Free NBRC ACCS Practice Test

Answer: B. 315 mL

PBW for a woman = 45.5 + 0.91 × (height in cm − 152.4) — the metric form of ARDSNet's 45.5 + 2.3 × (height in inches − 60). Here: 45.5 + 0.91 × 7.6 = 52.4 kg. Six mL/kg × 52.4 kg = 314 mL. Lung size tracks height and sex, not body weight, so obesity doesn't raise the target.

• A (340 mL) uses the male formula (50 + 0.91 × 7.6 = 56.9 kg × 6).
• C (420 mL) is 8 mL/kg PBW — the ARDSNet starting volume that is then stepped down to 6 mL/kg, not this order.
• D (710 mL) is 6 mL/kg of actual weight, which would expose small lungs to a dangerously large volume.

Sources: NHLBI ARDS Network ventilator protocol card; AARC Clinical Practice Guideline: Patient-Ventilator Assessment, Respir Care 2024

Answer: C. Suction the endotracheal tube and assess for airway obstruction or bronchospasm

At unchanged inspiratory flow, peak minus plateau reflects pressure spent on airway resistance. It jumped from 6 to 20 cmH₂O while plateau (the compliance side) didn't move, so the problem is in the airways or tube: secretions, bronchospasm, a kink, or biting. Rhonchi point to secretions first.

• A: Increasing PEEP does not address the suspected secretion-related obstruction.
• B: The unchanged plateau pressure favors increased resistance over a new loss of respiratory-system compliance; assess the airway and tube promptly.
• D: Shrinking the breath treats the number, not the obstruction.

Sources: Hess, Respiratory mechanics in mechanically ventilated patients, Respir Care 2014 (published PDF); AARC Clinical Practice Guidelines: Artificial Airway Suctioning, Respir Care 2022

Answer: D. Cardiogenic shock

Low cardiac index with high left-sided filling pressure (PCWP 26) and high SVR is the pump-failure pattern: the left ventricle can't move what it's given, so pressure backs up and the vasculature clamps down.

• A: Distributive septic shock commonly has low SVR; low SVR is not its diagnostic definition, and mixed shock patterns can occur.
• B: Hypovolemia shows low CVP and low PCWP.
• C: Massive PE raises right-sided pressure, but the left ventricle is under-filled, so PCWP is normal or low — not 26.

Sources: González-Hermosillo et al., hemodynamic profiles of shock, Arch Cardiol Mex 2020 (Table 1); Singer et al., Sepsis-3 definitions, JAMA 2016

Answer: A. Deflate the cuff completely

A one-way valve opens on inspiration and closes on exhalation, so every exhaled breath has to travel around the tube and out through the upper airway. Any inflated cuff blocks that path, the patient can't exhale, and air stacks with each breath.

• B: Partial deflation still narrows or blocks the exhalation route.
• C and D: An inflated cuff with a closed valve is the dangerous combination this question is about.

Source: Passy-Muir Valve instructions for use (cuff warning)

Answer: B. High anion gap metabolic acidosis with an elevated osmolar gap — suspect toxic alcohol ingestion

Anion gap = 140 − (100 + 10) = 30 (high). Calculated osmolality = 2(140) + 90/18 + 14/2.8 = 280 + 5 + 5 = 290. Osmolar gap = 320 − 290 = 30, well above about 10, which points to unmeasured osmoles such as methanol or ethylene glycol. The PaCO₂ of 24 is within the expected respiratory compensation range (1.5 × 10 + 8 = 23 ± 2). The pattern raises concern for toxic alcohol ingestion but does not identify a specific toxin.

• A: The gap is high, not normal.
• C: The osmolar gap is elevated. Normal glucose does not exclude euglycemic DKA; ketone testing and clinical context are needed.
• D: pH 7.24 is acidemia; the low PaCO₂ is compensation.

