Free NBRC TMC Practice Test
Answer 42 original, unofficial questions weighted to the scored TMC's section proportions, with the answer and a rationale for every option under each question. This focused set follows the TMC outline used through the exam's last test day, December 31, 2026; it is not a full-length exam.
Section I: Patient Data (15 questions)
Question 1 · TMCP-01
A trauma patient's supine portable chest radiograph report describes an abnormally deep, lucent left costophrenic angle. Which condition does this finding suggest?
Show answer and explanation
Answer: C. Left pneumothorax
This is the deep sulcus sign. When a patient lies supine, pleural air collects in the front and base of the chest and deepens the lateral costophrenic angle, so a pneumothorax may not show the familiar apical edge.
Why not the others
- A. Atelectasis adds density (whiter lung); it doesn't create an extra-lucent angle.
- B. Fluid also adds density and tends to blunt the angle, not deepen it.
- D. A tube in the right mainstem tends to collapse the left lung, which looks dense, not lucent.
Topic: I.A Evaluate data in the patient record. Source: SAEM CDEM — Chest Radiograph, Sections 3–4: lung fields and Deep Sulcus Sign; ARRS — Noncardiac Devices and Central Venous Catheters, p. 2 and Figure 1C–D
The scenarios are simplified for exam study and aren't instructions for treating a patient.
The real TMC gives you 3 hours for 160 questions, about 68 seconds each. At that pace, this set takes about 47 minutes if you want to time yourself. Pick an answer before you open the explanation, and jot down your first choice so you can score yourself at the end. NBRC TMC format
Deadlines and the 2027 change ↓
Question 2 · TMCP-02
An anxious adult's record shows this room-air ABG: pH 7.50, PaCO₂ 29 mm Hg, HCO₃⁻ 22 mEq/L. What is the primary acid-base disturbance?
Show answer and explanation
Answer: A. Acute respiratory alkalosis
pH above 7.45 is alkalemia, and the low PaCO₂ moves in the opposite direction to pH, which marks a respiratory cause. For acute respiratory alkalosis, HCO₃⁻ falls about 2 mEq/L per 10 mm Hg drop in PaCO₂: 40 − 29 = 11, so about 24 − 2.2 ≈ 22 — consistent with the expected acute compensation.
Why not the others
- B. A metabolic alkalosis needs a high HCO₃⁻; this one is slightly low.
- C. The pH is alkalemic, not acidemic.
- D. Compensation for a simple metabolic acidosis does not produce this alkalemic pH.
Topic: I.A Evaluate data in the patient record. Source: American Thoracic Society — Interpretation of ABGs, Steps 2–4
Question 3 · TMCP-03
Over the right lower chest you find dull percussion, increased tactile fremitus, and bronchial breath sounds. These findings are most consistent with:
Show answer and explanation
Answer: D. Consolidation
Solid, airless lung transmits vibration and sound better than normal lung. That gives increased fremitus and bronchial breath sounds, and the solid tissue percusses dull.
Why not the others
- A. Pneumothorax percusses hyperresonant, with reduced fremitus and breath sounds.
- B. An effusion is dull too, but fluid damps vibration, so fremitus and breath sounds decrease. That's the distinction this question tests.
- C. Emphysema gives hyperresonance and diminished breath sounds.
Topic: I.B Perform clinical assessment. Source: Loyola University Chicago — Pneumonia Case 1, Answer 5; Loyola University Chicago — The Lungs: Lung Resonance and Breath Sounds
Question 4 · TMCP-04
On postoperative day 1, an afebrile patient has coarse crackles over the central chest that disappear completely after a strong cough. The most likely cause is:
Show answer and explanation
Answer: B. Secretions in the larger airways
Coarse sounds that clear when the patient coughs are secretions moving in the larger airways. Coughing moves the mucus, and the sound goes with it.
Why not the others
- A. Fibrotic crackles are persistent and don't change with coughing.
- C. Pneumothorax reduces or removes breath sounds over the area; it doesn't cause crackles.
- D. Effusion diminishes breath sounds; it doesn't produce crackles that clear with a cough.
Topic: I.B Perform clinical assessment. Source: Loyola University Chicago — Adventitious Sounds; Loyola University Chicago — The Lungs: Lung Resonance and Breath Sounds
Question 5 · TMCP-05
A 12-year-old with type 1 diabetes has a blood glucose of 520 mg/dL and is breathing deeply and rapidly. ABG: pH 7.12, PaCO₂ 18 mm Hg, HCO₃⁻ 6 mEq/L. The breathing pattern is best described as:
Show answer and explanation
Answer: C. Kussmaul breathing compensating for metabolic acidosis
The ABG shows severe metabolic acidosis. Deep, rapid Kussmaul breathing blows off CO₂ to offset a severe metabolic acidosis. Check it with Winter's formula: expected PaCO₂ = 1.5 × 6 + 8 = 17 (±2). A PaCO₂ of 18 is consistent with appropriate respiratory compensation.
Why not the others
- A. A primary respiratory alkalosis would raise pH. Here pH is 7.12 and HCO₃⁻ is very low.
- B. Cheyne-Stokes breathing waxes and wanes with periods of apnea.
- D. Biot breathing is irregular, with clusters of breaths and apneas — not steady deep breathing.
Topic: I.B Perform clinical assessment. Source: ISPAD Clinical Practice Consensus Guidelines: Diabetic Ketoacidosis (2022), pp. 835–838; American Thoracic Society — Interpretation of ABGs, Steps 2–4; Merck Manual Professional — Evaluation of the Patient With Pulmonary Issues: Inspection
Question 6 · TMCP-06
A passive patient on volume control has a tidal volume of 500 mL, PIP 32 cm H₂O, plateau pressure 25 cm H₂O, and total PEEP 5 cm H₂O. What is the static compliance?
Show answer and explanation
Answer: B. 25 mL/cm H₂O
Static compliance = VT ÷ (plateau pressure − total PEEP) = 500 ÷ (25 − 5) = 25 mL/cm H₂O.
Why not the others
- A. 500 ÷ (32 − 5) uses peak pressure. That's dynamic compliance, which includes airway resistance.
- C. 500 ÷ 25 forgets to subtract PEEP.
- D. 500 ÷ 32 uses peak pressure and ignores PEEP.
