Castleport Test Prep

Free NBRC CSE Practice Test

This free NBRC CSE practice test contains 20 original, unofficial simulations, with every result and every choice explained. Use it for the Clinical Simulation Examination (CSE), available through December 31, 2027; the new RT Examination uses a different format.

Problem 1: COPD exacerbation on too much oxygen

A 71-year-old woman with COPD arrives in the emergency department after two days of worse breathlessness and more sputum. EMS started oxygen at 4 L/min by nasal cannula. She is alert, speaking in full sentences, and using her neck muscles slightly.

Section 1 — Information gathering. Select as many as you consider indicated.

  1. Level of consciousness
  2. Arterial blood gas on current oxygen
  3. Breath sounds
  4. Vital signs and SpO2
  5. Most recent stable arterial blood gas in her chart
  6. Full pulmonary function testing in the PFT lab
  7. Chest radiograph
Show results and rationale
Choice Result Rating Why
1. LOC Alert, oriented, follows commands Helpful No sign of CO2 narcosis.
2. ABG pH 7.36, PaCO2 58 mm Hg, PaO2 92 mm Hg, HCO3 32 mEq/L on 4 L/min Helpful Hypercapnia with a normal pH. She is not acidemic, and her PaO2 is higher than she needs.
3. Breath sounds Diminished bilaterally, scattered expiratory wheeze Helpful Fits airflow obstruction; no one-sided finding.
4. Vitals/SpO2 HR 102, RR 24, BP 142/84, SpO2 97% Helpful An SpO2 of 97% is above the 88–92% range used for COPD.
5. Stable ABG Six months ago on room air: pH 7.39, PaCO2 55 mm Hg, HCO3 32 mEq/L Helpful Shows chronic CO2 retention. Today's PaCO2 is close to her baseline.
6. Full PFTs — Harmful Not appropriate during an exacerbation; it delays treatment.
7. Chest radiograph Hyperinflation; no infiltrate, no pneumothorax Helpful Rules out findings that would change the plan.

Section 2 — Decision making. Choose only one. Bronchodilators and a systemic corticosteroid have been ordered.

  • A. Begin bilevel noninvasive ventilation (NIV) now
  • B. Change to an air-entrainment (Venturi) mask at a low FiO2 and titrate to an SpO2 of 88–92%
  • C. Increase the nasal cannula to 6 L/min
  • D. Switch to a nonrebreather mask
  • E. Intubate and begin mechanical ventilation
Show what happens
  • A — Not the best choice. Her pH is normal. The ERS/ATS guideline suggests not using NIV for hypercapnia without acidosis in a COPD exacerbation; medical therapy and oxygen targeted to 88–92% come first (ERS/ATS 2017, pp. 4–5).
  • B — Best. An air-entrainment mask delivers a set FiO2, which makes controlled titration easier. One hour later on 28%: SpO2 90%, pH 7.38, PaCO2 54 mm Hg, PaO2 60 mm Hg, HCO3 31 mEq/L. The AARC oxygen guideline (2022) targets 88–92% in COPD.
  • C — Harmful. More oxygen pushes SpO2 further above target and adds CO2-retention risk.
  • D — Harmful. Uncontrolled high FiO2 in a known CO2 retainer, with no indication.
  • E — Harmful. She is alert, protecting her airway, and not acidemic.

Section 3 — Decision making. Choose only one. She is on the 28% mask with the results above.

  • A. Remove oxygen because her PaCO2 is still elevated
  • B. Start bilevel NIV to bring her PaCO2 down to 40 mm Hg
  • C. Continue controlled oxygen and medical therapy, and reassess; recommend bilevel NIV if respiratory acidosis (pH 7.35 or lower) and respiratory distress persist despite initial therapy
  • D. Increase FiO2 to 0.40
Show what happens
  • C — Best. Her PaCO2 of 54 sits near her chronic baseline of 55. The ERS/ATS guideline recommends bilevel NIV for acute or acute-on-chronic respiratory acidosis; consider the pH, respiratory rate, work of breathing, and response to initial therapy together (pp. 5–6). Deteriorating consciousness, airway protection, or breathing requires urgent reassessment rather than waiting for a particular gas result.
  • A — Harmful. An elevated PaCO2 alone is not a reason to withdraw oxygen; titrate it to the target saturation and reassess.
  • B — Not the best choice. Normalizing a chronic retainer's PaCO2 isn't the goal, and she has no acidemia or worsening distress.
  • D — Not the best choice. Her SpO2 is already in range.

Takeaway: In a COPD exacerbation, assess pH, distress, and response to treatment together when considering NIV. Compare with a stable baseline gas, and titrate oxygen to 88–92%.

Category: Adult chronic airways disease (noninvasive management). Outline areas: I.A.1 patient history, I.A.5 blood gas results, III.C.1 oxygen therapy, III.F.3 guidelines.

Problem 2: Preterm infant on CPAP with rising oxygen needs

A 29-week infant, 1.1 kg, is 2 hours old. She was placed on nasal CPAP 6 cm H2O at birth and is breathing spontaneously without apnea or bradycardia. To keep SpO2 within the ordered 90–94% range, the FiO2 has climbed from 0.25 to 0.40 over the last hour.

Section 1 — Information gathering. Select as many as you consider indicated.

  1. Sweat chloride test
  2. CPAP interface fit and mouth leak
  3. Work of breathing
  4. SpO2 and FiO2 trend
  5. Capillary blood gas from a warm, well-perfused heel
  6. Diagnostic bronchoscopy
  7. Chest radiograph
Show results and rationale
Choice Result Rating Why
1. Sweat chloride — Not needed Has no bearing on this decision.
2. Interface Prongs fit well; mouth closed with chin strap; delivered CPAP verified at 6 cm H2O Helpful Confirms effective pressure delivery while evaluating the rising FiO2.
3. Work of breathing Grunting, nasal flaring, substernal retractions Helpful Increasing distress.
4. SpO2/FiO2 SpO2 91% on FiO2 0.40 Helpful Rising oxygen need on CPAP is the key surfactant trigger.
5. Capillary gas pH 7.27, PCO2 58 mm Hg, HCO3 26 mEq/L Helpful Respiratory acidosis. Use capillary pH and PCO2, not PO2.
6. Bronchoscopy — Harmful No indication; it would destabilize a fragile preterm infant.
7. Chest radiograph Low lung volumes, diffuse ground-glass pattern with air bronchograms Helpful Fits respiratory distress syndrome (RDS).

Section 2 — Decision making. Choose only one.

  • A. Increase FiO2 to 0.60 and observe
  • B. Intubate and begin mechanical ventilation without surfactant
  • C. Recommend rescue surfactant, ideally by less-invasive administration (LISA) while she stays on CPAP
  • D. Change to a 1 L/min nasal cannula
Show what happens
  • C — Best. Within the hour, FiO2 is down to 0.28 with SpO2 92%. The European RDS guideline, 2025 update (published 2026), recommends surfactant for worsening RDS in infants over 28 weeks; its suggested protocol includes noninvasive support with mean airway pressure at least 6 cm H2O and FiO2 at least 0.30. Thin-catheter administration is preferred for spontaneously breathing preterm infants (Surfactant recommendations 3–4).
  • A — Not the best choice. It chases the number while the surfactant deficiency progresses.
  • B — Not the best choice. She is breathing spontaneously. The guideline favors noninvasive support with early surfactant and avoiding mechanical ventilation where possible.
  • D — Harmful. It removes the distending pressure she needs.

Section 3 — Decision making. Choose only one. After surfactant she is on CPAP 6 cm H2O, FiO2 0.28, SpO2 97%.

  • A. Wean FiO2 to keep SpO2 within 90–94%
  • B. Increase FiO2 back to 0.40 in case she worsens again
  • C. Stop CPAP now that surfactant has been given
  • D. Give a second surfactant dose immediately
Show what happens
  • A — Best. Her SpO2 of 97% is above her ordered 90–94% range. Excess oxygen carries its own risks in preterm infants.
  • B — Harmful. Unneeded oxygen exposure.
  • C — Not the best choice. She still needs noninvasive support.
  • D — Not the best choice. Repeat doses are for ongoing evidence of RDS with a persistent high oxygen need; she is improving.

Takeaway: In a spontaneously breathing infant over 28 weeks with worsening RDS, needing FiO2 at least 0.30 on CPAP of at least 6 cm H2O supports early rescue surfactant. Then wean oxygen to the ordered target range.

Category: Neonatal (respiratory distress syndrome). Outline areas: I.B.2.d status of a neonate, I.A.8 imaging, III.C.3 nasal CPAP, III.E.4.n surfactants.

Problem 3: Headache and confusion after a generator was run indoors

During a power outage, a 38-year-old man ran a gasoline generator in his attached garage. His family found him confused, with a headache and nausea. He arrives by ambulance on room air. The triage pulse oximeter reads 99%. Begin emergency oxygen treatment while gathering information; do not wait for the tests below.

Section 1 — Information gathering. Select as many as you consider indicated.

