NBRC CSE Exam Prep: 9 Free Cases & 14-Day Study Plan

Nine original, unofficial practice simulations cover all seven problem categories on the NBRC Clinical Simulation Examination (CSE), with every choice explained. The CSE ends December 31, 2027 and requires the TMC (Therapist Multiple-Choice Examination) high cut score by December 31, 2026, plus the other CSE admission requirements.

Practice simulations (9 original problems)

Problem 1: COPD exacerbation in the emergency department

A 68-year-old man with known COPD who uses 2 L/min oxygen at home arrives in the ED after three days of worsening shortness of breath and thicker, discolored sputum. He is on his usual 2 L/min nasal cannula. He's sitting upright, speaking in short phrases, and using his neck muscles to breathe.

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

Arterial blood gas
Vital signs and SpO2
Breath sounds
Level of consciousness and ability to cough and clear secretions
Chest radiograph
Sputum culture and sensitivity
Full pulmonary function testing in the PFT lab
6-minute walk test

Show results and rationale

Choice	Result	Rating	Why
1. ABG	pH 7.29, PaCO2 68 mm Hg, PaO2 58 mm Hg, HCO3 32 mEq/L on 2 L/min	Helpful	Shows hypercapnic respiratory acidosis. The elevated HCO3 suggests compensation, but a previous stable gas is needed to establish his baseline. The acidemia and respiratory distress make ventilatory support urgent.
2. Vitals/SpO2	HR 112, RR 30, BP 148/88, SpO2 88%	Helpful	Tachypnea and tachycardia quantify distress and give you a baseline for judging response.
3. Breath sounds	Diminished bilaterally with scattered expiratory wheezes	Helpful	Fits airflow obstruction; marked asymmetry would raise concern for an additional problem.
4. Mental status/cough	Alert, oriented, follows commands, effective cough; no vomiting	Helpful	Alertness, cooperation, and secretion handling support a monitored NIV trial; also check for vomiting, hemodynamic instability, and other reasons to secure the airway.
5. Chest radiograph	Hyperinflation, flattened diaphragms, no infiltrate, no pneumothorax	Helpful	Shows no radiographic pneumothorax or infiltrate; either finding would change the plan.
6. Sputum culture	Pending	Helpful	This severe exacerbation needs ventilatory support, so a sputum culture can guide antibiotic selection. Collect it without delaying treatment; a delayed result is not the same as a useless test. (GOLD 2026, pp. 104–105.)
7. Full PFTs	—	Harmful	A trip to the PFT lab would delay stabilization and is not needed to decide on respiratory support.
8. 6-minute walk	—	Harmful	Exercise testing during an exacerbation adds risk and delays care.

Section 2 — Decision making. Choose only one. Initial bronchodilator treatment has not relieved his distress. A systemic corticosteroid and antibiotics have also been ordered. What do you recommend next?

A. Intubate and begin mechanical ventilation
B. Begin bilevel noninvasive ventilation (NIV) via full-face mask, titrating oxygen to an SpO2 of 88–92%
C. Switch to a nonrebreather mask
D. Continue the current therapy and repeat the ABG in 4 hours
E. Begin CPAP alone

Show what happens

A — Not the best choice. He is alert, handling secretions, and not in immediate respiratory arrest. A closely monitored NIV trial is appropriate; intubation is needed promptly if he deteriorates or the trial fails.
B — Best. Within the hour his respiratory rate falls to 24 and accessory muscle use eases. The ERS/ATS NIV guideline (2017, p. 5) strongly recommends bilevel NIV for COPD exacerbations with acute or acute-on-chronic respiratory acidosis at a pH of 7.35 or lower. The AARC oxygen guideline (2022, Table 3) targets 88–92% for patients with COPD.
C — Harmful. Oxygen alone does not correct this ventilatory failure. Titrate oxygen to 88–92% while providing ventilatory support instead of switching to uncontrolled high oxygen as the sole treatment.
D — Harmful. Waiting four hours with a pH of 7.29 and a respiratory rate of 30 risks fatigue and arrest.
E — Not the best choice. CPAP doesn't add inspiratory support. For this acidotic exacerbation, bilevel NIV provides the inspiratory assistance needed to support ventilation.

Section 3 — Information gathering. Select as many as you consider indicated. He has been on bilevel NIV for one hour.

ABG
Respiratory rate, accessory muscle use, and SpO2
Mask fit, leak, and skin over the nasal bridge
Level of consciousness
Exhaled tidal volume on the NIV device
Bronchoscopy

Show results and rationale

Choice	Result	Rating	Why
1. ABG	pH 7.35, PaCO2 60 mm Hg, PaO2 64 mm Hg, HCO3 32 mEq/L on FiO2 0.28	Helpful	Rising pH, falling PaCO2, and less respiratory distress support an early response to NIV.
2. RR/SpO2	RR 22, minimal accessory muscle use, SpO2 90%	Helpful	Clinical response matches the gas.
3. Mask	Small leak at the chin, no skin breakdown	Helpful	Leaks and pressure injury are common practical reasons NIV fails.
4. LOC	Alert, cooperative	Helpful	Declining alertness would require immediate reassessment of ventilation and airway protection; it has more than one possible cause.
5. Exhaled VT	About 450 mL	Helpful	Helps assess delivered ventilation alongside leak, respiratory rate, the ABG, and patient effort; tidal volume alone does not establish success.
6. Bronchoscopy	—	Harmful	No indication in this improving patient; an invasive procedure adds risk without answering a current clinical question.

Section 4 — Decision making. Choose only one.

A. Intubate before he tires
B. Stop NIV and return to 2 L/min nasal cannula
C. Increase FiO2 to 0.60
D. Continue bilevel NIV and current medications, and reassess with clinical exam and ABG

Show what happens

A — Not the best choice. He's improving on NIV. There's no indication to intubate.
B — Not the best choice. A pH of 7.35 after one hour is progress, not resolution. His response and ability to tolerate time off NIV still need assessment.
C — Harmful. His SpO2 is already in the 88–92% target. Increasing FiO2 to 0.60 without an indication risks excessive oxygen exposure.
D — Best. He's improving but not yet back to baseline. Keep the treatment that's working and keep measuring.