Topic: I.C Pulmonary compliance and airways resistance. Source: Hamilton Medical — Measurements of Respiratory Mechanics, §§3.4.1.1, 4.2–4.3; Hamilton Medical — Static Compliance vs. Dynamic Compliance
Question 7 · TMCP-07
In a passive patient on volume-controlled ventilation with a constant (square-wave) inspiratory flow of 60 L/min, PIP is 35 cm H₂O and plateau pressure is 25 cm H₂O. What is the airway resistance?
Show answer and explanation
Answer: D. 10 cm H₂O/(L/s)
Airway resistance = (PIP − plateau) ÷ flow in L/s. Convert first: 60 L/min = 1 L/s. So (35 − 25) ÷ 1 = 10 cm H₂O/(L/s). Peak pressure includes the pressure spent pushing gas through the airways; plateau is measured with no flow, so the difference is the resistive part.
Why not the others
- A. 10 ÷ 60 leaves flow in L/min. To express resistance in cm H₂O/(L/s), convert flow to L/s first.
- B. 35 ÷ 1 uses peak pressure alone, which also includes the elastic (plateau) pressure.
- C. 25 ÷ 1 uses plateau pressure, which has no resistive component at all.
Topic: I.C Pulmonary compliance and airways resistance. Source: Hamilton Medical — Measurements of Respiratory Mechanics, §§3.4.1.1, 4.2–4.3; Penn Medicine — Endotracheal Tube Obstruction, slide 10: Increasing Airway Resistance
Question 8 · TMCP-08
To measure auto-PEEP in a passive patient on volume control, the therapist should:
Show answer and explanation
Answer: A. Perform an end-expiratory hold
Closing the circuit for a few seconds at the end of exhalation lets alveolar pressure and airway pressure equalize. The reading is total PEEP; subtract the set PEEP to get auto-PEEP. The patient must be passive, because breathing efforts during the hold distort it.
Why not the others
- B. An end-inspiratory hold measures plateau pressure.
- C. Trigger sensitivity changes how easily a breath starts; it measures nothing.
- D. Peak pressure reflects resistance and compliance during flow, not trapped end-expiratory pressure.
Topic: I.C Auto-PEEP determination. Source: Hamilton Medical — Measurement of AutoPEEP and Total PEEP; Hamilton Medical — Measurements of Respiratory Mechanics, §§3.4.1.1, 4.2–4.3
Question 9 · TMCP-09
A 3-day-old on nasal CPAP has a warmed heel-stick capillary blood gas: pH 7.32, PCO₂ 48 mm Hg, PO₂ 38 mm Hg. The heel is warm and well perfused, and SpO₂ is 94%. Which interpretation is best?
Show answer and explanation
Answer: B. The pH and PCO₂ are useful, but capillary PO₂ underestimates arterial PO₂; judge oxygenation by SpO₂
AARC's 2022 guideline says capillary pH and PCO₂ agree well with arterial values in well-perfused sites, but capillary PO₂ does not — it significantly underestimates arterial PO₂. The guideline recommends using SpO₂ to assess oxygenation when capillary samples are used.
Why not the others
- A. Acting on the capillary PO₂ would treat a number that underestimates the baby's real oxygenation; the SpO₂ of 94% tells a different story.
- C. The pH and PCO₂ are useful here; only the PO₂ is unreliable.
- D. It's the opposite: capillary PO₂ runs low compared with arterial.
Topic: I.C Blood gas sample collection and analysis. Source: AARC Clinical Practice Guideline: Capillary Blood Gas Sampling (2022), pp. 1197, 1201–1202
Question 10 · TMCP-10
An adult confirmed to be breathing room air at sea level has this ABG: pH 7.48, PaCO₂ 30 mm Hg, PaO₂ 142 mm Hg. The syringe arrived with air bubbles still in it. What is the most likely explanation?
Show answer and explanation
Answer: C. Air contamination of the sample
Air bubbles can distort blood-gas results. In a room-air sample, equilibration with air can raise the measured PO₂; pH and PCO₂ may also be affected. The visible bubbles make this sample unsuitable for accepting the results as the patient's true blood-gas values. Obtain a new, properly collected sample and remove any air bubbles immediately after collection.
Why not the others
- A. Hyperventilation can raise PaO₂, but it does not make a visibly air-contaminated sample reliable.
- B. Venous blood has a low PO₂, not a high one.
- D. The visible air contamination prevents accepting these as reliable normal results.
Topic: I.D Evaluate procedure results. Source: AARC Clinical Practice Guideline: Blood Gas Analysis and Hemoximetry (2013), §§4.4, 6.1.2, 6.3; Toffaletti and McDonnell — Effect of Small Air Bubbles on Blood-Gas Parameters
Question 11 · TMCP-11
Pulmonary function results: TLC 62% predicted (below the lower limit of normal), FEV₁/FVC 0.86 (within the normal range), DLCO 45% predicted (below the lower limit of normal). These findings indicate:
Show answer and explanation
Answer: A. Restriction with impaired gas transfer, as in interstitial lung disease
Restriction is defined by a TLC below the lower limit of normal, and the preserved FEV₁/FVC does not show an obstructive spirometric pattern. The low DLCO is a separate finding: overall gas transfer is reduced, a pattern that can occur with interstitial lung disease.
Why not the others
- B. An obstructive spirometric pattern requires a reduced FEV₁/FVC. Here the low TLC establishes restriction.
- C. This option specifies normal gas transfer, but the measured DLCO is reduced. These results alone do not establish muscle weakness as the cause.
- D. Both TLC and DLCO are abnormal.
Topic: I.D Evaluate procedure results. Source: ERS/ATS Technical Standard: Interpretive Strategies for Lung Function Tests (2022), Figs. 8, 10–11; pp. 17, 21–24
Question 12 · TMCP-12
An adult performs three acceptable forced expiratory maneuvers. FEV₁ values are 2.10 L, 1.98 L, and 1.85 L. Does FEV₁ meet the 2019 ATS/ERS repeatability criterion?
Show answer and explanation
Answer: D. Yes — the two largest differ by 0.12 L, which is under 0.150 L
Repeatability compares the largest and the next-largest acceptable values. 2.10 − 1.98 = 0.12 L (120 mL), which is under the 0.150 L criterion for people older than 6.
Why not the others
- A. The third value doesn't have to fall within 0.150 L of the largest; only the top two are compared.
- B. 0.050 L is not the criterion for this age group.
- C. FVC repeatability is judged separately; FEV₁ repeatability uses the FEV₁ values.