  1. Blood CO-oximetry (carboxyhemoglobin)
  2. Rely on the triage pulse oximeter reading
  3. 6-minute walk test
  4. Review the initial arterial blood gas drawn on arrival before oxygen was started
  5. Neurologic exam and level of consciousness
  6. Exposure history, including others in the home
  7. 12-lead ECG and cardiac biomarkers
Show results and rationale
Choice Result Rating Why
1. CO-oximetry Carboxyhemoglobin 28%; oxyhemoglobin 70% Helpful Confirms CO poisoning. CDC notes that a conventional two-wavelength pulse oximeter is not accurate when carboxyhemoglobin is present.
2. Pulse ox reading 99% Harmful Relying on it would falsely reassure you.
3. 6-minute walk — Harmful Exertion in a poisoned, confused patient adds risk and no useful information.
4. ABG Initial room-air sample: pH 7.32, PaCO2 32 mm Hg, PaO2 96 mm Hg, HCO3 16 mEq/L Helpful Metabolic acidosis with a normal PaO2. PaO2 measures dissolved oxygen, not how much hemoglobin carries oxygen.
5. Neuro exam Disoriented to time; slow responses Helpful Neurologic impairment is one of the findings CDC lists for considering hyperbaric oxygen.
6. Exposure history Wife and two children were also in the house Helpful Others may need evaluation.
7. ECG/biomarkers Sinus tachycardia; troponin pending Helpful CDC recommends an ECG and cardiac biomarkers when evaluating severe CO poisoning.

Section 2 — Decision making. Choose only one.

  • A. Give high-flow oxygen from a 100% oxygen source through a well-fitted nonrebreather mask now and recommend hyperbaric oxygen consultation
  • B. Titrate oxygen by nasal cannula to an SpO2 of 94–98%
  • C. No oxygen is needed because his SpO2 is 99%
  • D. Begin bilevel NIV
Show what happens
  • A — Best. CDC advises 100% oxygen and lists carboxyhemoglobin above 25–30%, neurologic impairment, cardiac involvement, and severe acidosis among reasons to consider hyperbaric oxygen.
  • B — Harmful. The SpO2 reading is unreliable here, so titrating to it undertreats.
  • C — Harmful. Same error, with no treatment at all.
  • D — Not the best choice. He is ventilating adequately. He needs a high inspired oxygen concentration, not ventilatory support.

Takeaway: Suspect CO when SpO2 looks normal but the story doesn't. Confirm with blood CO-oximetry and treat with 100% oxygen right away.

Category: Adult medical or surgical (other). Outline areas: I.A.5 hemoximetry results, I.C.6 CO-oximetry, III.C.1 oxygen therapy, III.E.2.i specialist consultation.

Problem 4: Sudden breathlessness after hip surgery

A 66-year-old woman is on postoperative day 3 after a total hip replacement. She suddenly became short of breath, with sharp chest pain on inspiration. Assess and treat hypoxemia promptly while the diagnostic workup proceeds; do not withhold oxygen to obtain a room-air sample.

Section 1 — Information gathering. Select as many as you consider indicated.

  1. Review the arterial blood gas drawn immediately on presentation, before oxygen was started
  2. Chest radiograph
  3. Bronchoscopy
  4. Breath sounds
  5. 12-lead ECG
  6. Examination of both legs
  7. Vital signs and SpO2
  8. D-dimer
Show results and rationale
Choice Result Rating Why
1. ABG pH 7.49, PaCO2 30 mm Hg, PaO2 58 mm Hg, HCO3 22 mEq/L Helpful Hypoxemia with acute respiratory alkalosis. At sea level, the A–a gradient is about 54 mm Hg (0.21 × 713 − 30 ÷ 0.8 ≈ 112; 112 − 58 = 54).
2. Chest radiograph No infiltrate, edema, or pneumothorax Helpful A near-normal film with this degree of hypoxemia raises suspicion of a vascular cause.
3. Bronchoscopy — Harmful No indication; it delays the diagnosis.
4. Breath sounds Clear and equal Helpful Clear lungs with hypoxemia point away from pneumonia, edema, and pneumothorax.
5. ECG Sinus tachycardia Helpful Screens for other causes, such as myocardial ischemia.
6. Legs Right calf swollen and tender Helpful Suggests a deep vein thrombosis as the source.
7. Vitals/SpO2 HR 118, RR 28, BP 128/76, SpO2 89% Helpful Tachycardic and hypoxemic, but blood pressure is stable.
8. D-dimer — Not needed With a high clinical probability, proceed to diagnostic imaging rather than using D-dimer to rule out PE.

Section 2 — Decision making. Choose only one. Oxygen has been started. Renal function is acceptable for contrast, and she has no iodinated-contrast allergy.

  • A. Recommend a D-dimer first, and imaging only if it's positive
  • B. Recommend incentive spirometry for presumed atelectasis
  • C. Begin bilevel NIV
  • D. Recommend CT pulmonary angiography
Show what happens
  • D — Best. The scan shows bilateral segmental pulmonary emboli. The 2026 AHA/ACC guideline recommendations call for imaging when clinical probability is high and prefer CTPA over ventilation/perfusion scanning when CTPA can be performed (slides 23–24).
  • A — Not the best choice. It delays imaging in a high-probability patient.
  • B — Not the best choice. The findings don't fit atelectasis, and it delays the diagnosis.
  • C — Not the best choice. Nothing here establishes a need for NIV, and it would not replace urgent imaging for the suspected embolism.

Section 3 — Decision making. Choose only one. She remains alert, BP 126/74, SpO2 93% on 3 L/min. The physician has assessed her postoperative bleeding risk and found no active bleeding or absolute contraindication to anticoagulation.

  • A. Recommend intubation
  • B. Recommend anticoagulation as the physician orders and titrate oxygen to 94–98%
  • C. Recommend an IV diuretic
  • D. Recommend systemic thrombolysis
Show what happens
  • B — Best. She is hemodynamically stable. The 2026 AHA/ACC recommendations call for anticoagulation in confirmed acute PE when there is no absolute contraindication; the physician selects treatment after considering her recent surgery. The AARC oxygen guideline recommends 94–98% for most hospitalized adults, which fits this case.
  • A — Harmful. She is protecting her airway and ventilating adequately; nothing here indicates intubation.
  • C — Harmful. She isn't fluid-overloaded, and diuresis would reduce her preload.
  • D — Not the best choice. She is stable on oxygen and 3 days out from major surgery, which raises her bleeding risk. Systemic thrombolysis isn't the routine choice for a stable patient like her.

Takeaway: Sudden hypoxemia, clear lungs, a clear film, and a recent major operation: think PE, skip the D-dimer when probability is high, and go to CTPA.

Category: Adult cardiovascular (other: pulmonary embolism). Outline areas: I.A.5 blood gas results, I.C.8 P(A–a)O2, I.E.3 imaging studies, III.E.4.f cardiovascular drugs.

Problem 5: Falling blood pressure on the ventilator

A 70-year-old man with COPD was intubated 6 hours ago. Settings: volume control, tidal volume 500 mL, rate 24, PEEP 5 cm H2O, FiO2 0.40, constant inspiratory flow 50 L/min, with no inspiratory pause. He is passive during the breaths and pressure holds. His blood pressure has fallen from 118/70 to 86/50 over the past hour, and the bedside team is assessing the hypotension.

Section 1 — Information gathering. Select as many as you consider indicated.

  1. Expiratory flow waveform
  2. End-expiratory hold to measure total PEEP
  3. Peak and plateau pressures
  4. Transport for CT of the chest
  5. Minute ventilation
  6. Sputum culture
  7. Breath sounds
Show results and rationale
Choice Result Rating Why
1. Flow waveform Expiratory flow doesn't return to zero before the next breath Helpful The classic sign of air trapping.
2. Expiratory hold Total PEEP 15 cm H2O, so auto-PEEP = 15 − 5 = 10 cm H2O Helpful Quantifies intrinsic end-expiratory pressure; it does not directly measure trapped volume.
3. Pressures Peak 48 cm H2O; plateau 32 cm H2O Helpful The high plateau fits hyperinflation; the peak-to-plateau difference also reflects airway resistance.
4. Chest CT — Harmful Transporting a hypotensive patient delays the fix.
5. Minute ventilation 500 mL × 24 = 12.0 L/min Helpful At this rate, expiratory flow has not finished before the next breath.
6. Sputum culture — Not needed Doesn't address the hypotension.
7. Breath sounds Diminished but equal bilaterally, prolonged expiration, diffuse wheeze Helpful Equal sounds make a pneumothorax less likely.

Section 2 — Decision making. Choose only one.

  • A. Increase tidal volume to 650 mL
  • B. Increase set PEEP to 15 cm H2O without further assessment
  • C. Decrease the rate to 14, give an inline bronchodilator, and recheck auto-PEEP and blood pressure
  • D. Increase the rate to 30 to lower his PaCO2
Show what happens
  • C — Best. At 50 L/min, inspiration takes about 0.6 seconds. Dropping the rate from 24 to 14 stretches expiratory time from about 1.9 to about 3.7 seconds. Auto-PEEP falls to 3 cm H2O and BP rises to 112/68. The BTS/ICS guideline recommends a low rate and prolonged expiration during controlled ventilation for severe airflow obstruction (recommendation 14); bronchodilation also reduces the resistance contributing to air trapping.
  • A — Harmful. Auto-PEEP rises with tidal volume.
  • B — Not the best choice. Added PEEP may help in selected cases but must be titrated carefully, and it doesn't lengthen expiratory time. Giving him time to exhale comes first.
  • D — Harmful. Shortens expiratory time and worsens air trapping.