Takeaway: In COPD with hypercapnic acidosis, connect the gas to the bedside: use bilevel NIV when the patient is an appropriate candidate, with controlled oxygen at 88–92%. Then prove it's working with a repeat gas and bedside signs, and escalate promptly if it isn't.

Category: Adult chronic airways disease (noninvasive management). Outline areas: I.A.5 blood gas results, I.B auscultation and inspection, III.C.4.b noninvasive ventilation, III.F.3 guidelines (GOLD).

Problem 2: Chest trauma on the ventilator

A 34-year-old man was intubated in the ED after a high-speed motor vehicle crash with right-sided chest wall bruising. He is on volume-control ventilation. He is passive on the ventilator; tidal volume, inspiratory flow, and PEEP have not changed. Ten minutes after arrival in the ICU, the high-pressure alarm sounds and his SpO2 drops.

Section 1 — Information gathering. Select as many as you consider indicated. Call for emergency help and support oxygenation while making rapid bedside checks. Do not delay decompression once tension physiology is recognized.

Peak inspiratory and plateau pressures
Breath sounds
Blood pressure and heart rate
Tracheal position
Pass a suction catheter through the endotracheal tube
Arterial blood gas before any intervention
CT scan of the chest

Show results and rationale

Choice	Result	Rating	Why
1. Pressures	Peak rose from 28 to 52 cm H2O; plateau rose from 22 to 45 cm H2O	Helpful	The large plateau-pressure rise with unchanged settings points to reduced respiratory-system compliance; airway resistance alone would not explain it. (Pressure mechanics, Introduction.)
2. Breath sounds	Absent on the right, present on the left	Helpful	One-sided loss of breath sounds, together with shock and rising plateau pressure after chest trauma, supports an urgent pleural cause.
3. BP/HR	BP 74/40, HR 134; SpO2 82% on FiO2 1.0	Helpful	Hypotension plus hypoxemia makes this an unstable patient.
4. Trachea	Deviated to the left	Helpful	Shift away from the affected side supports tension physiology. It's a late, inconsistent sign, so don't wait for it.
5. Suction catheter	Passes easily; scant secretions	Helpful	Easy passage makes a major tube obstruction less likely. It does not exclude every tube or airway problem and must not delay treatment of tension physiology.
6. ABG first	—	Harmful	Waiting for a gas delays treatment of a reversible, life-threatening cause.
7. CT chest	—	Harmful	Transporting an unstable patient for imaging delays decompression.

Section 2 — Decision making. Choose only one.

A. Activate the trauma team for immediate right-chest decompression without waiting for a radiograph
B. Obtain a portable chest radiograph to confirm, then decide
C. Increase PEEP to improve oxygenation
D. Switch to pressure control to lower the peak pressure
E. Bag the patient with 100% oxygen and wait for the physician to examine him

Show what happens

A — Best. The clinician performs emergency needle decompression while chest-tube equipment is prepared. A rush of air returns from the right chest. Within a minute, BP rises to 104/62, SpO2 to 93%, and peak pressure falls to 31 cm H2O. Suspected tension pneumothorax with this degree of instability needs immediate treatment. The WSES–AAST thoracic-trauma guideline recommends emergency management; chest-tube drainage is definitive treatment, and needle or finger decompression may be an immediate bridge depending on the setting and expertise.
B — Harmful. A film confirms what the exam already shows, and the minutes spent waiting can end in cardiac arrest. Imaging first fits the stable patient, not this one.
C — Harmful. Increasing PEEP can worsen tension physiology and further reduce venous return.
D — Harmful. It treats the alarm, not the cause. Changing the mode does not decompress the pleural space and may reduce ventilation if pressure is lowered.
E — Harmful. Manual ventilation may be needed to support oxygenation, but waiting without urgently arranging decompression leaves the cause untreated.

Section 3 — Decision making. Choose only one. Emergency needle decompression has improved his blood pressure and oxygenation. Chest-tube equipment and the qualified clinician are ready.

A. Recommend extubation
B. Remove the decompression catheter now that he has improved
C. Recommend chest tube insertion on the right, followed by a chest radiograph
D. No further intervention; continue monitoring

Show what happens

A — Harmful. He just had a life-threatening event, is on high FiO2, and has an untreated pleural injury.
B — Harmful. Removing it with no chest tube in place risks re-accumulation on positive pressure.
C — Best. Needle decompression is a temporary measure. This ventilated patient needs definitive right-sided drainage, with reassessment and post-procedure imaging. (WSES–AAST guideline, Pleural injuries.)
D — Not the best choice. Positive-pressure ventilation and this recent tension event make recurrence a serious concern. He needs definitive drainage.

Takeaway: High peak and plateau pressure, one-sided absent breath sounds, and hypotension in a ventilated trauma patient make tension pneumothorax an emergency. Arrange decompression without delaying for imaging, then definitive drainage.

Category: Adult trauma. Outline areas: I.B.5 auscultation, I.B.3 palpation (tracheal deviation), I.A.11 monitoring trends, III.E.2.b treatment of pneumothorax, III.H.6 chest tube insertion.

Problem 3: Acute cardiogenic pulmonary edema

A 74-year-old woman with a history of heart failure is brought in at 3 a.m. She woke up gasping and couldn't lie flat. She's anxious and sitting bolt upright, and her daughter says she's been skipping her water pill.