Topic: I.D Evaluate procedure results. Source: ATS/ERS Standardization of Spirometry 2019 Update, Table 7 and pp. e79–e80
Question 13 · TMCP-13
During mechanical ventilation for an asthma exacerbation, the capnogram shows a slow, sloping upstroke and a plateau that keeps rising — a "shark fin" shape. This indicates:
Show answer and explanation
Answer: B. Bronchospasm with uneven emptying of the lungs
Narrowed airways empty unevenly, so CO₂ reaches the sensor gradually and the waveform slopes upward like a fin.
Why not the others
- A. Esophageal placement produces little or no sustained CO₂ waveform.
- C. A disconnection can cause abrupt loss of the waveform rather than this sustained shark-fin pattern.
- D. Rebreathing shows a baseline that doesn't return to zero.
Topic: I.D Evaluate procedure results. Source: ACEP Now — End-Tidal Capnography in Asthma, Figure 2 discussion; OpenAnesthesia — Capnography: Abnormal Waveform Patterns; AARC Clinical Practice Guideline: Capnography/Capnometry During Mechanical Ventilation (2011), §§4.1, 4.2, 4.3, 14
Question 14 · TMCP-14
Acceptable spirometry shows a low FVC with a normal FEV₁/FVC ratio. To find out whether the patient truly has restriction, the therapist should recommend:
Show answer and explanation
Answer: C. Lung volume measurement, including TLC
A low FVC can suggest restriction but doesn't prove it; the ERS/ATS standard says restriction must be confirmed by measuring TLC. A low FVC by itself goes with a low TLC less than half the time, and it can also reflect poor effort or early small-airway disease.
Why not the others
- A. Bronchodilator testing can assess a response to treatment, but it does not measure TLC or confirm restriction.
- B. Methacholine challenge tests airway hyperresponsiveness, not lung volume.
- D. Spirometry alone can't confirm restriction.
Topic: I.E Recommend diagnostic procedures. Source: ERS/ATS Technical Standard: Interpretive Strategies for Lung Function Tests (2022), Figs. 8, 10–11; pp. 17, 21–24; ATS/ERS Standardization of Spirometry 2019 Update, pp. e81–e82: Bronchodilator Responsiveness Testing
Question 15 · TMCP-15
A patient admitted with a COPD exacerbation was moved from 2 L/min to 4 L/min nasal cannula an hour ago and is now hard to rouse. SpO₂ is 95%. Urgent bedside assessment and support are underway. Which diagnostic test should the therapist recommend?
Show answer and explanation
Answer: A. An arterial blood gas now
New drowsiness after an oxygen increase in COPD raises concern for CO₂ retention, and pulse oximetry does not measure PaCO₂. An ABG measures PaCO₂ and pH to help guide oxygen titration and the assessment of ventilatory support needs. Testing must not delay airway or ventilatory support.
Why not the others
- B. More oxygen could worsen hypercapnia.
- C. Incentive spirometry doesn't address an acute change in consciousness.
- D. A sputum culture does not assess ventilation or acid-base status.
Topic: I.E Recommend diagnostic procedures. Source: BTS Guideline for Oxygen Use (2017), recommendation C3 and assessment guidance
Section II: Troubleshooting and Quality Control of Devices, and Infection Control (6 questions)
Question 16 · TMCP-16
A bubble humidifier on a nasal cannula running at 6 L/min begins whistling from its pressure-relief valve. The most likely cause is:
Show answer and explanation
Answer: D. Kinked or blocked tubing between humidifier and patient
The pop-off valve vents and sounds when pressure builds because flow can't get out downstream — a kink, a pinched cannula, or a blocked outlet. Trace the tubing from the humidifier to the patient.
Why not the others
- A. Low water affects humidity, not back-pressure.
- B. Lower flow means less pressure, not more.
- C. A loose lid creates a leak rather than the downstream obstruction indicated by the alarm.
Topic: II.A Humidifiers. Source: AirLife 7900 Bubble Humidifier Hospital-Use User Guide, steps 6 and 8
Question 17 · TMCP-17
A 4-year-old is prescribed budesonide inhalation suspension. The family brings an ultrasonic nebulizer from home to use with it. What should the therapist do?
Show answer and explanation
Answer: B. Use a jet nebulizer; the label excludes ultrasonic nebulizers
The prescribing information says budesonide inhalation suspension should be given by jet nebulizer and that ultrasonic nebulizers aren't suitable for adequate delivery.
Why not the others
- A. Device choice matters for suspensions; the label specifically excludes ultrasonic nebulizers.
- C. Mixing does not correct the device problem; the label directs separate administration of this suspension.
- D. A dry-powder inhaler is a different formulation and delivery system; it is not a substitute for the prescribed nebulized suspension.
Topic: II.A Nebulizers. Source: Budesonide Inhalation Suspension prescribing information (DailyMed), §§1.1, 2.2, 5.1–5.2, 17 and Patient Information
Question 18 · TMCP-18
A patient has a chest tube for pneumothorax. You notice continuous bubbling in the water-seal chamber of the drainage system. This indicates:
Show answer and explanation
Answer: A. An air leak from the chest or the system
Bubbling in the water seal means air is entering the system — either from the pleural space or the insertion site, or from a leak in the tubing and connections. Assess the patient, inspect the drainage system and connections, and report the leak to the responsible clinician. Do not routinely clamp a bubbling chest tube; clamping is reserved for specific circumstances under specialist supervision.
Why not the others
- B. Continuous bubbling indicates an air leak, even though air drainage may occur while a pneumothorax resolves.
- C. Clamping alone does not explain continuous bubbling; a leak downstream of a clamp can still introduce air.
- D. Losing suction doesn't create bubbling in the water seal.
Topic: II.A Pleural drainage. Source: BTS Clinical Statement on Pleural Procedures (2023), underwater-seal drain guidance, p. 3; Getinge/Atrium Oasis Chest Drain instructions, Warnings, Precautions and Water Seal, pp. 3–4
Question 19 · TMCP-19
A patient is admitted with suspected active pulmonary tuberculosis. Which precautions apply?
Show answer and explanation
Answer: C. Airborne precautions: a negative-pressure airborne isolation room and a fit-tested NIOSH-approved N95 or appropriate higher-level respirator
TB spreads through the air in tiny droplet nuclei. Use Airborne Precautions in addition to Standard Precautions, including an airborne isolation room and a fit-tested NIOSH-approved N95 or appropriate higher-level respirator for staff. A surgical mask is not a substitute for the required respirator for staff, though the patient can wear one outside the room.