Section 3 — Decision making. Choose only one. Thirty minutes later: pH 7.31, PaCO2 62 mm Hg, PaO2 78 mm Hg, HCO3 30 mEq/L; BP 112/68.

  • A. Accept the mild respiratory acidosis and keep the lower rate
  • B. Return the rate to 24
  • C. Increase tidal volume to bring PaCO2 to 40 mm Hg
  • D. Remove PEEP entirely
Show what happens
  • A — Best. Blood pressure recovered, and the air trapping improved. Accepting mild respiratory acidosis can be preferable to recreating dangerous hyperinflation; the BTS/ICS guideline allows permissive hypercapnia when needed to avoid high airway pressures in severe obstruction (recommendation 15). Continue to monitor his gas, pressures, and hemodynamics. This gas alone does not establish his chronic PaCO2 baseline.
  • B — Harmful. Brings back the air trapping and hypotension.
  • C — Harmful. Normalizing his PaCO2 isn't the goal, and a larger tidal volume worsens hyperinflation.
  • D — Not the best choice. Removing PEEP doesn't address the problem.

Takeaway: In a ventilated COPD patient with hypotension, check promptly for auto-PEEP while assessing other causes. Here, a lower rate gives more time to exhale and reduces trapped pressure.

Category: Adult chronic airways disease (intubation and mechanical ventilation). Outline areas: I.C.12 auto-PEEP determination, III.C.4.a ventilator settings, III.C.6 ventilator graphics.

Problem 6: Four-month-old with bronchiolitis

An otherwise healthy 4-month-old born at term has had a runny nose and cough for three days. Today he is breathing fast and feeding poorly.

Section 1 — Information gathering. Select as many as you consider indicated.

  1. Nasal secretions
  2. Viral testing panel
  3. Chest radiograph
  4. Breath sounds
  5. SpO2 on room air
  6. Feeding and wet-diaper history
  7. Respiratory rate and retractions
Show results and rationale
Choice Result Rating Why
1. Nasal secretions Thick, copious Helpful Infants breathe through their noses; clearing them helps feeding and breathing.
2. Viral panel — Not needed Laboratory tests aren't routinely needed and wouldn't change management.
3. Chest radiograph — Not needed The AAP diagnoses bronchiolitis from history and exam; radiographs aren't routine.
4. Breath sounds Fine crackles and scattered wheezes bilaterally Helpful Typical of bronchiolitis.
5. SpO2 93% on room air Helpful At 93%, the AAP allows withholding supplemental oxygen with continued clinical assessment.
6. Feeding Taking about half his usual feeds; fewer wet diapers Helpful Hydration status is a key decision point.
7. RR/retractions RR 58; mild subcostal retractions Helpful Moderate work of breathing.

Section 2 — Decision making. Choose only one.

  • A. Give a trial of nebulized albuterol
  • B. Recommend a systemic corticosteroid
  • C. Begin chest physiotherapy
  • D. Gently suction obstructing nasal secretions, provide supportive care, and recommend nasogastric or IV fluids if he can't stay hydrated orally
Show what happens
  • D — Best. The AAP guideline (Pediatrics 2014;134:e1474) is mostly a list of what not to give. It recommends nasogastric or IV fluids when an infant can't maintain hydration and allows withholding supplemental oxygen when saturation is above 90%. Here, gentle suction addresses secretions interfering with feeding; NICE recommends considering suction for that situation, rather than using it routinely (recommendations 1.4.6–1.4.7).
  • A — Not the best choice. The AAP recommends against albuterol in bronchiolitis.
  • B — Not the best choice. The AAP recommends against systemic corticosteroids.
  • C — Not the best choice. The AAP recommends against chest physiotherapy.

Section 3 — Decision making. Choose only one. Six hours later his SpO2 stays at 87–88% and his retractions are worse.

  • A. Start supplemental oxygen and reassess his work of breathing closely
  • B. Now give albuterol
  • C. Discharge home with suction instructions
  • D. Begin chest physiotherapy
Show what happens
  • A — Best. He is now below the 90% level, and his work of breathing is rising. Monitor for the need to escalate support.
  • B — Not the best choice. The recommendation against albuterol hasn't changed.
  • C — Harmful. He is getting worse.
  • D — Not the best choice. Still not recommended.

Takeaway: Bronchiolitis care is mostly supportive: clear obstructing nasal secretions, maintain hydration, and reassess breathing. For this otherwise healthy 4-month-old, persistent SpO2 below 90% calls for oxygen. Routine bronchodilators, steroids, and chest physiotherapy are not recommended.

Category: Pediatric (other: bronchiolitis). Outline areas: I.B.1 interviewing, I.B.2 inspection, III.B.2 suctioning, III.C.1 oxygen therapy, III.E.2.c fluid balance.

Problem 7: Cavitary lesion in a shared room

A 45-year-old man who lives in a shelter has had six weeks of cough, night sweats, weight loss, and blood-streaked sputum. He was admitted to a four-bed medical room. You've been asked to perform a sputum induction. Begin appropriate airborne precautions while gathering information; do not wait for test results or induce sputum in the shared room.

Section 1 — Information gathering. Select as many as you consider indicated.

  1. Room type and ventilation
  2. Spirometry in the PFT lab
  3. SpO2 and respiratory rate
  4. Symptom history
  5. Known TB exposures
  6. Chest radiograph
Show results and rationale
Choice Result Rating Why
1. Room Shared room; not negative pressure Helpful Suspected infectious TB creates an immediate exposure risk for others.
2. Spirometry — Harmful A cough-generating test outside isolation exposes others.
3. SpO2/RR SpO2 95% on room air; RR 20 Helpful He is stable; airborne precautions should proceed alongside assessment.
4. Symptoms Persistent cough, night sweats, weight loss, bloody sputum Helpful These are the symptoms CDC lists for suspecting TB disease.
5. Exposures A shelter contact was recently treated for TB Helpful Raises suspicion further.
6. Chest radiograph Right upper lobe cavity Helpful A cavity raises the likelihood that he is infectious.

Section 2 — Decision making. Choose only one.

  • A. Recommend immediate transfer to an airborne infection isolation (AII) room. Staff wear fit-tested N95 or higher respirators, and he wears a surgical mask whenever he leaves the room.
  • B. Use droplet precautions with surgical masks for staff
  • C. Perform the sputum induction now at his bedside
  • D. Wait for culture results before isolating him
Show what happens
  • A — Best. CDC's TB infection-control training places suspected TB patients in AII rooms, which are under negative pressure, has staff wear respirators such as N95s, and gives the patient a surgical mask (CDC Self-Study Module 5).
  • B — Harmful. A surgical mask is not adequate respiratory protection for staff caring for a patient with suspected infectious TB.
  • C — Harmful. Cough-inducing procedures belong in an AII room or booth.
  • D — Harmful. Cultures take weeks; isolation can't wait.

Section 3 — Decision making. Choose only one. He is now in an AII room.

  • A. Discontinue isolation as soon as he starts TB treatment
  • B. Collect one sputum sample, and discontinue isolation if the smear is negative
  • C. Collect serial sputum specimens for AFB smear and culture (three, 8–24 hours apart, at least one early morning), with any induction done inside the AII room
  • D. Perform bronchoscopy in the open endoscopy suite
Show what happens
  • C — Best. CDC diagnostic guidance calls for at least three sputum specimens 8–24 hours apart, including one early-morning specimen. It also recommends nucleic acid amplification testing on at least one respiratory specimen when pulmonary TB is being considered and the result would change management or infection control. Induction stays in the AII room; a negative smear alone does not exclude TB.
  • A — Harmful. Starting treatment does not by itself establish that he is noninfectious. CDC distinguishes suspected from confirmed TB: precautions may end for a suspected case when infectious TB is unlikely and an alternative diagnosis explains the illness or three properly timed smears are negative. If suspicion remains despite negative smears, precautions continue. Confirmed pulmonary TB requires additional treatment-response criteria.
  • B — Harmful. One negative smear doesn't establish that he is noninfectious.
  • D — Harmful. An aerosol-generating procedure outside isolation.

Takeaway: Suspected TB means airborne isolation first, then testing. Respirators protect staff; surgical masks on the patient protect everyone else.

Category: Adult medical or surgical (infectious disease). Outline areas: II.B.1 infection prevention, I.E.1 testing for tuberculosis, I.C.19 sputum induction.

Problem 8: Two years of exertional breathlessness

A 58-year-old woman with a 35-pack-year smoking history has had two years of worsening breathlessness on exertion and a morning cough with sputum. She is referred to the pulmonary function lab.

Section 1 — Information gathering. Select as many as you consider indicated.