Sources: ATSDR, Ethylene Glycol and Propylene Glycol Toxicity: Laboratory Tests (anion and osmolal gaps); Umpierrez et al., Hyperglycemic Crises in Adults With Diabetes: A Consensus Report, 2024; Jung et al., Diagnosis and management of metabolic acidosis: French expert-panel guidelines, 2019

Answer: D. The PEEP increase worsened respiratory-system mechanics; reassess PEEP and lung-protective settings

Driving pressure (plateau − total PEEP) went from 18 to 20 cmH₂O, and static compliance (VT ÷ driving pressure) fell from 23 to 21 mL/cmH₂O. Plateau is now above 30. The higher PEEP increased the pressure needed to deliver the same breath without improving oxygenation. This raises concern for overdistension and warrants reassessment; these measurements alone do not prove the mechanism.

• A: A net recruitment benefit would usually improve compliance; the observed compliance worsened.
• B: Plateau is measured with no flow, so it doesn't reflect resistance.
• C: Plateau rose 6 for a 4-cmH₂O PEEP change, and the 30 cmH₂O limit is now exceeded.

Sources: AARC Clinical Practice Guideline: Patient-Ventilator Assessment, Respir Care 2024; ATS Clinical Practice Guideline: Management of Adult Patients with ARDS, 2024; Hess, Respiratory mechanics in mechanically ventilated patients, Respir Care 2014 (published PDF)

Answer: C. Measure carboxyhemoglobin with CO-oximetry and continue 100% oxygen

Standard pulse oximeters read carboxyhemoglobin as if it were oxyhemoglobin, and a calculated SaO₂ is derived from PaO₂, which carbon monoxide doesn't lower. Blood CO-oximetry measures COHb directly. Continue 100% oxygen during urgent evaluation; CDC recommends it until the patient is symptom-free, with further treatment guided by symptoms and clinical severity.

• A: The 99% reading may be false reassurance.
• B: Imaging doesn't diagnose CO poisoning or justify delaying oxygen.
• D: The calculated value is blind to COHb by design.

Source: CDC, Carbon Monoxide Poisoning: Clinical Guidance

Answer: A. Prone positioning in sessions of at least 16 hours

P/F = 72 ÷ 0.80 = 90 — severe ARDS — despite lung-protective settings. Early, prolonged prone positioning reduced mortality in this population (PROSEVA enrolled P/F < 150 on FiO₂ ≥ 0.6, PEEP ≥ 5, and VT about 6 mL/kg PBW, with prone sessions of at least 16 hours), and guidelines recommend proning for severe ARDS.

• B: Larger tidal volumes increase ventilator-induced lung injury.
• C: Switching to pressure support for comfort does not address the persistent severe hypoxemia and is not the indicated next step in this sedated patient.
• D: Plateau is already under 30; cutting PEEP invites derecruitment and worse hypoxemia.

Sources: Guérin et al. (PROSEVA), Prone positioning in severe ARDS, N Engl J Med 2013; Fan et al., ATS/ESICM/SCCM guideline on mechanical ventilation in ARDS, 2017 (Question 2); ATS Clinical Practice Guideline: Management of Adult Patients with ARDS, 2024

Answer: C. Use thoracic ultrasound at the time of the procedure to locate the fluid and choose the site

For nonemergency pleural-fluid procedures, the British Thoracic Society recommends ultrasound in the procedure position, immediately before the procedure and without moving the patient after marking the site. Bedside ultrasound shows where the fluid is at the time of the procedure.

• A: A day-old, two-dimensional film doesn't show where the fluid sits now or how deep it is.
• B: Physical examination alone isn't image guidance.
• D: Fluid location and anatomy vary from patient to patient, so a fixed landmark can miss the fluid or hit something else.

Source: British Thoracic Society Clinical Statement on Pleural Procedures, Thorax 2023 (thoracic ultrasound)

Answer: B. Decrease the rate to 14/min and shorten the inspiratory time to lengthen exhalation

Expiratory flow that never reaches zero means the lungs are still emptying when the next breath arrives — auto-PEEP from dynamic hyperinflation (here 9 cmH₂O above set PEEP). The fix is more time to exhale: fewer breaths and a shorter inspiration. In this stable patient, prioritize reducing gas trapping over normalizing PaCO₂ while treating bronchospasm and monitoring pH and hemodynamics.