Why not the others
- A. Droplet precautions do not provide the required airborne protection for staff caring for suspected infectious TB.
- B. Contact precautions don't address airborne transmission.
- D. Standard precautions alone aren't enough for suspected infectious TB.
Topic: II.B Ensure infection prevention. Source: CDC — Transmission-Based Precautions: Airborne Precautions; CDC — Isolation Precautions, §§V.D.2, V.D.4 and V.D.5
Question 20 · TMCP-20
After suctioning a patient, a therapist removes and discards her gloves. What should she do next?
Show answer and explanation
Answer: D. Clean her hands immediately
CDC guidance says to clean your hands immediately after removing gloves; gloves are not a substitute for hand hygiene. Hands can be contaminated during removal or through tiny defects you can't see.
Why not the others
- A. Gloves don't replace hand hygiene.
- B. Hand hygiene after glove removal applies every time, torn or not.
- C. New gloves over contaminated hands carry the contamination forward.
Topic: II.B Ensure infection prevention. Source: CDC — Clinical Safety: Hand Hygiene for Healthcare Workers; CDC — Guideline for Hand Hygiene in Health-Care Settings: Gloving Policies
Question 21 · TMCP-21
According to the 2019 ATS/ERS spirometry standard, how often must a spirometer's calibration be verified with a 3-L syringe?
Show answer and explanation
Answer: B. At least daily
The standard requires calibration verification at least daily with a 3-L syringe (and lists daily verification in its quality-control table).
Why not the others
- A. Weekly is less often than the standard requires.
- C. Monthly is far less often than required.
- D. Verification is routine, not only after repairs.
Topic: II.C Perform quality control procedures. Source: ATS/ERS Standardization of Spirometry 2019 Update, pp. e75–e76: Device Quality Assurance and Table 3
Section III: Initiation and Modification of Interventions (21 questions)
Question 22 · TMCP-22
An adult who has been intubated for 8 days has passed a spontaneous breathing trial and otherwise meets extubation criteria. Because she is at high risk for postextubation stridor, the team performs a cuff leak test, which she fails. What should the therapist recommend before extubation?
Show answer and explanation
Answer: A. Systemic corticosteroids at least 4 hours before extubation
For an adult who fails a cuff leak test but is otherwise ready for extubation, the ATS/CHEST guideline suggests systemic corticosteroids at least 4 hours before extubation. This is a conditional recommendation with moderate certainty. A failed cuff leak test identifies increased risk; it does not by itself prove that airway obstruction will occur.
Why not the others
- B. Immediate extubation without the recommended precaution ignores the increased risk identified by the failed cuff leak test.
- C. Albuterol treats lower-airway bronchospasm; it is not the guideline-recommended prevention measure for this failed cuff leak test.
- D. Incentive spirometry does not address the risk identified by a failed cuff leak test.
Topic: III.A.8 Performing extubation. Source: ATS/CHEST Ventilator-Liberation Guideline (2017), recommendation 4 and Question 3b, pp. 121, 130
Question 23 · TMCP-23
An intubated patient using a heat-and-moisture exchanger (HME) now has thick, copious secretions, and peak pressure is rising. The therapist should recommend:
Show answer and explanation
Answer: C. Switching to a heated humidifier
The AARC humidification guideline lists thick, copious, or frankly bloody secretions as a contraindication to an HME and says a heated humidifier should replace it when secretions become copious or tenacious. Secretions clogging the HME also add resistance, which fits the rising peak pressure.
Why not the others
- A. Frequent HME changes do not address the contraindication to HME use in a patient with thick, copious secretions.
- B. AARC calls routine saline instillation unnecessary during suctioning.
- D. Increasing inspiratory flow does not correct unsuitable humidification or clear an obstructed HME.
Topic: III.A Maintain humidification. Source: AARC Clinical Practice Guideline: Humidification During Mechanical Ventilation (2012), §§4.1, 10.5–10.6; AARC Clinical Practice Guideline: Artificial Airway Suctioning (2022), pp. 258–259, 262, 266–267
Question 24 · TMCP-24
An intubated adult has coarse rhonchi over the trachea and visible secretions in the endotracheal tube. After correctly performed shallow suctioning (catheter advanced only to the end of the tube), secretions remain. The therapist has preoxygenated the patient before another suction pass; oxygenation and hemodynamics are stable. What should the therapist do next?
Show answer and explanation
Answer: B. Perform deep suctioning and reassess
AARC recommends shallow suctioning routinely and deep suctioning only when shallow suctioning is ineffective — which is the situation here. Reassess breath sounds, SpO₂, and secretions afterward.
Why not the others
- A. Routine saline instillation is unnecessary, per AARC.
- C. Deep suctioning is reserved for ineffective shallow suctioning; it should not become an automatic hourly procedure.
- D. Persistent secretions after ineffective shallow suctioning warrant reassessment and an appropriate clearance method.
Topic: III.B Suctioning. Source: AARC Clinical Practice Guideline: Artificial Airway Suctioning (2022), pp. 258–259, 262, 266–267
Question 25 · TMCP-25
A patient with amyotrophic lateral sclerosis (ALS) has retained secretions and a peak cough flow of 180 L/min. Which therapy best supports secretion clearance?
Show answer and explanation
Answer: D. Mechanical insufflation-exsufflation (cough assist)
The AARC guideline recommends cough-assist techniques in neuromuscular disease, particularly when peak cough flow is below 270 L/min, and cites ALS guidance supporting mechanical insufflation-exsufflation. The device delivers a positive-pressure breath, then switches quickly to negative pressure to create the expiratory flow the patient can't.
Why not the others
- A. Incentive spirometry is for lung expansion; it doesn't create a cough.
- B. PEP still depends on the patient's own expiratory effort and cough.
- C. Postural drainage can move secretions centrally but can't replace an effective cough.
Topic: III.B.3 Mechanical devices: insufflation/exsufflation. Source: AARC Clinical Practice Guideline: Nonpharmacologic Airway Clearance (2013), pp. 2187–2189
Question 26 · TMCP-26
An adult with pneumonia and no chronic lung disease has SpO₂ 88% on 6 L/min nasal cannula, a respiratory rate of 30, and PaCO₂ 34 mm Hg. He is alert, protecting his airway, and has no immediate need for intubation. What should the therapist recommend?