  1. Lung volumes
  2. Methacholine challenge
  3. Sweat chloride test
  4. Spirometry before and after a bronchodilator
  5. Diffusing capacity (DLCO)
  6. Chest radiograph
  7. Smoking history and current status
Show results and rationale
Choice Result Rating Why
1. Lung volumes TLC 118% predicted; RV 165% predicted; both above the laboratory upper limits of normal Helpful Hyperinflation and air trapping; a high TLC rules out restriction.
2. Methacholine — Not needed Obtain and interpret spirometry first. A provocation test is not the next test in this presentation and carries bronchospasm risk.
3. Sweat chloride — Not needed Nothing in the history points to cystic fibrosis.
4. Spirometry Pre: FEV1 1.30 L, FVC 2.24 L (ratio 0.58). Post: FEV1 1.38 L (52% predicted), FVC 2.26 L (ratio 0.61) Helpful The FEV1 rose 80 mL (about 6%), well short of the 12% and 200 mL that GINA uses to define a significant response.
5. DLCO 48% predicted Helpful Reduced gas transfer fits alveolar (emphysematous) involvement.
6. Chest radiograph Hyperinflation, flattened diaphragms Helpful Supports the physiology.
7. Smoking Still smokes about 15 cigarettes a day Helpful The main modifiable risk factor.

Section 2 — Decision making. Choose only one.

  • A. The results are most consistent with asthma
  • B. Persistent airflow obstruction (post-bronchodilator FEV1/FVC below 0.70) with hyperinflation and low DLCO, consistent with COPD; report it and recommend smoking-cessation support
  • C. The results show a restrictive defect
  • D. The results are normal for her age
Show what happens
  • B — Best. GOLD 2026 requires a post-bronchodilator FEV1/FVC below 0.7 in the right clinical context. Her ratio is 0.61, and the history, hyperinflation, and low DLCO fit COPD. Because a single ratio between 0.60 and 0.80 can vary, GOLD recommends repeat spirometry on a separate occasion to confirm the obstruction (printed pp. 29–30; PDF pp. 40–41).
  • A — Not the best choice. The smoking history, progressive symptoms, hyperinflation, and low DLCO favor COPD. She doesn't meet the GINA bronchodilator-response criteria on this test (p. 8), but a small response does not exclude asthma, and persistent obstruction can occur in asthma. GOLD advises against using the degree of bronchodilator reversibility to distinguish the two.
  • C — Not the best choice. Her TLC is increased, not reduced.
  • D — Harmful. It misses a significant, treatable disease.

Takeaway: Read the post-bronchodilator ratio in clinical context. A result below 0.70 supports obstruction; repeat a result between 0.60 and 0.80 to confirm it. Lung volumes and DLCO then help characterize the pattern.

Category: Adult chronic airways disease (diagnosis). Outline areas: I.C.22 spirometry, I.C.23 diffusing capacity, I.C.24 lung volumes; I.D.20–22 evaluate results; III.I.3 smoking cessation.

Problem 9: Head injury and a very low PaCO2

A 24-year-old man was intubated after a motorcycle crash 3 hours ago; his Glasgow Coma Scale score was 6. He arrives in the ICU with an intracranial pressure (ICP) monitor in place. Ventilator: volume control, tidal volume 480 mL, rate 26, PEEP 5 cm H2O, FiO2 0.50. He is sedated and has no patient-triggered breaths.

Section 1 — Information gathering. Select as many as you consider indicated.

  1. Breath sounds and tube position
  2. Bronchoscopy
  3. Blood pressure
  4. Spontaneous breathing trial
  5. End-tidal CO2
  6. Arterial blood gas
  7. ICP and cerebral perfusion pressure (CPP)
Show results and rationale
Choice Result Rating Why
1. Breath sounds/tube Equal; tube 23 cm at the lip, unchanged Helpful Checks for a change in tube position; assess it with the capnogram and other airway findings.
2. Bronchoscopy — Not needed No indication.
3. BP 118/66 (mean arterial pressure about 83) Helpful Avoiding hypotension matters in brain injury.
4. SBT — Harmful He has no spontaneous respiratory effort and has not met readiness criteria.
5. End-tidal CO2 24 mm Hg Helpful Lets you trend changes between gases.
6. ABG pH 7.57, PaCO2 25 mm Hg, PaO2 140 mm Hg, HCO3 22 mEq/L Helpful He is being heavily hyperventilated.
7. ICP/CPP ICP 14 mm Hg; CPP 69 mm Hg Helpful ICP is not elevated, so there is no reason for hyperventilation.

Section 2 — Decision making. Choose only one.

  • A. Keep the current rate to prevent a rise in ICP
  • B. Increase the rate to 30
  • C. Decrease FiO2 to 0.21 immediately
  • D. Decrease the rate to about 17 per minute, then confirm with end-tidal CO2 and an ABG
Show what happens
  • D — Best. To raise PaCO2 from 25 toward a normal 38, a common estimate is new rate = 26 × 25 ÷ 38 ≈ 17. It assumes unchanged tidal volume, dead space, and CO2 production, with the total rate following the set rate; confirm the response rather than treating the estimate as an exact prescription. The Brain Trauma Foundation guideline (4th ed., Ventilation Therapies) does not recommend prolonged prophylactic hyperventilation to a PaCO2 of 25 mm Hg or less. It also restates earlier advice to avoid hyperventilation in the first 24 hours, while distinguishing that advice from the fourth-edition evidence-graded recommendation. The ACS TBI guideline targets PaCO2 35–45 mm Hg in the absence of intracranial hypertension (pp. 40–41).
  • A — Harmful. This is exactly the prophylactic hyperventilation the guideline advises against.
  • B — Harmful. It worsens the cerebral vasoconstriction.
  • C — Not the best choice. Wean oxygen gradually by SpO2 and gas; an abrupt drop to room air risks hypoxemia in an injured brain.

Takeaway: In traumatic brain injury without intracranial hypertension, target a normal PaCO2. Hyperventilation may be a brief rescue measure for raised ICP or herniation, not routine prophylaxis.

Category: Adult trauma. Outline areas: I.A.11.c ICP trends, I.A.5 blood gas results, III.C.4.a ventilator settings, III.F.3 guidelines.

Problem 10: Morning treatments in cystic fibrosis

A 22-year-old woman with cystic fibrosis is admitted for a pulmonary exacerbation. Her orders include albuterol, 7% hypertonic saline, dornase alfa, high-frequency chest wall oscillation (the vest), and inhaled tobramycin. Rescue albuterol and oxygen are available under the unit’s adverse-reaction protocol.

Section 1 — Information gathering. Select as many as you consider indicated.

  1. Sputum amount and appearance
  2. SpO2
  3. Breath sounds
  4. Recent sputum culture results
  5. Sweat chloride test
  6. FEV1 compared with her usual value
Show results and rationale
Choice Result Rating Why
1. Sputum Thick, green, large amounts Helpful Supports aggressive airway clearance.
2. SpO2 93% on room air Helpful Baseline before treatments.
3. Breath sounds Coarse crackles bilaterally Helpful Retained secretions.
4. Sputum culture Pseudomonas aeruginosa Helpful Explains the inhaled antibiotic order.
5. Sweat chloride — Not needed Her diagnosis is already established.
6. FEV1 51% predicted (usual 68%) Helpful Documents a decline in lung function during this exacerbation.

Section 2 — Decision making. Choose only one. Which order do you use?

  • A. Inhaled tobramycin → albuterol → hypertonic saline → dornase alfa → vest
  • B. Albuterol → hypertonic saline → dornase alfa → vest → inhaled tobramycin
  • C. Hypertonic saline → albuterol → vest → dornase alfa → tobramycin
  • D. Mix hypertonic saline and dornase alfa in one nebulizer, then vest, then albuterol
Show what happens
  • B — Best. The Cystic Fibrosis Foundation advises a bronchodilator before hypertonic saline, then dornase alfa, then airway clearance while the mucus is still thin. The inhaled antibiotic goes last, onto cleared airways (CFF: Antibiotics). Follow her CF team’s prescribed timing if it differs.
  • A — Not the best choice. The antibiotic lands on mucus that hasn't been cleared yet.
  • C — Not the best choice. Hypertonic saline without a bronchodilator first risks chest tightness, which the CFF lists as a common side effect.
  • D — Harmful. The dornase alfa prescribing information says not to mix it with other drugs in the nebulizer: mixing can alter either medication’s properties or function.

Section 3 — Decision making. Choose only one. Two minutes into hypertonic saline, she reports chest tightness. You hear new wheezing, and SpO2 has fallen from 93% to 88%.

  • A. Continue the treatment; this is expected
  • B. Switch to tobramycin now
  • C. Stop the hypertonic saline, give rescue albuterol and oxygen under the adverse-reaction protocol, notify the team, and reassess before deciding whether to restart
  • D. Increase the nebulizer flow to finish faster
Show what happens
  • C — Best. Ten minutes after rescue treatment, her wheeze clears and SpO2 returns to 93%. Hypertonic saline can cause bronchospasm and a fall in SpO2 even after bronchodilator pretreatment (AARC airway-clearance guideline, pp.1074–1075). Stop the suspected trigger, use the prescribed reliever, and report the reaction so the team can adjust the plan (hypertonic-saline safety instructions, Side effects). Persistent or worsening symptoms need urgent clinical reassessment.
  • A — Harmful. Ignores bronchospasm with desaturation.
  • B — Not the best choice. Doesn't treat the bronchospasm.
  • D — Harmful. Continues exposure to the suspected trigger without treating the reaction.