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

Vital signs and SpO2
Breath sounds
Chest radiograph
Arterial blood gas
12-lead ECG
Sputum appearance
Spirometry

Show results and rationale

Choice	Result	Rating	Why
1. Vitals/SpO2	HR 118, RR 34, BP 182/98, SpO2 85% on 6 L/min nasal cannula	Helpful	Severe hypoxemia and tachypnea despite oxygen; hypertensive.
2. Breath sounds	Coarse inspiratory crackles in both lower and mid lung fields	Helpful	Bilateral crackles fit alveolar fluid.
3. Chest film	Enlarged heart, bilateral perihilar haziness, small bilateral effusions	Helpful	The classic cardiogenic edema pattern.
4. ABG	pH 7.30, PaCO2 48 mm Hg, PaO2 54 mm Hg, HCO3 23 mEq/L	Helpful	Respiratory acidosis with hypoxemia: ventilation and oxygenation are both impaired.
5. 12-lead ECG	Sinus tachycardia; no acute ST elevation	Helpful	Screens for an ischemic trigger that would change the team's priorities.
6. Sputum	Frothy, pink-tinged	Helpful	A quick bedside sign of pulmonary edema.
7. Spirometry	—	Harmful	Not appropriate in acute respiratory failure; delays support.

Section 2 — Decision making. Choose only one. She is alert, follows commands, handles secretions, and has no vomiting. The team finds no evidence of acute coronary syndrome or cardiogenic shock. The physician has ordered IV medication for fluid overload. What do you recommend for her breathing?

A. Intubate immediately
B. Albuterol by continuous nebulizer
C. Chest physiotherapy with postural drainage
D. Increase nasal cannula to 10 L/min
E. CPAP via full-face mask, with oxygen titrated to an SpO2 of 94–98%

Show what happens

A — Not the best choice. She's alert and a good NIV candidate. Intubate if NIV fails or she can't protect her airway.
B — Not the best choice. The crackles are fluid, not bronchospasm, and albuterol raises heart rate.
C — Harmful. She has no secretion-clearance problem, and head-down positioning would worsen her orthopnea while delaying respiratory support.
D — Not the best choice. Increasing conventional-cannula flow does not provide positive airway pressure. She needs prompt respiratory support and reassessment, not a flow increase alone.
E — Best. Within 30 minutes her RR is 24 and SpO2 is 93%. Continue titrating oxygen toward the stated target. The ERS/ATS NIV guideline (2017, p. 6) strongly recommends either CPAP or bilevel NIV for acute respiratory failure from cardiogenic pulmonary edema. Positive pressure recruits flooded alveoli and reduces the heart's workload. She has no history of CO2 retention, so the usual 94–98% target applies (AARC oxygen guideline, 2022).

Section 3 — Information gathering. Select as many as you consider indicated. She has been on CPAP for 45 minutes.

ABG
RR, work of breathing, SpO2
Blood pressure
Mask fit and patient tolerance
Urine output since the diuretic dose
Bronchoscopy

Show results and rationale

Choice	Result	Rating	Why
1. ABG	pH 7.36, PaCO2 42 mm Hg, PaO2 82 mm Hg, HCO3 23 mEq/L	Helpful	Acidosis resolving, oxygenation much better.
2. RR/SpO2	RR 22, speaking full sentences, SpO2 95%	Helpful	Clinical improvement matches the gas.
3. BP	148/86	Helpful	Positive pressure can lower BP; you need to know it's still adequate.
4. Mask	Good seal; she's calmer	Helpful	Tolerance determines whether CPAP can continue.
5. Urine output	650 mL	Helpful	Shows the fluid-overload treatment is working.
6. Bronchoscopy	—	Harmful	No indication.

Section 4 — Decision making. Choose only one.

A. Remove CPAP and place her on room air
B. Continue CPAP and reassess, weaning as her work of breathing and oxygenation allow
C. Increase FiO2 to 1.0
D. Intubate to secure the airway

Show what happens

A — Not the best choice. She still needs respiratory support; improvement on CPAP does not show she is ready for room air.
B — Best. She's improving but less than an hour into treatment. Wean based on response.
C — Harmful. Her SpO2 is already in range. Excess oxygen offers no benefit.
D — Not the best choice. She's responding to NIV.

Takeaway: In acute respiratory failure from cardiogenic pulmonary edema, CPAP or bilevel can support breathing while the team treats the cause. Check airway protection, blood pressure, and response.

Category: Adult cardiovascular (heart failure). Outline areas: I.A.8 imaging, I.A.5 blood gas, I.B.5 auscultation, III.C.3 mask CPAP, III.C.1 oxygen therapy.

Problem 4: Guillain-Barré syndrome on the medical floor

A 41-year-old man (body weight 71 kg) was admitted two days ago with Guillain-Barré syndrome after four days of weakness spreading up from his feet. The nurse calls because he "sounds different" and is coughing during meals.

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

Forced vital capacity (FVC), compared with his earlier value
Maximal inspiratory pressure (MIP)
Maximal expiratory pressure (MEP)
Cough strength and swallowing/secretion handling
Arterial blood gas
SpO2 and respiratory rate
Methacholine challenge

Show results and rationale

Choice	Result	Rating	Why
1. FVC	1.3 L now (18 mL/kg); 2.6 L twelve hours ago	Helpful	Below 20 mL/kg, and a 50% fall in 12 hours. The trend matters as much as the number.
2. MIP	−24 cm H2O	Helpful	Low inspiratory strength reinforces the concern raised by his falling FVC.
3. MEP	+32 cm H2O	Helpful	Low expiratory strength supports the bedside finding of a weak cough.
4. Cough/swallow	Weak cough, nasal voice, saliva pooling in the mouth	Helpful	Bulbar weakness means aspiration risk and an unprotected airway.
5. ABG	pH 7.41, PaCO2 41 mm Hg, PaO2 84 mm Hg on room air	Helpful	Normal, and that's the trap. Normal gas exchange does not exclude impending ventilatory failure or loss of airway protection.
6. SpO2/RR	SpO2 96%, RR 24, shallow	Helpful	Oxygenation is preserved now; the rapidly falling FVC and bulbar weakness still demand escalation.
7. Methacholine	—	Harmful	A bronchial provocation test has no role here and could precipitate distress.