• A and C: More rate or more volume adds air faster than it can leave and worsens trapping.
• D: A longer inspiration steals exhalation time.

Sources: BTS/ICS Guideline for the ventilatory management of acute hypercapnic respiratory failure in adults, Thorax 2016 (recommendations 14–15); Hess, Respiratory mechanics in mechanically ventilated patients, Respir Care 2014 (published PDF)

Answer: A. Consistent with apnea for brain death determination

For an adult without chronic CO₂ retention, the apnea test targets a PaCO₂ of at least 60 mmHg and at least 20 mmHg above baseline, with pH below 7.30, and no breathing effort. Here PaCO₂ rose 22 mmHg to 63 and pH fell to 7.21 with no effort — the test supports apnea. It is one component; the full determination includes the complete clinical exam.

• B: There's no 80 mmHg threshold.
• C: Acidemia (pH below 7.30) is part of the target, not a reason to stop.
• D: The test ends when targets are reached or instability forces it to stop — not on a fixed 20-minute clock.

Source: Greer et al., AAN/AAP/CNS/SCCM brain death/death by neurologic criteria guideline, Neurology 2023 (apnea testing)

Answer: D. Extubate directly to preventive noninvasive ventilation

For patients at high risk of extubation failure who have been ventilated more than 24 hours and pass an SBT, the guideline's one strong recommendation is to extubate straight to preventive NIV. Age over 65, chronic hypercapnia, and COPD put this patient squarely in the high-risk group. Low-level pressure support during the SBT also fits this plan: the 2024 AARC SBT guideline notes it makes sense when the patient will be extubated to NIV.

• A: With the SBT and extubation assessment passed, a routine 48-hour delay is not indicated.
• B: Nothing here suggests prolonged ventilation is needed.
• C: Waiting for failure before supporting is the outcome preventive NIV is meant to avoid.

Sources: Official ATS/ACCP guideline on liberation from mechanical ventilation, 2017 (executive summary); AARC Clinical Practice Guideline: Spontaneous Breathing Trials, Respir Care 2024

Answer: C. About 2.8 — high risk of HFNC failure; escalate care and prepare for intubation

ROX = (SpO₂ ÷ FiO₂) ÷ respiratory rate = (86 ÷ 0.80) ÷ 38 = 107.5 ÷ 38 ≈ 2.8. In the 2019 validation study of patients with pneumonia receiving HFNC, ROX ≥ 4.88 at 2, 6, or 12 hours was associated with a lower risk of intubation, while values below 3.85 at 12 hours flagged high failure risk. ROX supports, but doesn't replace, bedside judgment.

• A: 107 is SpO₂/FiO₂ before dividing by the rate.
• B: The arithmetic doesn't produce 4.5.
• D: ROX was studied at 2, 6, and 12 hours.

Source: Roca et al., ROX index validation, Am J Respir Crit Care Med 2019

Answer: B. Differential hypoxemia (north–south syndrome)

With femoral VA-ECMO, oxygenated circuit blood flows retrograde up the aorta. As the native heart recovers, it ejects blood that passed through poorly functioning lungs, and that blood reaches the coronary and upper-body arteries first. A right radial arterial sample helps detect upper-body hypoxemia and is an important monitoring site; it does not directly measure coronary oxygenation.

• A: A post-oxygenator PaO₂ of 410 shows the oxygenator is working.
• C: This is an arterial blood gas, not an oximeter reading.
• D: Recirculation is especially associated with VV-ECMO and does not explain this upper–lower body arterial oxygen difference.

Source: ELSO Interim Guidelines for Venoarterial ECMO in Adult Cardiac Patients, 2021

Answer: D. Advise against it; current guidelines recommend NEWS, NEWS2, MEWS, or SIRS over qSOFA as a single screening tool

The 2026 Surviving Sepsis Campaign guideline, which updates the 2021 edition, makes a strong recommendation to use NEWS, NEWS2, MEWS, or SIRS rather than qSOFA as a single screening tool for acutely ill hospital patients. A screen exists to catch patients early, and the guideline favors the broader tools for that job.