Takeaway: For this CF treatment session, open the airways, hydrate, thin, clear, then give the inhaled antibiotic. If hypertonic saline causes bronchospasm, stop it, follow the prescribed rescue plan, and reassess.

Category: Adult medical or surgical (cystic fibrosis). Outline areas: III.D.1 aerosolized preparations, III.B.3 mechanical airway clearance devices, III.E.1 treatment termination.

Problem 11: Clinic visit three weeks after a COPD admission

A 68-year-old man with COPD comes to the pulmonary clinic three weeks after a hospital stay for an exacerbation. He is breathing room air and resting comfortably. The team is assessing his need for home oxygen.

Section 1 — Information gathering. Select as many as you consider indicated.

  1. Cardiopulmonary exercise test
  2. Smoking status, including others in the home
  3. Arterial blood gas on room air at rest
  4. Resting SpO2 on room air
  5. Overnight oximetry
  6. Signs of cor pulmonale and hematocrit
Show results and rationale
Choice Result Rating Why
1. CPET — Not needed Doesn't change the decision about resting oxygen.
2. Smoking He quit two years ago; his son smokes indoors Helpful Oxygen fire safety becomes a priority.
3. ABG pH 7.40, PaCO2 48 mm Hg, PaO2 53 mm Hg, HCO3 29 mEq/L Helpful Documents a PaO2 at or below 55 mm Hg at rest on room air.
4. Resting SpO2 86% Helpful Points to resting hypoxemia; the ABG also assesses PaO2 and ventilation.
5. Overnight oximetry — Not needed He already has resting hypoxemia.
6. Cor pulmonale/Hct No edema; hematocrit 46% Helpful Not needed to qualify him here, but part of the picture.

Section 2 — Decision making. Choose only one.

  • A. Recommend home oxygen now for severe resting hypoxemia, at a flow and daily schedule the prescriber sets, with reassessment as he recovers
  • B. Recommend oxygen only during exercise
  • C. Recommend waiting until his PaO2 falls below 50 mm Hg
  • D. Recommend oxygen only at night
Show what happens
  • A — Best. The ATS home oxygen guideline (2020) recommends long-term oxygen for at least 15 hours a day for adults with COPD and severe chronic resting hypoxemia. His oxygen need should be treated now, but it may change as he recovers; arrange reassessment rather than assuming it is permanent. Medicare's coverage criteria use a PaO2 of 55 mm Hg or less, or a saturation of 88% or less, at rest on room air (CMS NCD 240.2). Meeting those coverage thresholds does not establish chronicity.
  • B — Not the best choice. His hypoxemia is present at rest.
  • C — Harmful. It withholds indicated therapy.
  • D — Not the best choice. Nocturnal-only oxygen addresses a different problem.

Section 3 — Decision making. Choose only one. Home oxygen is being arranged.

  • A. Store spare cylinders in the kitchen near the stove for convenience
  • B. Using oxygen is fine as long as smokers stay at least 3 feet away
  • C. Use the tubing extension so he can sleep with it across the hallway
  • D. Teach oxygen safety to him and his family: no smoking or open flames near oxygen, keep tubing from becoming a tripping hazard, and include his caregivers in training
Show what happens
  • D — Best. The ATS guideline's best-practice statement calls for education on equipment use and oxygen safety, including smoking cessation, fire prevention, and tripping hazards, with caregivers included.
  • A — Harmful. Places oxygen near an open flame.
  • B — Harmful. The safety teaching is no smoking near oxygen, not a distance rule; smoking around oxygen is a fire risk.
  • C — Harmful. Creates a tripping hazard.

Takeaway: Severe chronic resting hypoxemia in COPD supports long-term oxygen for at least 15 hours a day, plus real fire-safety teaching. After an exacerbation, treat the hypoxemia and reassess the oxygen need as recovery continues.

Category: Adult chronic airways disease (outpatient COPD). Outline areas: I.C.2 noninvasive monitoring, II.A.2 long-term oxygen therapy, III.I.1 safety, III.I.2 home care equipment.

Problem 12: Unresponsive with slow, shallow breathing

A 31-year-old man is found unresponsive in an emergency department restroom with a syringe nearby. His pupils are pinpoint. He takes about 4 shallow breaths a minute. A carotid pulse is present at 58. SpO2 is 78% on room air.

Section 1 — Decision making. Choose only one.

  • A. Start chest compressions
  • B. Apply a nonrebreather mask and wait for naloxone
  • C. Open the airway, begin bag-mask ventilation with oxygen (1 breath every 6 seconds), and give naloxone per protocol
  • D. Intubate before giving any breaths
Show what happens
  • C — Best. Within two minutes of naloxone, his respiratory rate climbs to 14 and he opens his eyes. For an adult who has a pulse but is not breathing normally, the AHA 2025 basic life support guideline supports 1 breath every 6 seconds. Give naloxone per protocol when opioid overdose is suspected; it must not delay ventilation.
  • A — Harmful. He has a pulse.
  • B — Not the best choice. Oxygen without ventilation doesn't fix a rate of 4.
  • D — Not the best choice. Bag-mask ventilation can start immediately, and naloxone may make intubation unnecessary.

Section 2 — Information gathering. Select as many as you consider indicated. Ten minutes after naloxone, he is on 2 L/min nasal cannula.

  1. Fingerstick blood glucose
  2. Breath sounds
  3. Pulmonary function testing
  4. Respiratory rate, SpO2, and level of consciousness
  5. Arterial blood gas
Show results and rationale
Choice Result Rating Why
1. Glucose 104 mg/dL Helpful Shows that he is not hypoglycemic at this assessment.
2. Breath sounds Crackles at the right base Helpful Possible aspiration while he was unresponsive.
3. PFTs — Harmful Not appropriate in this setting.
4. RR/SpO2/LOC RR 14, SpO2 95%, drowsy but answers questions Helpful Responding, but not back to baseline.
5. ABG pH 7.34, PaCO2 50 mm Hg, PaO2 88 mm Hg, HCO3 26 mEq/L Helpful Residual hypoventilation.

Section 3 — Decision making. Choose only one.

  • A. Discharge him now that he is awake
  • B. Continue close monitoring of breathing and oxygenation, with a bag-mask and more naloxone ready, because respiratory depression can recur as naloxone wears off
  • C. Give a sedative for agitation
  • D. Remove all monitoring once SpO2 stays above 94%
Show what happens
  • B — Best. The AHA 2025 opioid-overdose recommendations call for observation in a healthcare setting until recurrence risk is low, consciousness is normal, and vital signs are normal. The ideal observation time is not fixed; it depends on the opioid, the antagonist, and the patient's course. Repeat naloxone or an infusion may be needed for recurrent respiratory depression.
  • A — Harmful. Discharging him this early risks recurrence.
  • C — Harmful. Adds respiratory depression.
  • D — Harmful. A normal SpO2 now doesn't protect against recurrence, and supplemental oxygen can mask hypoventilation.

Takeaway: Opioid-induced inadequate breathing with a pulse: ventilate first, give naloxone, and keep watching, because naloxone can wear off before the opioid does.

Category: Adult neurological (CNS-depressant overdose). Outline areas: III.G.1.a emergency care, II.A.9 resuscitation equipment, III.E.4.j narcotic antagonists, I.A.5 blood gas results.

Problem 13: Breathless after a heart attack, with a pulmonary artery catheter in place

A 62-year-old man is in the ICU two days after an anterior myocardial infarction. He has become more breathless and can't lie flat. He has a pulmonary artery catheter and is on 4 L/min nasal cannula.

Section 1 — Information gathering. Select as many as you consider indicated.

  1. Chest radiograph
  2. Breath sounds
  3. Arterial blood gas
  4. Bronchoscopy
  5. Hemodynamic measurements
  6. Urine output
Show results and rationale
Choice Result Rating Why
1. Chest radiograph Vascular congestion; bilateral perihilar opacities Helpful Pulmonary edema pattern.
2. Breath sounds Bilateral crackles to the mid-lung fields Helpful Alveolar fluid.
3. ABG pH 7.45, PaCO2 34 mm Hg, PaO2 62 mm Hg, HCO3 23 mEq/L Helpful Hypoxemia with mild hyperventilation.
4. Bronchoscopy — Harmful No indication.
5. Hemodynamics BP 104/68, HR 108, CVP 12 mm Hg, PAP 46/28 mm Hg, PCWP 26 mm Hg, cardiac output 4.6 L/min, cardiac index 2.4 L/min/m² (BSA 1.9 m²) Helpful The elevated wedge pressure supports congestion in this clinical setting; cardiac index is 4.6 ÷ 1.9 ≈ 2.4 L/min/m².
6. Urine output 20 mL/h over 4 hours Helpful Low; he has received fluids since admission.

Section 2 — Decision making. Choose only one.

  • A. Recommend a 1-liter IV fluid bolus for the low urine output
  • B. Recommend albuterol for the crackles
  • C. Manage this as ARDS with low-tidal-volume ventilation
  • D. Recommend an IV loop diuretic and continue oxygen titrated to his target
Show what happens
  • D — Best. Six hours later: PCWP 17 mm Hg, urine output 900 mL, SpO2 95% on 2 L/min. A high PCWP supports a hydrostatic contribution to his pulmonary edema. The 2022 AHA/ACC/HFSA heart failure guideline recommends prompt IV loop diuretics for hospitalized patients with significant fluid overload, with treatment titrated to relieve congestion.
  • A — Harmful. Adds volume to a heart that is already overfilled.
  • B — Not the best choice. The crackles are fluid, not bronchospasm.
  • C — Not the best choice. The findings favor hydrostatic edema. Low-tidal-volume ventilation would not treat the fluid overload itself, and this case has not established a need for intubation.

