit of God would move
him to speak a word of comfort and encouragement to many who
were weary and heavy laden with fear and apprehension. Only a few
of the bravest among the Quaker community had ventured to attend
this first meeting, but as it was uninterrupted by the authorities, the
next time the doors were open many more would attend, there was
little doubt.

During this time Bessie Westland had taken up an occupation that

no one would have thought likely to attract her. A day or two after
she came to Soper Lane she asked to be allowed to work at hat-
making like one of the boy apprentices.

Dame Drayton looked rather horrified at the proposal, but Bessie

said—

"I ought to do something to help to pay what we shall cost you, and if
I learn this hat-making now, I may be able to earn some money to
help mother and father in the new country." For to comfort her, Dame
Drayton had told her that a way would doubtless be opened for her
and her sisters to go to the plantations when her mother went.

So with this hope to spur her, Bessie took up the task of pasting and
sewing, doing all the lighter portions of the work required in the
manufacture of a hat, Master Drayton taking care that there was no
opportunity for the apprentices to talk to or interfere with her.

To his surprise the girl proved a far more apt pupil than any boy he
had ever had, and the same energy and enthusiasm that made her
father a most aggressive Quaker, being turned into this channel by
the force of circumstances, in Bessie showed itself in a marvellous
quickness and dexterity in doing all the lighter part of hat-making;
and the girl grew more content as the weeks went on.

Dame Drayton, however, did not know what to think of a girl taking
up what had always been considered boys' work. She would fain
have kept Bessie among the children or helping Deborah
occasionally with the bread-making and cooking, but as the girl
certainly seemed happier now that she had secured some constant
employment, she could only think this must be best for Bessie,
however strange it might be to her.
She told her husband, however, that Bessie puzzled her. She could
not understand the girl wanting to do boys' work when she and Deb
were ready to teach her all sorts of womanly handiwork.

"Thou and I must trust it is the Lord's will she should do this, for she
hath certainly most deft and useful fingers, and a quick
understanding for all kinds of hat-work. Quick and thorough is she,
so that her work can be relied upon already, and I should sorely miss
the wench now from my side."

Things were in this position when the winter set in, and the Quakers,
having met with no disturbance from the authorities, gathered at their
meeting-house each First Day—as they chose to call Sunday.

Of course Bessie was most regular in her attendance; but Dame

Drayton did not always go with her husband and Bessie, preferring
to take some of the children to All Hallow's Church, which was close
to her home. One Sunday, however, Bessie was suffering from a bad
cold, and wholly unfit to go out in the bleak drizzling rain that was
falling, and so her friends insisted that she should remain in bed.
Dame Drayton decided to go to the meeting-house with her
husband, for there was to be a gathering of the Friends afterwards,
to hear something more concerning the plan for founding a Quaker
colony across the seas.

But, alas! that meeting was never held, for the Lord Mayor had
ordered that the place should be watched, and as soon as the
Friends were all assembled, the doors were forced open by a party
of men-at-arms, and after a little parleying with those who kept the
door, the Quakers were informed they might consider themselves
under arrest, and until their names were taken none were allowed to
leave the building.
When this business had been got through by the officer in charge,
some half-dozen names were read out as being the ringleaders in
this seditious gathering, and among them were those of Master
Drayton and his wife.

For a minute the heart of the poor woman seemed turned to stone,
and her thoughts instantly flew to the children at home,—her own
and those who had been practically orphaned by the rigour of the
law,—and she covered her face with her hands in the agony of her
anxiety.

The halberdier who had been placed in charge of her, so far

respected her grief that he did not disturb her until he was compelled
by the officer to lead her out in the rear of some half-dozen others
who were being conducted to Newgate.
It was a pitiful sight. No resistance had been made by the
unoffending people, for it was one of the rules of their Society that
they should submit meekly to whatever outrage was perpetrated
upon them, and so Dame Drayton, comforted now by the thought
that God would surely protect her darlings, walked through the wet
muddy streets behind her husband. When they reached Newgate
they were thrust into the common prison, where thieves and
drunkards were making the place a very hell by their oaths and ribald
songs.

The little company of Quakers sat down in one corner by

themselves, and for a time could only listen with shivering horror to
what was going on around them. But, hardened as most of this
crowd were, Dame Drayton's sympathy was soon awakened by the
appearance of a young girl with a baby in her arms, and leaving her
husband's side, she went and sat down by the girl to say a few
words of comfort to her. From speaking to one, she grew courageous
enough to speak to others, and thus helped to pass the long weary
hours of that dreadful day.

On Monday morning they were taken before the Lord Mayor, and
charged with opening premises for seditious meetings, that had
previously been closed by order of the court. Master Drayton was
one of the four trustees holding the premises, and moreover he was
known to be one of the jury who had refused to convict Penn some
time before; which circumstance was brought forward against him,
as proving him to be an obstinate Quaker, who richly deserved to
lose his ears and be transported beyond the seas.

The court, however, sentenced him to six months' imprisonment, but

released his wife, when it was pleaded that she was a regular
attendant at her parish church, and was only guilty to the extent of
having married a Quaker.

It was an intense relief to Master Drayton when he heard that his

wife was not to be sent to prison. He could bear the hardship of this
far better if he knew that she was safe at home, though how they
were to live through the winter while he was in prison he did not