• A: That is the practice the guideline recommends against.
• B: Lactate can contribute to assessment, but sepsis should not be ruled in or out using a single biomarker.
• C: Positive cultures are not required before screening. The guideline recommends collecting cultures in suspected sepsis, ideally before antimicrobial treatment.

Source: Surviving Sepsis Campaign 2026 (SCCM), Screening, Biomarkers, and Blood culture recommendations

Answer: A. Give systemic corticosteroids at least 4 hours before extubation

This patient is at high risk of post-extubation stridor (traumatic intubation, more than 6 days intubated), and the cuff leak test has failed. For high-risk adults who fail a cuff leak test, guidelines suggest systemic steroids at least 4 hours before extubation; a repeat cuff leak test isn't required.

• B: A failed result in this high-risk patient supports considering the guideline’s steroid strategy, rather than disregarding the airway risk.
• C: Upsizing the tube does not address the extubation risk; a large endotracheal tube is itself a listed risk factor for stridor.
• D: A failed cuff leak test alone does not establish a need for tracheostomy.

Source: ATS/CHEST liberation guideline executive summary (2017), Table 1 recommendation 6b and Question 6, pp. 117–118

Answer: B. Report the passed SBT together with the weak cough and secretion burden, so the team weighs airway-clearance risk before deciding to extubate

Passing this SBT shows the patient tolerated the trial’s level of support. It doesn't show the patient can protect the airway and clear secretions, and the 2024 AARC SBT guideline uses exactly this example — abundant secretions with a weak cough — to warn against treating liberation and extubation as the same decision. The therapist's job here is to put both findings in front of the team.

• A: That merges two separate questions; the airway-clearance risk is still unanswered.
• C: The patient met the trial's criteria. Calling it a failure hides accurate information the team needs.
• D: The AARC guideline suggests not raising FiO₂ during an SBT, because extra oxygen can mask hypoxemia — and a repeat trial doesn't address secretions.

Source: AARC Spontaneous Breathing Trials guideline (2024), Introduction and PICO 1 and 4

Answer: C. Wean the dose stepwise and watch for rebound hypoxemia and pulmonary hypertension before discontinuing

Abruptly stopping iNO can cause rebound pulmonary hypertension: oxygenation worsens and pulmonary artery pressure rises. The label says to reinstate iNO immediately if rebound occurs, so the safe path is a stepwise wean with monitoring. iNO's FDA-approved indication is for neonates; adult ICU use is specialist-directed and off-label, but the rebound risk and the methemoglobin and NO₂ monitoring in the label still apply.

• A: Abrupt stopping can trigger rebound even after oxygenation has improved.
• B: A higher dose adds methemoglobin and NO₂ exposure without helping the wean.
• D: Substituting heliox does not provide the monitored, stepwise withdrawal of iNO required here.

Source: INOmax prescribing information (revised April 2023), §§1, 2.2, and 5.1–5.3 (DailyMed)

Answer: A. Recommend maintaining normal PaCO₂; prolonged prophylactic hyperventilation to 25 mmHg or lower isn't recommended

Hyperventilation lowers ICP by constricting cerebral vessels, but it also cuts cerebral blood flow and can push injured tissue into ischemia. The Brain Trauma Foundation's 4th-edition recommendation is against prolonged prophylactic hyperventilation to PaCO₂ ≤ 25 mmHg. This scenario does not describe an acute ICP crisis requiring rescue treatment.

• B and C: Both are prolonged, prophylactic hyperventilation.
• D: CO₂ dilates cerebral vessels and raises ICP.

Source: Brain Trauma Foundation, Severe TBI Guidelines, 4th edition, §5 Ventilation Therapies, Level II B

Answer: D. Right side down (bleeding lung dependent)

Placing the bleeding lung down helps limit blood spilling into the nonbleeding lung. Positioning supports urgent airway protection and definitive bleeding control; it does not replace them.

• A: Left side down places the nonbleeding lung dependent, increasing the risk of blood contaminating it.
• B and C: Neither position specifically places the known bleeding lung dependent.