Takeaway: In this patient, pulmonary edema plus a high wedge pressure supports fluid overload: treat the congestion rather than giving an automatic fluid bolus for low urine output.

Category: Adult cardiovascular (heart failure). Outline areas: I.A.11.g hemodynamic parameters, I.D.8 hemodynamic monitoring, III.E.4.m diuretics, III.E.2.c fluid balance.

Problem 14: Two hours of NIV, and she's getting worse

A 74-year-old woman with COPD was started on bilevel NIV in the emergency department 2 hours ago. Her starting gas was pH 7.28, PaCO2 70 mm Hg, HCO3 32 mEq/L.

Section 1 — Information gathering. Select as many as you consider indicated.

  1. Ability to clear secretions and protect her airway
  2. Spirometry
  3. Mask fit and leak
  4. Level of consciousness
  5. Repeat arterial blood gas
  6. Exhaled tidal volume and respiratory rate
Show results and rationale
Choice Result Rating Why
1. Airway Unable to clear pooled secretions; vomited once into the mask Helpful Now an aspiration risk with an unprotected airway.
2. Spirometry — Harmful Not possible or relevant.
3. Mask Good seal; small leak Helpful Makes a major mask leak less likely; it does not explain her loss of airway protection.
4. LOC Opens her eyes only to voice; drifting off Helpful Declining consciousness.
5. ABG pH 7.23, PaCO2 82 mm Hg, PaO2 60 mm Hg, HCO3 33 mEq/L Helpful The acidosis is worse after 2 hours, not better.
6. VT/RR Exhaled VT 310 mL; RR 34 Helpful Rapid, shallow breathing despite support.

Section 2 — Decision making. Choose only one.

  • A. Recommend intubation and invasive mechanical ventilation
  • B. Raise the inspiratory pressure and continue NIV for another 2 hours
  • C. Switch to a nonrebreather mask
  • D. Switch to CPAP alone
Show what happens
  • A — Best. The ERS/ATS guideline notes that responders usually show improvement in pH or respiratory rate within the first 1–4 hours, and that lower-pH patients need close monitoring with rapid access to intubation if they aren't improving (pp. 5–6). Hers are worsening, she is less conscious, and she has vomited.
  • B — Harmful. Delaying needed intubation in a patient with an unprotected airway and worsening acidosis.
  • C — Harmful. Removes ventilatory support from a patient in ventilatory failure.
  • D — Not the best choice. Gives less inspiratory support and doesn't protect the airway.

Takeaway: NIV is a trial. In this patient, worsening acidosis, declining consciousness, and inability to protect the airway call for prompt intubation rather than extending a failing trial.

Category: Adult chronic airways disease (noninvasive management). Outline areas: I.A.5 blood gas trends, III.C.4.b noninvasive ventilation, III.E.2.e insertion of artificial airway, III.E.1 treatment termination.

Problem 15: Meconium and a limp newborn

A baby is born at 41 weeks through thick meconium-stained fluid. She is limp and not breathing. After warming, drying, positioning, and stimulation, her heart rate is 70/min and she is still apneic.

Section 1 — Decision making. Choose only one.

  • A. Intubate and suction the trachea before giving any breaths
  • B. Begin positive-pressure ventilation with 21% oxygen within the first minute and place a pulse oximeter on the right hand
  • C. Give blow-by oxygen and keep stimulating
  • D. Begin chest compressions
Show what happens
  • B — Best. The AHA/AAP 2025 neonatal guidelines call for ventilation within 60 seconds for an apneic newborn or one with a persistent heart rate below 100 (§11.1). Routine endotracheal suctioning isn't recommended whether the fluid is clear or meconium-stained (§9.4).
  • A — Harmful. Routine tracheal suctioning hasn't been shown to help and delays ventilation.
  • C — Harmful. An apneic baby needs breaths.
  • D — Harmful. The heart rate is above 60, and ventilation hasn't started.

Section 2 — Information gathering. Select as many as you consider indicated. After 30 seconds of mask ventilation:

  1. Chest rise
  2. Heart rate
  3. Blood glucose
  4. Result of the ventilation corrective steps
  5. Mask seal and head position
Show results and rationale
Choice Result Rating Why
1. Chest rise None Helpful Ventilation isn't effective.
2. Heart rate 70/min, not rising Helpful A rising heart rate is the main sign of effective ventilation.
3. Glucose — Not needed Important later, not while ventilation is failing.
4. Corrective steps Mask reapplied, head repositioned, mouth and nose suctioned, mouth opened, pressure increased: still no chest rise Helpful Persistent failure despite corrective steps raises concern for airway obstruction.
5. Seal/position Good seal; neutral head position Helpful Common mask-seal and positioning problems have been addressed.

Section 3 — Decision making. Choose only one.

  • A. Begin chest compressions
  • B. Give epinephrine
  • C. Continue mask ventilation at the same pressure
  • D. Intubate and perform tracheal suctioning to relieve a suspected obstruction, then ventilate through the tube
Show what happens
  • D — Best. Thick meconium is suctioned from the trachea, the chest rises with each breath, and the heart rate climbs to 130. The guideline says intubation and tracheal suction can help when there is evidence of tracheal obstruction during ventilation (§9.4), and an alternative airway is part of the corrective steps (§11.3).
  • A — Harmful. The heart rate is above 60, and the lungs aren't being inflated.
  • B — Harmful. No indication.
  • C — Not the best choice. Repeating what isn't working wastes time.

Takeaway: Meconium no longer means routine tracheal suctioning. Ventilate first; consider tracheal suctioning when ventilation remains ineffective and there is evidence of airway obstruction.

Category: Neonatal (resuscitation). Outline areas: I.B.2.d status of a neonate, III.G.1.a emergency care, III.A.3.d endotracheal tube, III.B.2 suctioning.

Problem 16: Severe ARDS on protective settings

A 47-year-old man with influenza pneumonia has ARDS and is on his second day of mechanical ventilation. He is 70 inches tall. Settings: volume control, tidal volume 440 mL, rate 30, PEEP 14 cm H2O, FiO2 0.90. He is passive during valid inspiratory and expiratory holds. The team has assessed positioning risks and found no contraindication to proning.

Section 1 — Information gathering. Select as many as you consider indicated.

  1. Predicted body weight and tidal volume per kg
  2. Plateau pressure
  3. Blood pressure and vasopressor needs
  4. Diagnostic bronchoscopy
  5. Total PEEP and driving pressure
  6. Spontaneous breathing trial
  7. Arterial blood gas and P/F ratio
Show results and rationale
Choice Result Rating Why
1. PBW 50 + 2.3 × (70 − 60) = 73 kg; 440 mL ≈ 6 mL/kg Helpful Settings are already lung-protective.
2. Plateau 28 cm H2O Helpful Within the limit of 30.
3. Hemodynamics BP 108/64 on a stable low-dose vasopressor Helpful Informs monitoring during the prone turn.
4. Bronchoscopy — Not needed The cause is known; it won't improve oxygenation.
5. Driving pressure Total PEEP 14 cm H2O, with no auto-PEEP; 28 − 14 = 14 cm H2O Helpful Driving pressure is plateau pressure minus total PEEP (AARC patient-ventilator assessment guideline, p. 1046).
6. SBT — Harmful He isn't ready for liberation testing.
7. ABG pH 7.32, PaCO2 52 mm Hg, PaO2 64 mm Hg, HCO3 26 mEq/L; P/F = 64 ÷ 0.90 ≈ 71 Helpful Severe hypoxemia despite high FiO2 and PEEP.

Section 2 — Decision making. Choose only one.

  • A. Increase tidal volume to 8 mL/kg to improve oxygenation
  • B. Perform a prolonged recruitment maneuver at 40 cm H2O
  • C. Recommend prone positioning for more than 12 hours a day
  • D. Decrease PEEP to 8 cm H2O
Show what happens
  • C — Best. Four hours after proning, his PaO2 is 92 mm Hg on FiO2 0.70. The ATS/ESICM/SCCM guideline (2017) strongly recommends prone positioning for more than 12 hours a day in severe ARDS.
  • A — Not the best choice. Increasing tidal volume from about 6 to 8 mL/kg solely to improve oxygenation is not the indicated next step. Although 8 mL/kg can fall within a protective-volume range, the volume must remain appropriate to plateau pressure and the patient's response.
  • B — Harmful. The 2024 ATS update recommends against prolonged lung recruitment maneuvers.
  • D — Harmful. Can cause derecruitment and worsen hypoxemia; the case gives no reason to reduce PEEP.

Takeaway: For severe ARDS despite protective ventilation, prolonged prone positioning is a recommended next step when it can be performed safely.

Category: Adult medical or surgical (ARDS). Outline areas: I.C.8 P/F ratio, I.C.11 plateau pressure, III.C.4.a ventilator settings, III.E.3.a patient position, III.F.3 guidelines.