Section 2 — Decision making. Choose only one.

A. Wait for the PaCO2 to rise before intervening
B. Recheck FVC in 4 hours
C. Begin bilevel NIV and continue to monitor on the floor
D. Recommend ICU transfer and elective intubation with mechanical ventilation
E. Start incentive spirometry every hour

Show what happens

A — Harmful. Waiting for hypercapnia means waiting until he's already failing.
B — Not the best choice. His FVC halved in 12 hours. Another four hours could mean an emergency intubation.
C — Not the best choice. NIV doesn't protect an airway threatened by pooled secretions and a weak cough.
D — Best. He's intubated in a controlled setting. His FVC has halved in 12 hours, and he cannot manage secretions. The 2023 EAN/PNS guideline links rapid respiratory decline to early ICU care and planned ventilation; its monitoring flowchart identifies bulbar dysfunction with aspiration risk as an indication for intubation (PICO 7 and Figure 2).
E — Not the best choice. Breathing exercises can't overcome progressive neuromuscular weakness or protect his airway.

Takeaway: In neuromuscular disease, trend the bedside mechanics (FVC, MIP, MEP) and watch the airway. Don't let a normal blood gas reassure you.

Category: Adult neurological or neuromuscular. Outline areas: I.C.4 mechanics of spontaneous ventilation, I.C.25 MIP/MEP, I.A.11.e pulmonary mechanics trends, III.E.2.e insertion of artificial airway.

Problem 5: Severe ARDS on a non-protective tidal volume

A 54-year-old woman with pneumonia-related sepsis was intubated overnight in another unit and has just been transferred to you. She is 5 feet 4 inches (64 in) tall and weighs 96 kg. Settings: volume control, tidal volume 520 mL, rate 16, PEEP 8 cm H2O, FiO2 0.80. The treating team has diagnosed ARDS. Pneumonia cultures are already available and guide antibiotics.

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

Plateau pressure
Predicted body weight
ABG on current settings
Chest radiograph
Echocardiogram or other evidence on cardiac function already in the chart
Spontaneous breathing trial
Bronchoalveolar lavage

Show results and rationale

Choice	Result	Rating	Why
1. Plateau	34 cm H2O	Helpful	Above the 30 cm H2O ceiling.
2. PBW	54.7 kg (45.5 + 2.3 × [64 − 60])	Helpful	Tidal volume is set from height and sex, not weight. 520 mL is about 9.5 mL/kg PBW.
3. ABG	pH 7.39, PaCO2 44 mm Hg, PaO2 58 mm Hg, HCO3 26 mEq/L	Helpful	P/F ratio = 58 ÷ 0.80 ≈ 73: severe hypoxemia.
4. Chest film	Bilateral diffuse opacities; tube in good position	Helpful	Bilateral infiltrates fit ARDS; the film also confirms tube position.
5. Cardiac function	Echo yesterday: normal LV function	Helpful	Helps assess whether cardiac dysfunction explains the opacities; normal LV systolic function alone is not a complete assessment.
6. SBT	—	Harmful	She's on FiO2 0.80 with severe hypoxemia; she isn't ready for liberation testing.
7. BAL	—	Not needed	Cultures already guide antibiotics; BAL won't fix the ventilator settings that are hurting her now.

Section 2 — Decision making. Choose only one.

A. Decrease tidal volume to 330 mL (6 mL/kg PBW) and increase rate to 25 to maintain minute ventilation
B. Set tidal volume to 576 mL (6 mL/kg of actual weight)
C. Increase tidal volume to improve oxygenation
D. Leave settings unchanged because the pH is normal

Show what happens

A — Best. Plateau pressure falls to 27 cm H2O. The ATS/ESICM/SCCM ARDS guideline (2017) strongly recommends limiting tidal volume to 4–8 mL/kg PBW and plateau pressure to below 30. The ARDSNet protocol starts at 6 mL/kg PBW and allows rate up to 35 to hold ventilation. Here 6 × 54.7 kg = 328.2 mL, rounded to 330 mL; 16 × 520 mL = 8.32 L/min, and 25 × 330 mL = 8.25 L/min. That approximately preserves total minute ventilation, not necessarily PaCO2; reassess the gas and patient.
B — Harmful. Using actual weight gives a higher tidal volume than she has now. Lung size follows height and sex, not weight.
C — Harmful. Larger volumes raise plateau pressure and worsen ventilator-induced lung injury.
D — Harmful. A normal pH doesn't make a plateau of 34 safe.

Section 3 — Information gathering. Select as many as you consider indicated. Thirty minutes after the change:

ABG
Plateau pressure
Check for breath stacking or patient-ventilator dyssynchrony
SpO2 trend
Maximal inspiratory pressure

Show results and rationale

Choice	Result	Rating	Why
1. ABG	pH 7.32, PaCO2 52 mm Hg, PaO2 52 mm Hg, HCO3 26 mEq/L on FiO2 0.80, PEEP 8 cm H2O	Helpful	pH is within the ARDSNet goal of 7.30–7.45 (mild permissive hypercapnia). PaO2 is below the 55–80 mm Hg goal.
2. Plateau	27 cm H2O	Helpful	Now within the limit.
3. Synchrony	Synchronous; no double triggering	Helpful	Low tidal volumes can provoke air hunger and breath stacking, so you check.
4. SpO2	86–87%	Helpful	Below the ARDSNet SpO2 goal of 88–95%.
5. MIP	—	Not needed	A weaning measurement with no role at this stage.

Section 4 — Decision making. Choose only one. The pH is acceptable; oxygenation is not. Blood pressure is 116/68 mm Hg. For this exercise, the team has ordered stepwise adjustment using the ARDSNet lower-PEEP/FiO2 table while reassessing respiratory mechanics and circulation.