Show answer and explanation
Answer: A. Heated high-flow nasal cannula
This is new (de novo) acute hypoxemic respiratory failure. The 2026 ATS guideline strongly recommends high-flow nasal cannula for adults with acute hypoxemic respiratory failure, based primarily on its effect on the need for intubation. Monitor closely and escalate if he worsens.
Why not the others
- B. A simple mask is still standard oxygen; the guideline supports escalation to HFNC for this clinical group.
- C. Nothing in the stem calls for intubation right now.
- D. Incentive spirometry won't correct acute hypoxemic respiratory failure.
Topic: III.C Start and adjust oxygen therapy. Source: ATS Guideline: Noninvasive Respiratory Support (2026), abstract Results and Conclusions
Question 27 · TMCP-27
According to the AARC's 2022 guideline on managing oxygen in acute care, what SpO₂ range is optimal for most adults who need supplemental oxygen (those without COPD)?
Show answer and explanation
Answer: B. 94–98%
The guideline supports an SpO₂ of 94–98% for most patients requiring supplemental oxygen and 88–92% for patients with COPD.
Why not the others
- A. 88–92% is the range for COPD.
- C. Aiming for 99–100% risks giving more oxygen than needed.
- D. 85–88% is below the recommended ranges.
Topic: III.C Start and adjust oxygen therapy. Source: AARC Clinical Practice Guideline: Managing Oxygen in Acute Care (2022), Table 2 p. 120
Question 28 · TMCP-28
An adult with acute cardiogenic pulmonary edema is alert, breathing 34 times a minute, with SpO₂ 86% on a nonrebreather and BP 168/96. There is no sign of acute coronary syndrome or shock. The therapist should recommend:
Show answer and explanation
Answer: C. CPAP or bilevel noninvasive ventilation by mask
The ERS/ATS guideline strongly recommends either CPAP or bilevel NIV for acute respiratory failure from cardiogenic pulmonary edema. Positive airway pressure improves respiratory mechanics and reduces left ventricular afterload. The guideline excludes acute coronary syndrome and cardiogenic shock, which the stem rules out.
Why not the others
- A. Less oxygen than a nonrebreather won't fix this hypoxemia.
- B. Incentive spirometry can't treat flooded alveoli.
- D. Percussion can't clear fluid from the alveoli; it doesn't treat pulmonary edema.
Topic: III.C Start and adjust mask CPAP. Source: ERS/ATS Guideline: Noninvasive Ventilation for Acute Respiratory Failure (2017), Question 2a
Question 29 · TMCP-29
A patient with COPD on assist-control shows visible inspiratory efforts — neck muscle contraction and small dips on the pressure waveform — that don't trigger breaths. Expiratory flow doesn't return to zero before the next breath, and the trigger sensitivity is set appropriately. What best explains the missed triggers?
Show answer and explanation
Answer: A. Auto-PEEP raising the trigger threshold
Expiratory flow that does not return to zero before the next breath indicates incomplete exhalation and supports air trapping (auto-PEEP). The patient must first breathe in hard enough to overcome that trapped pressure before the ventilator senses any effort — AARC describes this as an increased trigger threshold.
Why not the others
- B. An overly sensitive trigger causes extra (auto-triggered) breaths, not missed ones.
- C. A circuit leak does not explain the combination of incomplete exhalation and missed inspiratory efforts as well as auto-PEEP does.
- D. Reduced respiratory drive from sedation can contribute to ineffective triggering, but it does not account for the incomplete exhalation described here; auto-PEEP best explains the combined findings.
Topic: III.C Patient-ventilator dyssynchrony. Source: AARC Clinical Practice Guideline: Patient-Ventilator Assessment (2024), Table 2 and p. 1046; Hamilton Medical — How to Diagnose and Avoid Ineffective Efforts; HAMILTON-C3 Operator's Manual, Tables 4-2 and 6-5, pp. 97, 133
Question 30 · TMCP-30
A patient with COPD uses fluticasone/salmeterol (Advair Diskus) twice daily. She asks whether to take an extra dose when she suddenly feels short of breath. The therapist should tell her to:
Show answer and explanation
Answer: D. Use a short-acting bronchodilator such as albuterol for quick relief
The prescribing information says fluticasone/salmeterol is not indicated for relief of acute bronchospasm and directs patients to use a short-acting inhaled beta₂-agonist for immediate relief.
Why not the others
- A. Salmeterol isn't for rescue, and extra doses add long-acting beta-agonist exposure.
- B. Doubling doses doesn't treat symptoms happening now.
- C. Inhaled steroids don't open airways quickly, so they don't relieve sudden symptoms. The Diskus also delivers a fixed combination, so its steroid component cannot be selected separately.
Topic: III.D Administer medications. Source: ADVAIR DISKUS Prescribing Information (rev. 3/2026), §§1.2, 2.2, 3, 5.2–5.3
Question 31 · TMCP-31
A ventilated adult meets the unit's daily readiness screen: the reason for intubation is improving, SpO₂ is 96% on FiO₂ 0.40 with PEEP 5 cm H₂O, blood pressure is stable without vasopressors, and the patient is triggering breaths. A colleague says no spontaneous breathing trial can start until a rapid shallow breathing index (RSBI) is measured. Based on the AARC's 2024 guideline, what should the therapist do?
Show answer and explanation
Answer: C. Start the trial; RSBI isn't required to judge readiness
The AARC 2024 guideline suggests that an RSBI is not needed to determine readiness for a spontaneous breathing trial; a simple screen like this one is likely enough. (Conditional recommendation, moderate certainty.)
Why not the others
- A. Requiring RSBI as a gate is what the guideline advises against.
- B. Nothing in the stem calls for an ABG before the trial.
- D. 80 isn't a readiness requirement, and RSBI isn't required at all.
Topic: III.E Recommend ventilator liberation. Source: AARC Clinical Practice Guideline: Spontaneous Breathing Trials (2024), pp. 2, 4–5, 8
Question 32 · TMCP-32
Fifteen minutes into a spontaneous breathing trial on FiO₂ 0.40, an adult's respiratory rate rises from 18 to 36, heart rate from 98 to 128, and SpO₂ falls to 87%. He is using accessory muscles and sweating. A colleague suggests raising FiO₂ to 0.60 so he can finish the 30-minute trial. What should the therapist do?