Source: CIRSE Standards of Practice on Bronchial Artery Embolisation (2022), affected-lung-dependent positioning during unstable hemoptysis

Answer: C. Overdamped system; inspect for air bubbles, clot, kinks, and connection problems, then correct identified faults according to the device and unit protocol

A slow return with no oscillation and a blunted tracing indicate overdamping. This can underestimate systolic pressure and narrow pulse pressure; diastolic pressure may be overestimated. Check the patient and the measurement system before treating the displayed systolic value as true hypotension. Do not flush visible air toward the patient or force a blocked catheter.

• A: Underdamping produces extra oscillations and an overshooting systolic peak.
• B: The stable clinical assessment and abnormal dynamic response require verification of the measurement before starting a vasopressor for this reading alone.
• D: A transducer below the phlebostatic axis reads falsely high, not low.

Sources: Edwards Clinical Education, Quick Guide to Cardiopulmonary Care, 4th edition, §§2.5–2.8; Edwards TruWave Instructions for Use, English p. 2: Dynamic Response, Air Emboli, and Abnormal Pressure Readings

Answer: B. −8 cmH₂O

Transpulmonary pressure = airway pressure − esophageal pressure, used here as an estimate of pleural pressure: 10 − 18 = −8 cmH₂O. This is a pressure estimate, not a PEEP prescription. Selecting PEEP also requires reliable measurements and assessment of lung mechanics, gas exchange, and hemodynamics. EPVent2 did not show a significant improvement in its primary outcome with esophageal-pressure-guided PEEP compared with an empirical high-PEEP strategy.

• A: The subtraction is reversed.
• C: This adds the two pressures.
• D: This adds the pressure magnitudes and then assigns a negative sign.

Source: Beitler et al., EPVent2 randomized clinical trial, JAMA 2019: Introduction, Key Points, and Conclusions

Answer: A. Abdominal compartment syndrome; notify the surgical team because decompression may be needed

Abdominal compartment syndrome is sustained intra-abdominal pressure above 20 mmHg with new organ dysfunction. Here, new oliguria and worsening respiratory mechanics accompany sustained pressure above 20 mmHg.

• B: Normal intra-abdominal pressure in critically ill adults is roughly 5–7 mmHg; intra-abdominal hypertension starts at 12.
• C: Grade I is 12–15 mmHg, and organ dysfunction changes the picture.
• D: Increasing PEEP alone does not treat the elevated intra-abdominal pressure or replace urgent surgical assessment.

Source: WSACS consensus definitions and guidelines (2013), Table 1, p. 1193, and decompressive laparotomy recommendation

Answer: D. Awake intubation (for example, a flexible scope after topical anesthesia), preserving spontaneous breathing

When both ventilation and intubation are expected to be difficult and the patient can cooperate, airway guidelines favor considering awake intubation. This allows the airway to be secured while spontaneous breathing is preserved, with oxygenation, monitoring, skilled help, and a backup plan.

• A and B: Induction can remove spontaneous breathing and airway tone before a secure rescue plan is established.
• C: Blind nasal intubation provides no visualization of this anticipated difficult airway; a planned awake technique with visualization is the better-supported choice here.

Source: 2022 ASA difficult-airway adult algorithm reproduced by APSF: Pre-induction Decision Chart and adult algorithm captions

Answer: B. Refeeding syndrome

Restarting calories after prolonged undernutrition can cause sharp falls in phosphorus, potassium, and magnesium; insulin drives phosphorus and potassium into cells. Severe hypophosphatemia impairs respiratory muscle function and can cause acute respiratory failure — a likely contributor to this failed SBT. Risk factors here: alcohol use, low BMI, prolonged poor intake, and aggressive advancement. Prompt clinician-led electrolyte correction, thiamine, and reassessment of calorie delivery are needed. ASPEN advises reducing calories for precipitous electrolyte falls and considering temporary cessation when levels are severely low.

• A: Excess calories can increase CO₂ production, but the new electrolyte depletion after feeding points to refeeding syndrome.
• C: Possible in prolonged critical illness, but the electrolyte pattern and timing fit refeeding.
• D: Nothing here supports a thyroid cause.