A. Return tidal volume to 520 mL
B. Increase FiO2 to 1.0 and leave PEEP at 8
C. Increase PEEP in 2-cm H2O steps toward 14 cm H2O under the ordered table, reassessing oxygenation, plateau pressure, and blood pressure
D. Decrease PEEP to 5 cm H2O to lower plateau pressure

Show what happens

A — Harmful. That undoes lung protection.
B — Not the best choice. A brief increase in FiO2 may be needed as rescue support, but leaving PEEP at 8 does not address the ordered titration in this case.
C — Best. On the table specified for this case, FiO2 0.80 is paired with PEEP 14. The supplied follow-up findings are SpO2 91%, plateau pressure below 30 cm H2O, and stable blood pressure. If her oxygenation stays severely impaired on optimized settings, the ATS/ESICM/SCCM guideline strongly recommends prone positioning for more than 12 hours a day in severe ARDS; that's the team's next conversation. The 2024 ATS update conditionally favors higher-PEEP strategies without lung recruitment maneuvers in moderate-to-severe ARDS and recommends against prolonged recruitment maneuvers; the chosen strategy still needs to fit the patient.
D — Harmful. Her plateau pressure is already within the protocol limit; reducing PEEP would move away from its oxygenation strategy and may worsen hypoxemia.

Takeaway: In ARDS, calculate predicted body weight first. Under this protocol, start at 6 mL/kg PBW, target plateau pressure at 30 or less and pH 7.30–7.45, and use the ordered FiO2/PEEP table while reassessing oxygenation and blood pressure.

Category: Adult medical or surgical (ARDS). Outline areas: I.C.11 plateau pressure, I.C.8 cardiopulmonary calculations (P/F), III.C.4.a mechanical ventilation settings, III.F.3 guidelines (ARDSNet).

Problem 6: Severe asthma exacerbation in a 7-year-old

A 7-year-old girl with asthma is carried into the pediatric ED by her father. She has been coughing and wheezing since yesterday, and her rescue inhaler "stopped working" this morning. She is alert and breathing spontaneously. The team begins urgent assessment and treatment together; do not delay treatment to complete tests.

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

Ability to speak, and use of accessory muscles
SpO2 and respiratory rate
Breath sounds
Peak expiratory flow, if she can perform it without delaying treatment
Recent rescue-inhaler use and prior ICU admissions or intubations
Chest radiograph
Delay urgent treatment for spirometry with a full flow-volume loop

Show results and rationale

Choice	Result	Rating	Why
1. Speech/muscles	Speaks only single words; suprasternal and intercostal retractions	Helpful	Signs of a severe exacerbation.
2. SpO2/RR	SpO2 89% on room air; RR 42	Helpful	Hypoxemic and tachypneic.
3. Breath sounds	Diminished throughout with faint expiratory wheeze	Helpful	Faint wheeze with poor air movement is more worrying than loud wheezing.
4. PEF	35% of her personal best	Helpful	Objective severity and a baseline for response.
5. History	Six puffs in the past 2 hours; one prior PICU admission, never intubated	Helpful	Heavy rescue use and a prior PICU stay are risk factors for a severe course.
6. Chest film	—	Not needed	Not routine in asthma unless you suspect a complication such as pneumothorax or pneumonia. It doesn't change initial treatment.
7. Full spirometry	—	Harmful	A full laboratory-style assessment would delay urgent treatment; use the brief bedside assessment she can tolerate.

Section 2 — Decision making. Choose only one.

A. Intubate now
B. Albuterol by MDI and discharge with an asthma action plan
C. Chest physiotherapy
D. A sedative to reduce her anxiety
E. Oxygen to correct hypoxemia, nebulized albuterol with ipratropium, and a systemic corticosteroid

Show what happens

A — Not the best choice. She is still breathing spontaneously and has no supplied signs of respiratory arrest. Start urgent therapy with close monitoring and airway support available if she deteriorates.
B — Harmful. She's hypoxemic and speaking in single words. Discharge is unsafe.
C — Harmful. It increases distress and doesn't treat bronchospasm.
D — Harmful. Sedation can suppress her respiratory drive. Her anxiety is a symptom of hypoxemia and air hunger.
E — Best. This matches GINA's 2026 emergency treatment for children 6–11 years with a severe exacerbation: prompt inhaled albuterol, added ipratropium, oxygen for hypoxemia, and systemic corticosteroid treatment (pp. 184–187, Box 9-6). Albuterol is a short-acting beta agonist (SABA).

Section 3 — Information gathering. Select as many as you consider indicated. One hour later, after three combined albuterol/ipratropium treatments and a systemic corticosteroid:

Work of breathing and speech
SpO2 on current oxygen
Breath sounds
Peak flow, if she can cooperate without delaying escalation
Sweat chloride test

Show results and rationale

Choice	Result	Rating	Why
1. Work of breathing	Still retracting; now quieter and looking tired	Helpful	Fatigue is a warning sign, not improvement.
2. SpO2	91% on 4 L/min	Helpful	Still needs oxygen.
3. Breath sounds	Markedly diminished	Helpful	Poor air movement persists.
4. PEF	30% of personal best	Helpful	No objective improvement. Do not force another maneuver if fatigue prevents it.
5. Sweat chloride	—	Not needed	Tests for cystic fibrosis; no bearing on this emergency.

Section 4 — Decision making. Choose only one.

A. Switch to albuterol MDI every 4 hours and admit to a general ward
B. Request urgent pediatric critical-care assessment, continue inhaled bronchodilator treatment with continuous albuterol under the hospital pathway, and give IV magnesium as an adjunct with close monitoring
C. Discharge home on oral corticosteroids
D. Stop bronchodilator treatment and wait for the corticosteroid to work

Show what happens

A — Harmful. It de-escalates therapy in a child who is getting worse.
B — Best. Her fatigue and poor response require urgent reassessment for respiratory failure and a monitored escalation plan. The 2025 AARC/PALISI guideline suggests continuous inhaled SABA for critical asthma and IV magnesium as an adjunct; these are conditional recommendations, with very low and low certainty respectively. Magnesium does not replace bronchodilator therapy or airway assessment.
C — Harmful. She's failing ED treatment.
D — Harmful. She still has severe obstruction; waiting without bronchodilator treatment leaves the immediate problem untreated.