Show answer and explanation
Answer: B. End the trial, restore full support, and look for the cause
Rising rate and heart rate, falling SpO₂, accessory-muscle use, and sweating mean he is not tolerating the trial. AARC suggests that FiO₂ should not be increased merely to continue a spontaneous breathing trial. This patient needs the trial stopped, adequate oxygenation and ventilatory support restored, and the cause of intolerance assessed.
Why not the others
- A. Increasing FiO₂ just to finish the trial can mask failed oxygenation while leaving the other signs of intolerance unresolved.
- C. He's failing the trial; extubation isn't on the table.
- D. Leaving a deteriorating patient in a failing trial is unsafe.
Topic: III.E Modify the care plan (ventilator liberation). Source: AARC Clinical Practice Guideline: Spontaneous Breathing Trials (2024), pp. 2, 4–5, 8
Question 33 · TMCP-33
An adult completes a 30-minute spontaneous breathing trial with a steady rate of 20, tidal volume 450 mL, and stable vital signs. He is awake but has a weak cough and has needed suctioning every hour for thick, copious secretions. What is the best interpretation?
Show answer and explanation
Answer: D. He tolerated the trial, but cough and secretions still bear on extubation
AARC's 2024 guideline says passing a spontaneous breathing trial doesn't by itself mean a patient is ready for extubation; airway protection and the ability to clear secretions are separate factors. Bring the weak cough and secretion burden to the team's extubation decision.
Why not the others
- A. A passed trial is one factor, not the whole decision.
- B. The trial results are valid; he did tolerate breathing on his own.
- C. Nothing here establishes that he needs a tracheostomy today.
Topic: III.E Recommend extubation. Source: AARC Clinical Practice Guideline: Spontaneous Breathing Trials (2024), pp. 2, 4–5, 8
Question 34 · TMCP-34
An adult with uncomplicated right lower lobe pneumonia has a strong, effective cough and little sputum. The order is chest physiotherapy with percussion four times a day. What should the therapist recommend?
Show answer and explanation
Answer: C. Discontinue chest physiotherapy, since it isn't indicated here
The AARC guideline states that chest physiotherapy is not recommended for routine treatment of uncomplicated pneumonia. This patient clears secretions on his own.
Why not the others
- A. Continuing treatment without an indication adds cost and discomfort with no expected benefit.
- B. More of an unindicated therapy doesn't help.
- D. Cough assist is for an ineffective cough, which he doesn't have, and it isn't a pneumonia treatment.
Topic: III.E Modify airway clearance. Source: AARC Clinical Practice Guideline: Nonpharmacologic Airway Clearance (2013), pp. 2187–2189
Question 35 · TMCP-35
A 9-year-old is admitted to the pediatric ICU with a severe asthma exacerbation that hasn't responded to frequent intermittent albuterol and systemic corticosteroids. Which bronchodilator approach does the 2025 AARC/PALISI guideline suggest?
Show answer and explanation
Answer: A. Continuous inhaled albuterol
For pediatric critical asthma — a severe exacerbation needing admission that hasn't responded to intermittent SABA and systemic steroids — the guideline suggests continuous inhaled SABA over frequent intermittent dosing. It's a conditional recommendation based on very low-certainty evidence.
Why not the others
- B. Salmeterol is long-acting and not for acute relief.
- C. Nothing in the stem gives a reason to stop bronchodilator therapy; the guideline's suggestion is to give inhaled SABA continuously.
- D. Using a dry-powder inhaler does not provide the continuous inhaled SABA regimen the guideline suggests for this setting.
Topic: III.E Recommend bronchodilator changes. Source: AARC/PALISI Pediatric Critical Asthma Guideline (2025), Recommendation 1 and Tables 1, 4; ADVAIR DISKUS Prescribing Information (rev. 3/2026), §§1.2, 2.2, 3, 5.2–5.3
Question 36 · TMCP-36
An adult with ARDS has a PaO₂/FiO₂ ratio of 90 on FiO₂ 0.90 and PEEP 16 cm H₂O, with lung-protective settings already in place. Which evidence-based intervention should the therapist recommend?
Show answer and explanation
Answer: B. Prone positioning for more than 12 hours a day
The ATS/ESICM/SCCM guideline strongly recommends prone positioning for more than 12 hours a day in severe ARDS. A P/F ratio of 90 is in the severe range.
Why not the others
- A. Larger tidal volumes abandon lung protection.
- C. The same guideline recommends against routine HFOV in moderate or severe ARDS.
- D. Stopping sedation isn't an evidence-based treatment for severe hypoxemia in ARDS.
Topic: III.F Utilize evidence-based practice. Source: ATS/ESICM/SCCM ARDS Guideline (2017), prone positioning and high-frequency oscillation recommendations
Question 37 · TMCP-37
For a mechanically ventilated adult without a contraindication to head elevation, which practice is part of evidence-based ventilator-associated pneumonia prevention?
Show answer and explanation
Answer: D. Elevating the head of the bed to 30–45°
Elevating the head of the bed is listed among the essential VAP-prevention practices in the 2022 SHEA/IDSA/APIC compendium update; keeping the head up reduces aspiration of secretions.
Why not the others
- A. AARC calls routine saline instillation unnecessary.
- B. Flat positioning works against the reason head elevation is recommended.
- C. An automatic hourly schedule ignores whether suctioning is needed.
Topic: III.A.7 Initiating protocols to prevent ventilator-associated infections. Source: SHEA/IDSA/APIC — Preventing Ventilator-Associated Pneumonia: 2022 Update, adult essential practices; AARC Clinical Practice Guideline: Artificial Airway Suctioning (2022), pp. 258–259, 262, 266–267
Question 38 · TMCP-38
An intubated, ventilated adult is going to CT. Tube placement was confirmed with waveform capnography two hours ago. The transport plan leaves the capnograph behind to save setup time. What should the therapist recommend?
Show answer and explanation
Answer: A. Continue capnography monitoring throughout transport
Tubes can move during transfers between beds and scanners. AARC lists PETCO₂ monitoring as one of the objective standards for monitoring patients in transport and suggests continuous capnometry for ventilated patients being transported.
Why not the others
- B. Pulse oximetry measures oxygenation and can lag behind a change in ventilation; capnography provides continuous information about exhaled CO₂.
- C. Tube displacement can occur during a transfer, which this plan leaves unmonitored.
- D. A single check at the end misses displacement during the trip.