Source: ASPEN Consensus Recommendations for Refeeding Syndrome (2020), Proposed Definition, Pathophysiology, Tables 3–4 and 6

Answer: C. Assess for and treat inadequate sedation and analgesia

Neuromuscular blockers have no sedative or analgesic effect. Paralysis limits movement-based assessment. Tachycardia, hypertension, and tearing should prompt assessment of analgesia, sedation, drug delivery, and other causes; they do not diagnose pain or awareness by themselves. Adequate analgesia and sedation must be maintained before and during paralysis.

• A: More paralysis provides neither analgesia nor sedation.
• B: Sugammadex reverses rocuronium and vecuronium, not cisatracurium — and reversing paralysis isn't the goal here.
• D: A beta-blocker addresses a sign without assessing pain, awareness, or another underlying cause.

Sources: Cisatracurium besylate prescribing information (revised April 2026), §5.6 (DailyMed); Bridion (sugammadex) prescribing information (revised March 2026), §§1 and 5.14; SCCM Guidelines for Neuromuscular Blockade in Adults With ARDS (2026), Sedation evaluation and Monitoring analgesia-sedation

Answer: A. Look for a leak: inspect the insertion site and dressing and every connection from the patient to the drainage unit

Gentle, continuous bubbling belongs in the suction-control chamber. Continuous bubbling in the water-seal chamber means air is entering the system — from the patient or from a leak at the site or a connection. In a previously sealed, stable patient, check the system first. Report a new or persistent patient air leak to the treating team.

• B: That describes the suction-control chamber, not the water seal.
• C: Clamping a tube with an ongoing air leak risks a tension pneumothorax.
• D: More suction doesn't find or fix a leak.

Sources: Teleflex Pleur-evac air leak pocket guide; Teleflex Pleur-evac Rain Series wet-suction/wet-seal guide (July 2022), pp. 2, 4, 6–7

Answer: D. A transport ventilator that can deliver the set PEEP and FiO₂ up to 1.0, matched to ICU settings, with adequate oxygen supply and monitoring

Losing PEEP in a PEEP-dependent patient can collapse recruited lung, causing hypoxemia or hemodynamic instability. Transport guidance calls for a ventilator capable of PEEP and FiO₂ 1.0, an adequate portable oxygen supply, and monitoring. The guideline also notes transport ventilators can give more consistent ventilation than manual bagging.

• A: Dropping from PEEP 16 to zero invites derecruitment.
• B: Clinical need, not a fixed PEEP number, decides whether the scan happens.
• C: Hyperventilation by bag can cause respiratory alkalosis, dysrhythmias, and hypotension, and rate doesn't replace PEEP.

Source: AARC Clinical Practice Guideline: In-Hospital Transport of the Mechanically Ventilated Patient, 2002 revision

Answer: B. Change to sterile gloves

CDC lists the minimum barrier precautions for peripheral arterial catheter insertion as a cap, a mask, sterile gloves, and a small sterile fenestrated drape. Everything is in place except the gloves.

• A: Maximal sterile barriers are called for at axillary or femoral sites, not as the minimum for this radial arterial insertion.
• C: In adults, CDC prefers radial, brachial, or dorsalis pedis sites over femoral or axillary sites to reduce infection risk.
• D: Sterile gloves are part of the minimum.

Source: CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections, summary §17 (peripheral arterial catheters)

Answer: C. Subglottic secretion drainage port

Secretions pool above the cuff and can leak down around it. A subglottic drainage port lets that pool be aspirated, and the 2022 SHEA/IDSA/APIC compendium lists them as an additional approach for patients expected to be ventilated beyond 48–72 hours. Do not extubate and reintubate solely to exchange a conventional tube for one with subglottic drainage.

• A: Wire reinforcement resists kinking; it is not the secretion-drainage feature in this recommendation.
• B: RAE tubes keep the tube out of a surgical field.
• D: Double-lumen tubes isolate the lungs; a double-lumen design is not the subglottic-drainage feature.