Takeaway: In severe pediatric asthma, give oxygen, albuterol plus ipratropium, and systemic steroids early. If she isn't responding, continue bronchodilation, obtain urgent critical-care assessment, and consider IV magnesium as an adjunct while watching for respiratory failure.

Category: Pediatric (asthma). Outline areas: I.B.1 interviewing, I.B.2 inspection, I.C.3 peak flow, III.D.1.c bronchodilators, III.F.3 guidelines (NAEPP).

Problem 7: Newborn resuscitation

You're called to the delivery of a term baby (39 weeks). After birth, the infant is limp and not breathing. The team has warmed, dried, positioned the airway, and stimulated the baby. The heart rate by auscultation is 80/min, and the baby is still apneic.

Section 1 — Decision making. Choose only one.

A. Continue drying and stimulating for another minute
B. Give 100% blow-by oxygen and continue stimulating
C. Begin chest compressions
D. Begin positive-pressure ventilation with 21% oxygen and place a pulse oximeter on the right hand

Show what happens

A — Harmful. Delaying ventilation in an apneic newborn wastes the most critical minute.
B — Harmful. An apneic baby needs breaths, not oxygen near the face.
C — Harmful. The heart rate is above 60, and ventilation hasn't even started.
D — Best. Apnea, or a heart rate under 100/min after the initial steps, calls for ventilation within the first minute. For babies 35 weeks or older, it's reasonable to start with 21% oxygen, and preductal saturation is read on the right hand or wrist (AHA/AAP 2025 neonatal guidelines, §§11.1, 12).

Section 2 — Information gathering. Select as many as you consider indicated. Fifteen seconds into PPV:

Chest movement with each breath
Heart rate
Mask seal and head position
Pulse oximeter reading
Blood glucose

Show results and rationale

Choice	Result	Rating	Why
1. Chest movement	No visible chest rise	Helpful	Ventilation isn't effective.
2. Heart rate	70/min	Helpful	A rising heart rate is the main sign ventilation works, and it isn't rising.
3. Mask/position	Leak at the chin; head slightly flexed	Helpful	You found the likely cause.
4. Oximeter	No reliable reading yet	Helpful	Common in the first minutes; you still need it in place.
5. Glucose	—	Not needed	Important later, but not while ventilation is ineffective.

Section 3 — Decision making. Choose only one.

A. Perform ventilation corrective steps: reapply the mask, reposition the head, suction if needed, open the mouth, increase inflation pressure, and consider an alternative airway
B. Begin chest compressions because the heart rate is falling
C. Increase oxygen to 100% and continue the same ventilation
D. Give epinephrine

Show what happens

A — Best. After resealing the mask and repositioning, the chest rises with each breath. Corrective maneuvers are the guideline response when initial breaths aren't effective (AHA/AAP 2025, §11.3).
B — Harmful. The rate is above 60, and the lungs haven't been inflated yet. Fix ventilation first.
C — Not the best choice. Extra oxygen doesn't reach lungs that aren't being inflated.
D — Harmful. No indication: the heart rate is above 60, and ventilation hasn't been optimized.

Section 4 — Information gathering. Select as many as you consider indicated. The heart rate remains below 100/min despite corrective steps, so the team places an alternative airway and ECG leads. After intubation and 30 seconds of ventilation that moves the chest:

Heart rate on ECG, checked against auscultation
Chest rise and breath sounds with the endotracheal tube
CO2 detector color change or reading
Apgar score recorded at 1 minute

Show results and rationale

Choice	Result	Rating	Why
1. Heart rate	50/min	Helpful	Under 60 despite effective ventilation.
2. Chest/breath sounds	Equal chest rise; equal breath sounds	Helpful	Shows that ventilation inflates both lungs; the persistent bradycardia still requires the next resuscitation step.
3. CO2 detector	Color change present	Helpful	Supports tracheal tube placement.
4. Apgar	Assigned by the team	Not needed	Documented, but it doesn't guide resuscitation steps; heart rate and ventilation do.

Section 5 — Decision making. Choose only one.

A. Continue ventilation alone and recheck in 60 seconds
B. Give epinephrine now, before compressions
C. Begin chest compressions coordinated 3:1 with ventilation and increase oxygen to 100%
D. Give a normal saline bolus

Show what happens

A — Harmful. A heart rate under 60 after effective ventilation needs compressions now.
B — Not the best choice. Compressions come before epinephrine.
C — Best. Guidelines recommend compressions when the heart rate stays under 60/min despite 30 seconds of ventilation, ideally through an endotracheal tube, using a 3:1 ratio, and 100% oxygen during compressions is reasonable. Epinephrine follows only if the rate stays under 60 after ventilation and compressions are optimized (AHA/AAP 2025, §§13.1, 13.2, 15). Once compressions are no longer needed, titrate oxygen back to saturation targets.
D — Not the best choice. Volume is for suspected blood loss or hypovolemia; nothing here suggests it.

Takeaway: In neonatal resuscitation, apnea and heart rate guide action. After the initial steps, ventilate an apneic infant or one with a persistent heart rate under 100/min. If the heart rate isn't rising, fix ventilation. Under 60 after 30 seconds of ventilation that moves the chest, start coordinated compressions; 100% oxygen during compressions is reasonable.

Category: Neonatal (resuscitation). Outline areas: I.B.2.d status of a neonate, II.A.9 resuscitation equipment, III.C.1 oxygen therapy, III.H.1 intubation.