Topic: III.G Patient transport within a hospital. Source: AARC Clinical Practice Guideline: Capnography/Capnometry During Mechanical Ventilation (2011), §§4.1, 4.2, 4.3, 14
Question 39 · TMCP-39
Right after intubation, waveform capnography shows a normal, sustained CO₂ waveform. What does this confirm?
Show answer and explanation
Answer: C. That the tube is in the trachea rather than the esophagus
Together with clinical assessment, a normal sustained exhaled-CO₂ waveform supports tracheal rather than esophageal placement. It doesn't show how deep the tube is.
Why not the others
- A. A tube in one mainstem bronchus still returns CO₂; capnography can't tell you both lungs are ventilated.
- B. Depth is confirmed by a chest radiograph.
- D. The PaCO₂–PETCO₂ gradient can widen with increased alveolar dead space; capnography does not replace PaCO₂ measurement.
Topic: III.H Assist with intubation. Source: AARC Clinical Practice Guideline: Capnography/Capnometry During Mechanical Ventilation (2011), §§4.1, 4.2, 4.3, 14; ARRS — Noncardiac Devices and Central Venous Catheters, p. 2 and Figure 1C–D
Question 40 · TMCP-40
Just after the physician intubates an adult, the capnogram is normal, but breath sounds are heard only on the right and the left chest isn't rising. A portable chest radiograph shows the tube tip in the right mainstem bronchus and no pneumothorax. The therapist should recommend:
Show answer and explanation
Answer: B. Withdrawing the tube to an appropriate tracheal depth, reassessing bilateral ventilation, and confirming the new position on a chest radiograph
A tube placed too deep usually enters the right mainstem bronchus, ventilating the right lung while the left can collapse. Withdraw the tube under the team's airway-management procedure, reassess bilateral ventilation, and confirm depth on a frontal chest radiograph (tip about 5 ± 2 cm above the carina with the neck neutral).
Why not the others
- A. Advancing makes a too-deep tube worse.
- C. More volume overinflates the one lung that's being ventilated.
- D. The radiograph establishes right mainstem intubation and shows no pneumothorax; correct the tube position rather than inserting a chest tube.
Topic: III.H Assist with intubation. Source: ARRS — Noncardiac Devices and Central Venous Catheters, p. 2 and Figure 1C–D; AARC Clinical Practice Guideline: Patient-Ventilator Assessment (2024), Table 2 and p. 1046
Question 41 · TMCP-41
After teaching a patient to use a metered-dose inhaler with a valved holding chamber at home, what is the best way to confirm he has learned the skill?
Show answer and explanation
Answer: D. Watch him do it unassisted (return demonstration)
AARC's patient-training guideline says the patient should return-demonstrate the skill without assistance. Watching him do it shows whether he can actually perform it — and lets you correct errors on the spot.
Why not the others
- A. A yes to "do you understand" doesn't show he can do it.
- B. A handout supports learning but doesn't confirm it.
- C. Explaining the steps shows recall, not the hands-on skill.
Topic: III.I Conduct patient and family education. Source: AARC Clinical Practice Guideline: Providing Patient and Caregiver Training (2010), §9.2
Question 42 · TMCP-42
The parent of a 7-year-old prescribed daily nebulized budesonide says they only give it when the child is wheezing and don't do anything special afterward. What should the therapist teach?
Show answer and explanation
Answer: A. Give it daily as prescribed, use the prescribed rescue inhaler for sudden symptoms, and rinse the mouth and spit out the water after each dose
Budesonide inhalation suspension is a maintenance (preventive) medicine and is not indicated for relief of acute bronchospasm. The label advises rinsing the mouth and spitting out the water after inhalation.
Why not the others
- B. Budesonide isn't a rescue drug; it works by being taken regularly.
- C. Do not double the prescribed dose without the treating clinician's instructions; extra budesonide would not give fast relief.
- D. Stopping prescribed maintenance therapy isn't appropriate advice.
Topic: III.I Conduct patient and family education. Source: Budesonide Inhalation Suspension prescribing information (DailyMed), §§1.1, 2.2, 5.1–5.2, 17 and Patient Information
Score your practice set
Count only your first answer to each question. If you opened an explanation before choosing, leave that question out of your score and just study it.
Use the number you answered before revealing as your denominator. Leave unanswered questions out too; if you answered none before revealing, don't calculate a percentage.
| TMC section | Scored items on the real TMC | Questions here | Question numbers | First-try correct / answered before reveal | Reviewed before answering |
|---|---|---|---|---|---|
| I. Patient Data | 50 | 15 | 1–15 | ___ / ___ | ___ |
| II. Troubleshooting and Quality Control of Devices, and Infection Control | 20 | 6 | 16–21 | ___ / ___ | ___ |
| III. Initiation and Modification of Interventions | 70 | 21 | 22–42 | ___ / ___ | ___ |
| Total | 140 | 42 | ___ / ___ | ___ |
The 42 questions match the real exam's section proportions exactly: 50, 20 and 70 out of 140 scale to 15, 6 and 21 out of 42.
Answer key: 1 C · 2 A · 3 D · 4 B · 5 C · 6 B · 7 D · 8 A · 9 B · 10 C · 11 A · 12 D · 13 B · 14 C · 15 A · 16 D · 17 B · 18 A · 19 C · 20 D · 21 B · 22 A · 23 C · 24 B · 25 D · 26 A · 27 B · 28 C · 29 A · 30 D · 31 C · 32 B · 33 D · 34 C · 35 A · 36 B · 37 D · 38 A · 39 C · 40 B · 41 D · 42 A
What your score can and can't tell you. Your total is your result on these 42 questions. It isn't an NBRC score, it can't be converted to the TMC's low or high cut score, and it doesn't predict whether you'll pass. Six questions in Section II is far too few to call that section a strength or a weakness. Use the result to pick what to review:
- Section III is half the real exam, and it holds most of the TMC's analysis-level questions. If your misses cluster there, especially ventilator liberation (Questions 31–33) and oxygen and ventilation support (26–29), start there.
- Missed a calculation? Rework it from the explanation without looking. For compliance, resistance and spirometry repeatability, check the inputs, units and each calculation step.
- Chose a plausible second-best answer? Find the detail in the stem that rules it out — alert versus drowsy, plateau unchanged versus rising, shallow suction already tried. TMC questions turn on details like these.
Turn a missed question into a review task
- Find the clue in the stem that points to the best answer.