Problem 17: Asthma that isn't controlled

A 29-year-old woman with asthma visits the clinic. She has been prescribed a daily low-dose inhaled corticosteroid (ICS) by pressurized metered-dose inhaler (MDI), plus albuterol as needed.

Section 1 — Information gathering. Select as many as you consider indicated.

  1. Refill and adherence history
  2. Triggers and exposures at home
  3. Symptoms over the past 4 weeks
  4. Watch her use the inhalers
  5. CT of the chest
  6. Methacholine challenge
  7. Spirometry
Show results and rationale
Choice Result Rating Why
1. Adherence ICS refilled once in 6 months; 4 albuterol canisters Helpful Low adherence and heavy reliever use.
2. Exposures A new cat at home Helpful A possible trigger if she is sensitized.
3. Symptoms Daytime symptoms 5 days a week, wakes 2 nights a week, albuterol 5–6 days a week Helpful Three of GINA's four control questions are positive: uncontrolled.
4. Technique Doesn't shake the inhaler as its instructions require, fires it after she has finished inhaling, no breath hold; no spacer Helpful Poor technique reduces effective ICS delivery. For this device, actuate as inhalation starts, then continue inhaling slowly (NHLBI inhaler instructions, p. 1).
5. Chest CT — Not needed Doesn't change management.
6. Methacholine — Not needed Her asthma diagnosis is already established.
7. Spirometry FEV1 74% predicted Helpful Documents current lung function.

Section 2 — Decision making. Choose only one.

  • A. Correct her inhaler technique by demonstration and teach-back, add a spacer for the ICS inhaler, address adherence barriers, and give a written asthma action plan before any step-up
  • B. Step up to high-dose ICS-LABA today
  • C. Stop the ICS and use albuterol alone as needed
  • D. Recommend daily oral prednisone
Show what happens
  • A — Best. GINA 2026 says to check adherence, inhaler technique, risk factors, and comorbidities before stepping up (pp. 14, 22), to correct technique by demonstration (p. 16), that patients using ICS by pressurized MDI should use a spacer (p. 16), and that every patient needs a written action plan (p. 21).
  • B — Not the best choice. Stepping up without fixing technique and adherence treats the wrong problem.
  • C — Harmful. GINA recommends against SABA-only treatment because of the increased risk of severe exacerbations and death (p. 15).
  • D — Harmful. Maintenance oral corticosteroids are a last resort (p. 27).

Takeaway: Uncontrolled asthma? Watch the inhaler technique and check the refills before reaching for a stronger drug.

Category: Adult chronic airways disease (outpatient asthma). Outline areas: I.B.1 interviewing, II.A.7 MDIs and spacers, III.I.5 disease management, III.F.3 guidelines.

Problem 18: Going home after an asthma admission

An 8-year-old boy is ready for discharge after 2 days in the hospital for an asthma exacerbation. He is on room air with SpO2 96%, speaking in full sentences, and taking albuterol every 4 hours. Before admission he used only albuterol, with no controller.

Section 1 — Information gathering. Select as many as you consider indicated.

  1. Home exposures
  2. Chest radiograph
  3. Current symptoms and peak flow
  4. Watch him use his inhaler
  5. Sweat chloride test
  6. Whether a follow-up appointment can be scheduled
Show results and rationale
Choice Result Rating Why
1. Exposures A parent smokes in the car Helpful A modifiable risk factor.
2. Chest radiograph — Not needed Not needed for discharge planning.
3. Symptoms/PEF Comfortable; PEF 85% of personal best Helpful Supports discharge readiness.
4. Technique Uses the MDI without a spacer and inhales too quickly Helpful Needs a spacer and training.
5. Sweat chloride — Not needed No indication.
6. Follow-up Clinic can see him in 3 days Helpful GINA advises follow-up within 2–5 days for children.

Section 2 — Decision making. Choose only one.

  • A. Discharge on albuterol as needed only
  • B. Scheduled home nebulized albuterol every 4 hours indefinitely
  • C. Follow up in 3 months
  • D. Start the ICS-containing maintenance treatment prescribed, train MDI use with a valved holding chamber using teach-back, give a written action plan with reliever use as needed, advise a smoke-free car and home, and book follow-up within a few days
Show what happens
  • D — Best. GINA 2026 advises, before discharge, starting or increasing ICS-containing therapy, taking the reliever as needed rather than routinely, training inhaler technique with a spacer, and arranging follow-up within 2–5 days for children (pp. 35–36). It also says children 6–11 should not be treated with SABA alone (p. 28).
  • A — Harmful. SABA-only treatment leaves him exposed to repeat severe exacerbations.
  • B — Harmful. Regular SABA use isn't recommended, and GINA links home nebulized SABA with increased risk of asthma death (p. 15).
  • C — Not the best choice. Too late after a hospitalization.

Takeaway: Every asthma discharge needs an ICS-containing controller, real inhaler training with a spacer when using a pressurized MDI, a written action plan, and early follow-up.

Category: Pediatric (asthma). Outline areas: II.A.7 MDIs and valved holding chambers, III.I.5 disease management, III.I.3 lifestyle changes, III.F.3 guidelines.

Problem 19: Low saturation the day after abdominal surgery

A 56-year-old woman is on postoperative day 1 after an open cholecystectomy. She is breathing shallowly because of incisional pain and hasn't been out of bed. SpO2 is 91% on room air, and her temperature is 38.0 °C. She is alert, converses normally, and has no escalating respiratory distress. Her prescribed oxygen target is 94–98%.

Section 1 — Information gathering. Select as many as you consider indicated.

  1. CT of the chest
  2. Inspiratory capacity (incentive spirometer volume)
  3. Mobility since surgery
  4. Sputum culture
  5. Breath sounds
  6. Chest radiograph
  7. Pain score
Show results and rationale
Choice Result Rating Why
1. Chest CT — Not needed The film answers the question.
2. Inspiratory capacity About 800 mL Helpful Low effort; a baseline to track.
3. Mobility Has stayed in bed Helpful Immobility contributes.
4. Sputum culture — Not needed She isn't producing sputum, and the picture fits atelectasis.
5. Breath sounds Diminished at both bases; no rhonchi Helpful Fits atelectasis rather than retained secretions.
6. Chest radiograph Bibasilar plate-like atelectasis; no consolidation Helpful Confirms atelectasis.
7. Pain 8/10; limits deep breaths Helpful Pain is driving the shallow breathing.

Section 2 — Decision making. Choose only one.

  • A. Incentive spirometry 10 times an hour as the only intervention
  • B. Provide oxygen titrated to her prescribed target and recommend better pain control, early mobilization, deep breathing with directed coughing, and incentive spirometry as part of that bundle
  • C. Chest physiotherapy with postural drainage every 4 hours
  • D. Recommend intubation
Show what happens
  • B — Best. By the next morning she has walked twice, her pain is 4/10, and SpO2 is 95% on room air. The AARC incentive spirometry guideline (Respir Care 2011;56:1600–1604) recommends incentive spirometry together with deep breathing, directed coughing, early mobilization, and optimal analgesia. Titrate oxygen to her prescribed target while treating the cause of her hypoxemia (AARC adult oxygen guideline).
  • A — Not the best choice. The same guideline does not recommend incentive spirometry alone for routine postoperative use.
  • C — Not the best choice. She has no secretion problem; chest physiotherapy doesn't address pain-limited shallow breathing.
  • D — Not the best choice. She has hypoxemia that needs treatment, but the findings do not establish a need for invasive ventilation.

Takeaway: Postoperative atelectasis needs pain control and getting the patient moving and breathing deeply. An incentive spirometer alone isn't the plan.

Category: Adult medical or surgical (other: postoperative). Outline areas: I.B.1.b level of pain, III.B.5 hyperinflation therapy, III.E.3.e hyperinflation, III.I patient education.

Problem 20: High-pressure alarm in status asthmaticus

A 33-year-old woman was intubated 8 hours ago for status asthmaticus. Settings: volume control, tidal volume 420 mL, rate 12, PEEP 5 cm H2O, inspiratory flow 60 L/min. The high-pressure alarm is sounding, and her SpO2 has dropped from 94% to 89%. Her blood pressure is 122/70. Tidal volume, inspiratory flow, and set PEEP have not changed. She is passive during valid inspiratory and expiratory holds, and an immediate circuit check finds no kink or water obstruction.

Section 1 — Information gathering. Select as many as you consider indicated.

  1. Preoxygenate and pass a suction catheter
  2. Expiratory hold for auto-PEEP
  3. Breath sounds
  4. Tube depth and whether she is biting the tube
  5. Prepare for chest tube insertion
  6. Peak and plateau pressures, compared with earlier values
Show results and rationale
Choice Result Rating Why
1. Suction A catheter passes without force after preoxygenation and returns thick secretions; secretions and rhonchi remain Helpful Secretions are contributing, and clearance is not yet complete.
2. Auto-PEEP 2 cm H2O Helpful A small measured auto-PEEP compared with the marked rise in peak-to-plateau pressure difference.
3. Breath sounds Equal bilaterally; coarse rhonchi over the large airways; diffuse wheeze Helpful Equal sounds argue against pneumothorax.
4. Tube 22 cm at the lip, unchanged; bite block in place Helpful Makes major tube movement and biting less likely; continue to assess airway patency.
5. Chest tube — Not needed The current findings do not justify chest-tube preparation; assess the airway and pressure change first.
6. Pressures Before suction: peak 52 cm H2O (was 38); plateau 22 cm H2O (was 21) Helpful The peak-to-plateau gap widened from 17 to 30 while plateau barely moved: a resistance problem, not a compliance problem (Al-Rawas et al., Introduction).