Problem 8: Ventilator liberation after a COPD exacerbation

A 63-year-old woman with COPD was intubated three days ago for a severe exacerbation. The ICU uses a daily protocol to screen ventilated patients for a spontaneous breathing trial (SBT). She is on volume control. You're doing the morning screen.

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

Whether the cause of respiratory failure is improving
Current FiO2, PEEP, and SpO2
Blood pressure and need for vasopressors
Level of consciousness and whether she triggers breaths on her own
Rapid shallow breathing index (RSBI)
Repeat CT scan of the chest
Full pulmonary function testing

Show results and rationale

Choice	Result	Rating	Why
1. Cause improving	Wheezing much improved; sputum thinner; afebrile	Helpful	The reason she needed the ventilator has to be improving before liberation makes sense.
2. FiO2/PEEP/SpO2	FiO2 0.35, PEEP 5 cm H2O, SpO2 91%	Helpful	Low oxygen and PEEP requirements. 91% sits in her ordered 88–92% range.
3. Hemodynamics	BP 128/76; no vasopressors	Helpful	Hemodynamic stability is part of this readiness screen.
4. LOC/triggering	Awake, follows commands, triggering above the set rate	Helpful	She can breathe on her own and cooperate with a trial.
5. RSBI	64	Not needed	Many protocols still record it, but the AARC SBT guideline (2024, p. 5) suggests RSBI isn't needed to decide SBT readiness. It won't change this decision.
6. Repeat CT	—	Not needed	No new problem calls for imaging; it adds transport risk and delay.
7. Full PFTs	—	Harmful	A full pulmonary-function laboratory assessment is not the bedside readiness test; it would delay this indicated trial.

Section 2 — Decision making. Choose only one. She passes the readiness screen.

A. Extubate now because she passed the screen
B. Begin a protocol SBT with low-level pressure support or a T-piece, keep FiO2 unchanged, and monitor her tolerance
C. Increase FiO2 to 0.60 for the trial so her SpO2 stays high
D. Wait for her RSBI to fall further before starting any trial

Show what happens

A — Not the best choice. The readiness screen and the SBT are separate steps. She hasn't shown she can sustain her own breathing yet.
B — Best. The AARC guideline suggests SBTs can be done with or without low-level pressure support, and that FiO2 shouldn't be increased during an SBT (2024, pp. 5, 8). Passing a screen means she's ready to try, not ready to come off.
C — Not the best choice. Raising FiO2 can hide a failing trial and isn't recommended during an SBT.
D — Not the best choice. Her screen is already positive, and RSBI isn't needed to decide readiness. Waiting for an arbitrary lower RSBI would delay the indicated trial.

Section 3 — Information gathering. Select as many as you consider indicated. After 60 minutes on the SBT:

RR, SpO2, heart rate, and signs of distress
Cough strength during suctioning
Amount and character of secretions, and suctioning frequency
Level of consciousness
Bronchoalveolar lavage

Show results and rationale

Choice	Result	Rating	Why
1. Tolerance	RR 22, SpO2 91%, HR unchanged, no distress	Helpful	She tolerated the trial.
2. Cough	Weak; barely moves secretions into the tube	Helpful	Ability to clear secretions predicts extubation success.
3. Secretions	Copious, thick; suctioned every 30–45 minutes	Helpful	A heavy secretion load with a weak cough raises the risk of failed extubation.
4. LOC	Alert, follows commands	Helpful	Mental status is part of airway protection.
5. BAL	—	Not needed	Doesn't answer the question in front of you.

Section 4 — Decision making. Choose only one.

A. Repeat the SBT on FiO2 1.0
B. Extubate to nasal cannula now because she passed the SBT
C. Increase sedation and schedule a tracheostomy today
D. Hold extubation for now: report her good SBT tolerance along with the weak cough and heavy secretions, continue secretion clearance, and reassess extubation readiness

Show what happens

A — Harmful. Raising FiO2 can mask poor oxygen tolerance and has nothing to do with secretion clearance.
B — Not the best choice. A passed SBT answers only the breathing question. Ignoring her weak cough and heavy secretions risks reintubation.
C — Not the best choice. She's improving and awake. These findings call for secretion management and reassessment, not an automatic tracheostomy decision. More sedation works against liberation.
D — Best. The AARC guideline says passing an SBT doesn't by itself mean she's ready for extubation; airway protection and the ability to clear secretions also predict success (2024, pp. 2, 5). Her breathing passed; her airway clearance hasn't.

Takeaway: A readiness screen, an SBT, and extubation are three separate decisions. Passing a trial answers the breathing question; cough and secretions answer the airway question.

Category: Adult chronic airways disease (intubation and mechanical ventilation). Outline areas: I.A.11.d ventilator liberation parameters, I.C.13 spontaneous breathing trial, III.C.8 liberating a patient from mechanical ventilation, III.E.2.g extubation.

Problem 9: Preterm infant with RDS and a capillary blood gas

A 2-day-old infant born at 30 weeks with respiratory distress syndrome (RDS) is on nasal CPAP 6 cm H2O at FiO2 0.30. The neonatology team's ordered SpO2 range is 90–95%. A blood gas result posts with a low oxygen value, and the nurse asks whether to turn the oxygen up.

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

Sample type and site, and perfusion at the site
Pulse oximeter trend and signal quality
Work of breathing and CPAP interface
Heart rate, color, and perfusion
Apgar scores from birth
Chest CT

Show results and rationale

Choice	Result	Rating	Why
1. Sample/site	Capillary heel stick from a warm, well-perfused heel, run promptly: pH 7.33, PCO2 49 mm Hg, PO2 38 mm Hg, HCO3 25 mEq/L	Helpful	This is the key fact. It's a capillary sample, so the 38 is not a PaO2.
2. SpO2	93% with a clean waveform; steady for the past several hours	Helpful	A reliable SpO2 inside the ordered range is the better oxygenation picture here.
3. WOB/interface	Mild retractions, unchanged; prongs fit well	Helpful	No clinical sign of worsening.
4. HR/perfusion	HR 150, pink, capillary refill under 3 seconds	Helpful	Good perfusion supports using the capillary pH and PCO2 alongside the clinical findings.
5. Apgars	—	Not needed	History from day 0 doesn't help you interpret today's sample.
6. Chest CT	—	Harmful	Radiation and transport risk with no question it would answer.