Source: Klompas et al., SHEA/IDSA/APIC strategies to prevent VAP/VAE, 2022 update

Answer: A. Pulmonary embolism

A clot blocks perfusion to ventilated alveoli, creating dead space. End-tidal CO₂ can fall while arterial CO₂ rises, widening the gap between them. The abrupt change and postoperative risk make pulmonary embolism the best fit among these choices. Unchanged airway pressures do not rule out pneumothorax, tube malposition, or other causes of deterioration.

• B and D: These can reduce compliance and raise plateau pressure, but airway-pressure measurements alone cannot exclude them.
• C: Bronchospasm typically raises peak pressure with a widened peak–plateau gap under comparable passive, volume-controlled conditions.

Sources: Walsh et al., AARC Capnography/Capnometry During Mechanical Ventilation, 2011, §7; Yücel et al., end-tidal CO₂ and alveolar dead space in pulmonary embolism, Pulmonology 2020; Hess, Respiratory Mechanics in Mechanically Ventilated Patients, Respir Care 2014

Answer: D. Venovenous (VV) ECMO

This is refractory gas-exchange failure with an intact heart — the profile VV-ECMO is built for. VV-ECMO oxygenates and removes CO₂ from venous blood and returns it to the venous side, relying on the patient's own cardiac output. ATS guidance conditionally supports VV-ECMO for selected patients with severe ARDS.

• A: VA-ECMO adds circulatory support this patient doesn't need, with added arterial cannulation risk.
• B: An IABP supports a failing left ventricle; it does nothing for gas exchange.
• C: ECCO₂R alone does not provide the oxygenation support needed for this profound hypoxemia.

Sources: Qadir et al., ATS clinical practice guideline update on ARDS, Am J Respir Crit Care Med 2024; ELSO guideline: Management of Adult Patients Supported with VV ECMO, 2021

Answer: B. 13

Absolute risk reduction = 0.40 − 0.32 = 0.08. NNT = 1 ÷ 0.08 = 12.5, conventionally rounded up to 13. This is a 28-day point estimate for one additional death prevented compared with control, not a guarantee for each group of 13 patients.

• A: Uses the ARR as a whole number (8 percentage points) instead of its reciprocal.
• C: Would require an ARR of 4%.
• D: Takes the reciprocal of an event rate, not the risk difference.

Source: Cochrane Handbook, Chapter 15, §§15.4.2 and 15.4.4.1: interpreting and calculating NNT

Answer: A. Epoprostenol

Inhaled epoprostenol (a prostacyclin) preferentially reaches ventilated lung regions and dilates their pulmonary vessels, which can improve V/Q matching and lower pulmonary vascular resistance. Inhaled use is off-label, and systemic hypotension can still occur.

• B: Nebulized TXA is an antifibrinolytic studied for non-massive hemoptysis.
• C: Heparin is an anticoagulant, not a pulmonary vasodilator.
• D: Inhaled tobramycin is an antimicrobial.

Sources: Ghadimi et al., inhaled epoprostenol versus nitric oxide for right ventricular support after major cardiac surgery, Circulation 2023; Hawn et al., safety comparison of inhaled epoprostenol formulations in mechanically ventilated adults with ARDS, Ann Pharmacother 2020; Epoprostenol prescribing information, revised January 2026, intravenous route and vasodilator effects; Wand et al., nebulized tranexamic acid for hemoptysis, Chest 2018

Answer: C. Respect the documented informed refusal, escalate to the attending physician, and pursue accepted blood-conservation alternatives

An adult with capacity may refuse any treatment, including life-sustaining blood products, after an informed discussion. Sedation doesn't erase a documented refusal. Care continues with the treatments the patient accepts, such as controlling the bleeding and limiting blood loss from lab draws.

• A: Transfusing over a known refusal violates the patient's autonomy.
• B: A surrogate can't override a capable patient's own documented decision.
• D: Care continues; only the refused treatment is withheld.