Section 2 — Decision making. Choose only one.

  • A. Needle-decompress the left chest
  • B. Increase the rate to 20
  • C. After preoxygenation, use brief suction passes as needed to clear the remaining secretions, give the ordered inline bronchodilator, and recheck peak and plateau pressures
  • D. Switch to pressure control with the pressure limit at 30 cm H2O
Show what happens
  • C — Best. After suctioning and albuterol, peak pressure is 39 cm H2O, plateau 21, and SpO2 94%. With unchanged flow and tidal volume and a valid plateau measurement, a larger peak-to-plateau difference supports increased resistance: secretions, bronchospasm, or a narrowed tube. The AARC suctioning guideline supports suctioning when secretions and breath sounds indicate it, with preoxygenation and brief passes.
  • A — Harmful. No evidence of tension physiology: plateau unchanged, breath sounds equal, blood pressure stable.
  • B — Harmful. More breaths per minute shorten expiratory time in an asthmatic.
  • D — Not the best choice. Changing modes does not remove the obstruction, and delivered tidal volume may fall when pressure is limited. Treat the cause and reassess ventilation.

Takeaway: With comparable flow and tidal volume, a rising peak-to-plateau gap points to increased resistance: check the tube, circuit, secretions, and bronchospasm. If plateau also rises, reassess compliance, total PEEP, and tidal volume rather than diagnosing from the alarm alone.

Category: Adult chronic airways disease (intubation and mechanical ventilation). Outline areas: I.C.10 compliance and airways resistance, I.C.11 plateau pressure, III.B.2 suctioning, III.D.1.c bronchodilators.

Answer key at a glance

Use this after you've worked the problems, to find your misses fast. Full explanations stay with each problem above.

Problem Category All information-gathering choices rated Helpful Best decision(s)
1 Chronic airways: noninvasive 1, 2, 3, 4, 5, 7 S2: B · S3: C
2 Neonatal: RDS 2, 3, 4, 5, 7 S2: C · S3: A
3 Medical/surgical: other (CO) 1, 4, 5, 6, 7 A
4 Cardiovascular: PE 1, 2, 4, 5, 6, 7 S2: D · S3: B
5 Chronic airways: ventilation 1, 2, 3, 5, 7 S2: C · S3: A
6 Pediatric: bronchiolitis 1, 4, 5, 6, 7 S2: D · S3: A
7 Medical/surgical: infectious 1, 3, 4, 5, 6 S2: A · S3: C
8 Chronic airways: diagnosis 1, 4, 5, 6, 7 B
9 Trauma 1, 3, 5, 6, 7 D
10 Medical/surgical: CF 1, 2, 3, 4, 6 S2: B · S3: C
11 Chronic airways: outpatient COPD 2, 3, 4, 6 S2: A · S3: D
12 Neurological S2: 1, 2, 4, 5 S1: C · S3: B
13 Cardiovascular: heart failure 1, 2, 3, 5, 6 D
14 Chronic airways: noninvasive 1, 3, 4, 5, 6 A
15 Neonatal: resuscitation S2: 1, 2, 4, 5 S1: B · S3: D
16 Medical/surgical: ARDS 1, 2, 3, 5, 7 C
17 Chronic airways: outpatient asthma 1, 2, 3, 4, 7 A
18 Pediatric: asthma 1, 3, 4, 6 D
19 Medical/surgical: other (postoperative) 2, 3, 5, 6, 7 B
20 Chronic airways: ventilation 1, 2, 3, 4, 6 C

Check your own work (not a score)

In information-gathering sections, write down every option you'd select before opening the results. In decision-making sections, commit to one choice first. Later sections follow the stated clinical course regardless of your earlier choice; read the supplied updates before continuing.

Helpful, Not needed, Harmful, and Best are teaching labels for these cases, not NBRC point values. For each problem, tally three things:

  • Helpful choices you selected out of the total available
  • Harmful choices you selected (aim for zero)
  • Decision sections you got right on the first try

For each miss, write one line naming the clinical principle you broke, not just the letter you picked ("used peak pressure where plateau pressure was needed"). Then look for patterns rather than a percentage. Missing the same kind of step twice (skipping the stable baseline gas, forgetting to check the airway, reaching for imaging in an unstable patient) tells you what to study. This tally isn't NBRC scoring and can't predict a pass. NBRC adds the points from your choices across the whole exam and compares the total with one cut score (Candidate Handbook, p. 12). This page's tally cannot be converted into that score.

The problem mix on this test

The 20 problems follow the patient-type counts in NBRC's CSE Detailed Content Outline (Test Form Assembly Specifications), which applies to the CSE through December 31, 2027.

Category on the outline Scored problems on a CSE form Problems here
Adult chronic airways disease 7 (2 intubation/ventilation, 2 noninvasive, 1 outpatient COPD, 1 outpatient asthma, 1 diagnosis) 5, 20 · 1, 14 · 11 · 17 · 8
Adult medical or surgical 5 (1 CF or bronchiectasis, 1 infectious disease, 1 ARDS, 2 other) 10 · 7 · 16 · 3, 19
Adult cardiovascular 2 (1 heart failure, 1 other) 13 · 4
Pediatric 2 (1 asthma, 1 other) 18 · 6
Neonatal 2 (1 respiratory distress syndrome, 1 resuscitation) 2 · 15
Adult trauma 1 9
Adult neurological or neuromuscular 1 12

The outline doesn't list examples for the neurological category; we used an opioid overdose here.

How the real CSE differs from this page

These 20 study problems contain 20 information-gathering sections and 30 decision-making sections. Matching the patient-type counts does not establish equivalent exam length or difficulty, and this set has no official score conversion.

  • Length and time: 22 problems, 20 scored and 2 unidentified pretest problems, in 4 hours (NBRC CSE page).
  • No unselecting: In information gathering, each choice reveals its result and stays revealed. After advancing to the next section, you cannot make more selections in the previous one. Here you can reread freely, which makes the habit of committing first more important.
  • Choosing again: In decision making, the software may tell you to make another selection. On this page you see every option's rationale at once.
  • One combined score: Points from both section types are summed across the exam, not per problem (Candidate Handbook, CSE scoring and software sections).

Where to practice next

  • NBRC's free CSE practice: one problem, linked from the NBRC CSE page, useful for learning the software. NBRC says its difficulty doesn't reflect the real exam.

  • Not eligible for the CSE? From 2027, the RRT comes from the high cut score on the new multiple-choice Respiratory Therapy Examination; this page doesn't practice that format. Our respiratory therapist certification guide covers both routes.

Common questions

Is there an official free NBRC CSE practice test? Yes, but it's a single problem meant to teach the exam software. See the Candidate Handbook, pp. 13–14, for its purpose and limits.

How many problems are on the CSE, and how long is it? 22 problems (20 scored, 2 unscored pretest problems you can't identify) in 4 hours.

What score do I need to pass? NBRC compares your summed points with a single cut score set through the exam committee's judgments. Your official score report shows your result; this page's practice tally does not establish whether you would pass (Candidate Handbook, p. 12).

Can I still take the CSE? Only if you passed the TMC at the high cut score by December 31, 2026 and meet the CSE admission requirements; the CSE ends December 31, 2027 (NBRC CSE page). If you meet the RT Examination's admission requirements, you can instead choose that exam in 2027, but decide before you apply: NBRC's September 10, 2026 notice says that once you apply for the RT Examination, you can no longer apply for the CSE (as posted by Indiana's Professional Licensing Agency). Retake rules and timing are in the NBRC Candidate Handbook, p. 13.

Are these real NBRC questions? No. Every problem here was written for this page; none is copied or recalled from an NBRC exam.

Sources

NBRC (checked October 30, 2026)

Clinical sources used in the problems (checked October 30, 2026 unless noted)

By Castleport Test Prep Editorial Team

How we checked this page: We matched the problem mix to NBRC's CSE content outline, confirmed exam facts on NBRC's CSE page, and checked each problem's key decision against the clinical source listed beside it. We also recalculated every blood gas (Henderson–Hasselbalch), predicted body weight, ratio, and ventilator time in the problems. The problems are original; they haven't been reviewed by NBRC or by a clinical reviewer. AI tools assisted with drafting and source checking under our editorial methodology; source checking is not professional clinical review. In real patient care, follow your facility's protocols and the physician's orders.

Last verified: October 30, 2026 (NBRC exam facts and the clinical guidance cited in these problems).

Castleport Test Prep is an independent exam prep publisher. It is not affiliated with, endorsed by, or approved by the National Board for Respiratory Care (NBRC). Exam and credential names identify their subjects; trademarks belong to their respective owners. The practice simulations on this page are original and are not NBRC exam problems.

Free NBRC CSE Practice Test: 20 Cases With Answers