- Say in one sentence why the best answer fits.
- Say why the answer you chose falls short.
- Review the principle behind it, then retry the question a few days later.
A short log keeps this honest:
| Question | What I need to understand | Next review action |
|---|---|---|
| 14 (example) | A low FVC alone doesn't prove restriction | Review how TLC confirms restriction, then redo Questions 11 and 14 |
TMC deadlines and the 2027 change
The NBRC is replacing the TMC and the Clinical Simulation Examination (CSE) with one Respiratory Therapy (RT) Examination.
| Date | What happens |
|---|---|
| December 15 or 17, 2026 | Last day the NBRC accepts TMC applications (its pages disagree — see below) |
| December 31, 2026 | Last day to take the TMC |
| January 4, 2027 | RT Examination available |
| December 31, 2027 | Last day of the CSE, for candidates who reached the TMC high cut in time |
The application cutoff. NBRC's RT Examination page says it accepts TMC applications through December 15, 2026, and its Resources FAQ says December 17. Plan around the earlier published date, and contact the NBRC (info@nbrc.org, 913-895-4900) to confirm the cutoff before relying on either date. The handbook's general no-deadline wording does not resolve these specific retirement notices, and submitting an application does not guarantee an available testing appointment. Online credit-card applications receive an immediate response; if eligibility cannot be confirmed, NBRC asks for additional information. Mailed applications take about five to seven business days to process, according to the NBRC.
If you reach the high cut on the TMC. The high cut earns the CRT and, if you meet the admission requirements, eligibility for the CSE — the second exam toward the RRT. NBRC's exam overview says the CSE stays open through December 31, 2027 for people who pass the TMC at the high cut "by Dec. 31, 2026"; its transition announcement says "prior to December 31, 2026." If your test date is December 31 itself, confirm with the NBRC how that day counts.
If you don't test by December 31, 2026. For a multiple-choice attempt in 2027, the route is the RT Examination, subject to its admission requirements: 185 questions (160 scored, 25 unscored pretest) in 4 hours, for $360 as a new applicant or $300 as a repeat applicant. Its low cut earns the CRT; its high cut earns the RRT, with no separate simulation exam. NBRC says earlier TMC and CSE attempts don't count toward the RT Examination's attempt limit.
Will these questions help for the RT Examination? Partly. The RT outline's Breadth of Knowledge portion (100 scored items) keeps the TMC's Patient Data and Initiation and Modification of Interventions section names and folds devices and infection control into a section on devices and patient safety. It also adds a 60-item Depth of Clinical Judgment portion that this set doesn't cover. Check the RT Detailed Content Outline before relying on TMC practice for a 2027 test.
Sources: NBRC — CRT and RRT (RT Examination page); NBRC Resources — RT Examination FAQs; NBRC Examinations overview; NBRC — Examination Changes Coming in 2027; NBRC Candidate Handbook; NBRC — Certified Respiratory Therapist (CRT)
The real TMC at a glance
| TMC detail | Official format |
|---|---|
| Questions | 160 multiple-choice: 140 scored, 20 unscored pretest |
| Time | 3 hours |
| Fee | $190 for new applicants, $150 for repeat applicants |
| Scored sections | Patient Data 50 · Devices, Quality Control, and Infection Control 20 · Interventions 70 |
| Outcomes | Low cut: CRT. High cut: CRT plus CSE eligibility, if you meet the CSE admission requirements |
| Results | Score information at the test center when you finish |
| Retakes | Three attempts, then at least 120 days between later attempts |
| Where | PSI assessment centers, Monday through Saturday |
An NBRC credential isn't a license. Your state board decides your license and the requirements for it.
Sources: NBRC — Certified Respiratory Therapist (CRT); TMC Detailed Content Outline, effective January 2020–December 31, 2026; NBRC Candidate Handbook
NBRC's official free practice exam
The NBRC offers its own free TMC practice examination, listed on its Free Practice Exams page next to a separate RT practice exam for 2027 test dates. According to the NBRC, it runs on the same software as the real exam, you log in with an email address, and you need to finish in one sitting for your results to be shown and emailed. The NBRC prohibits copying or sharing its practice content.
A sensible order with the weeks left: work this set and read every explanation, review the topics behind your missed answers, then take NBRC's free practice exam in one timed sitting closer to test day.
More respiratory-care guidance
- Respiratory therapist certification — CRT vs. RRT, licensing, and the routes after 2026.
Sources and verification
Last verified October 29, 2026: TMC format, fees, scoring outcomes, retake limits, official free-practice access instructions, outline section counts, and 2026–2027 transition dates, checked against the NBRC pages listed here. Each practice question's explanation links to the guideline or reference behind its answer; those were also checked October 29, 2026. Source checks are not a professional clinical review.
NBRC:
- Certified Respiratory Therapist (CRT)
- CRT and RRT — Respiratory Therapy Examination
- Examinations overview
- Resources and FAQs
- Candidate Handbook (rev. September 3, 2026)
- Examination Changes Coming in 2027 — New Details Added
- TMC Detailed Content Outline (effective January 2020–December 31, 2026)
- RT Detailed Content Outline (effective January 2027)
- Free Practice Exams
Clinical guidelines used most often in the explanations: AARC Clinical Practice Guidelines on spontaneous breathing trials (2024), patient-ventilator assessment (2024), oxygen in acute care (2022), artificial airway suctioning (2022), capillary blood gas sampling (2022), humidification (2012), capnography (2011) and airway clearance (2013); the AARC/PALISI pediatric critical asthma guideline (2025); ATS/CHEST ventilator-liberation guidance (2017); BTS pleural-procedure guidance (2023); ATS/ERS spirometry (2019) and ERS/ATS lung-function interpretation (2022) standards; ERS/ATS noninvasive ventilation (2017), ATS/ESICM/SCCM ARDS (2017) and ATS noninvasive respiratory support (2026) guidelines; and FDA prescribing information for the inhaled medicines named.
By Castleport Test Prep Editorial Team. How we create and check our practice questions.
Castleport Test Prep is an independent exam prep publisher. We are not affiliated with, endorsed by, or approved by the National Board for Respiratory Care (NBRC). TMC, CRT, RRT and other exam and credential names identify their subjects; trademarks belong to their respective owners. These practice questions are original and are not NBRC examination questions. Results on this page don't predict exam performance, and nothing here guarantees a passing score, credential, license, or job.