Sources: AMA Code of Medical Ethics, Opinion 5.3 (withholding or withdrawing treatment); AMA Code of Medical Ethics, Opinion 2.1.1 (informed consent)

Answer: D. Bilevel noninvasive ventilation

Acute hypercapnic respiratory failure (pH ≤ 7.35) from a COPD exacerbation, in a patient who is alert and can protect the airway, is exactly where the ERS/ATS guideline gives bilevel NIV a strong recommendation.

• A: There is no stated indication for immediate intubation. A trial of NIV requires close reassessment and prompt intubation if the patient deteriorates or does not improve.
• B: Bilevel NIV is the guideline-supported treatment for this acidotic COPD exacerbation. HFNC does not provide equivalent bilevel pressure support, and uncontrolled high-FiO₂ oxygen can worsen hypercapnia.
• C: A nonrebreather mask increases oxygen delivery without providing bilevel ventilatory support.

Source: Rochwerg et al., ERS/ATS guideline on NIV for acute respiratory failure, 2017, Question 1b and implementation considerations

Answer: A. Propofol or dexmedetomidine targeting light sedation, rather than a benzodiazepine infusion

With pain controlled, aim for light sedation. The 2018 PADIS guideline suggests light rather than deep sedation and, for medical and non-cardiac-surgical patients, propofol or dexmedetomidine over benzodiazepines. The 2025 focused update adds a conditional preference for dexmedetomidine over propofol when light sedation and/or delirium reduction are the highest priorities. Either way, a deep benzodiazepine infusion is the pattern the guidance steers away from.

• B: Deep benzodiazepine sedation is what the guidance moves away from.
• C: Paralysis without sedation would leave an agitated patient aware and unable to move.
• D: Restraints don't treat the cause of agitation.

Sources: Devlin et al., SCCM PADIS guideline, 2018: light sedation and sedative choice; SCCM focused update of the PADIS guideline, 2025

Answer: B. Airborne infection isolation room; staff wear fit-tested, NIOSH-approved N95 or higher-level respirators

CDC lists measles among the diseases that need Airborne Precautions: an airborne infection isolation room (AIIR) and a fit-tested, NIOSH-approved N95 or higher-level respirator for staff.

• A: Droplet precautions and surgical masks do not provide the respiratory protection CDC recommends for measles.
• C: Contact precautions alone miss the airborne route.
• D: A shared room exposes other patients.

Source: CDC, Interim Infection Prevention and Control Recommendations for Measles in Healthcare Settings, §§3A–3B

Answer: C. Guide an appropriately shaped bougie through the visible glottic opening under vision, then advance the tube over it

A bougie can help direct the tube when the glottic opening is visible but tube delivery is difficult. Maintain oxygenation and limit attempts. Confirm placement with sustained exhaled CO₂ on waveform capnography and visualization of the tube passing through the vocal cords when possible. Blind bougie insertion when only the epiglottis is seen is not recommended.

• A: Blind techniques aren't a preferred rescue.
• B: Repeated attempts add airway trauma. Each further attempt should include a change to improve the chance of success.
• D: An emergency surgical airway is not indicated while oxygenation is maintained and appropriate intubation or rescue options remain.

Source: Ahmad et al., Difficult Airway Society 2025 guidelines, Br J Anaesth 2026;136:283–307, pp289–290: tracheal tube introducers and attempts

Answer: D. Complete the safety screen and begin protocolized rehabilitation directed toward early mobilization as tolerated

For adults ventilated more than 24 hours, liberation guidelines suggest protocolized rehabilitation directed toward early mobilization. These findings support screening for active mobilization; they do not replace assessment of cardiovascular, respiratory, neurologic, and device-related safety. Mechanical ventilation alone is not a reason to defer activity.

• A, B, and C: Mechanical ventilation alone does not require delaying active mobilization, and there is no universal 72-hour sedation-free waiting period. Activity should follow the safety screen and the patient's tolerance.

Sources: ATS/ACCP 2017 liberation guideline: rehabilitation protocols; SCCM PADIS guideline, 2018: rehabilitation/mobilization safety statements; SCCM focused PADIS update, 2025: enhanced mobilization/rehabilitation