Section 2 — Decision making. Choose only one.

A. Use the capillary pH and PCO2 to judge ventilation, judge oxygenation by the reliable SpO2 and clinical status, and recommend an arterial sample only if a true PaO2 is needed
B. Increase FiO2 to 1.0 to correct the low PO2
C. Document the infant's PaO2 as 38 mm Hg and notify the team of hypoxemia
D. Discard the whole result because capillary samples are unreliable

Show what happens

A — Best. The AARC capillary blood gas guideline (2022) finds capillary pH and PCO2 can provide useful information about acid–base balance and ventilation when sample quality and perfusion are adequate (Table 2 and Summary, pp. 1201–1203). Capillary PO2 is not a substitute for arterial PO2, and an arterial sample may be warranted when PaO2 is needed to guide care. The infant's reliable SpO2 is in the ordered range and clinical status is unchanged; the capillary PO2 alone is not a reason to raise oxygen.
B — Harmful. Raising oxygen on the strength of an unreliable number, with SpO2 already in range, exposes a preterm infant to unneeded oxygen.
C — Not the best choice. Labeling a capillary PO2 as PaO2 puts a wrong number in the chart and starts the wrong conversation.
D — Not the best choice. Capillary PO2 is not a substitute for arterial PO2. A good-quality capillary sample can still provide useful pH and PCO2 information; collection errors or changing perfusion can affect those values too.

Takeaway: Check the specimen type before you interpret a gas. Capillary pH and PCO2 can be useful from a warm, well-perfused site; capillary PO2 can't stand in for PaO2. If perfusion drops, the whole sample becomes less reliable.

Category: Neonatal (respiratory distress syndrome). Outline areas: I.A.5 blood gas results, I.C.5 blood gas sample collection, I.D.5 blood gas analysis, I.A.9 perinatal history, III.C.3 nasal CPAP.

How to use these practice simulations

These are unofficial Castleport practice problems written for this page. They are not NBRC exam problems, they don't reproduce NBRC's software or point values, and they don't produce a score or a prediction. The nine problems contain 32 sections: 15 information-gathering sections and 17 decision-making sections. They represent all seven patient categories, but they are not a full-length exam or complete coverage of every subtopic. Each case follows a fixed teaching path; its findings and responses are fictional scenario data, not guaranteed treatment outcomes.

How to use them: Read the scenario. In information-gathering sections, write down every option you'd select before opening the results. In decision-making sections, commit to one choice first. Then compare. For information gathering, compare your selections with every Helpful choice and review any unnecessary or unsafe choice. For decision making, identify the Best choice and explain why the alternatives do not fit.

These are this page's teaching labels, not NBRC scoring categories:

Helpful — indicated for this patient right now
Not needed — has no useful indication for the decision being asked here
Harmful — delays urgent care, adds risk, or worsens the patient
Best — the single best decision
Not the best choice — another option better fits the supplied findings

The CSE in one screen

The CSE has 22 problems: 20 scored and 2 unmarked pretest problems you can't tell apart, so treat every one as real. You get 4 hours. The standard fee is $200 for a first or repeat attempt. (NBRC CSE page)

The applicable outline is effective January 2020 and remains the CSE outline through December 31, 2027. Its three task headings are Patient Data; Troubleshooting and Quality Control of Equipment, and Infection Control; and Initiation and Modification of Interventions. The patient-category counts below are a separate form-assembly map, not percentage weights for those task headings.

The 20 scored problems follow a fixed mix from NBRC's CSE Detailed Content Outline (Test Form Assembly Specifications):

Problem category	Scored problems	What that includes	Practice on this page
Adult chronic airways disease	7	2 intubation/ventilation, 2 noninvasive management, 1 outpatient COPD, 1 outpatient asthma, 1 diagnosis	Problems 1, 8
Adult medical or surgical	5	1 CF or non-CF bronchiectasis, 1 infectious disease, 1 ARDS, 2 other (e.g., immunocompromised, shock, bariatric, psychiatric)	Problem 5
Adult cardiovascular	2	1 heart failure, 1 other (e.g., arrhythmia, pulmonary hypertension, MI, pulmonary embolism)	Problem 3
Pediatric	2	1 asthma, 1 other (e.g., bronchiolitis, chronic lung disease of prematurity, congenital defect)	Problem 6
Neonatal	2	1 respiratory distress syndrome, 1 resuscitation	Problems 7, 9
Adult trauma	1	—	Problem 2
Adult neurological or neuromuscular	1	—	Problem 4

Twelve of the 20 scored problems are chronic airways or medical/surgical, so give those categories substantial attention. The counts tell you the problem mix, not how many hours each topic needs. Adjust your study time to the errors you actually make.

CSE problems use two kinds of sections; follow each section's instructions (Candidate Handbook, pp. 14–15):

Information gathering: "select as many" as you consider indicated. Each choice reveals a result, and you can't unselect anything once it's revealed.
Decision making: "choose only one" unless the screen tells you to choose again. The software may ask you to make another selection. After you leave a section, you cannot return to add choices, although its revealed information remains in the history.

How the CSE is scored

The Candidate Handbook (Rev. 09/03/2026, p. 12) explains that points from all your choices, in both information gathering and decision making, are added up across the whole exam into one score. That score is compared with one cut score. You pass or fail the exam as a whole, with no separate pass for each problem or section type.

The cut score is linked to the exam committee's decisions about which positively scored options are required to show minimal competence and which could be forgiven. Neither the handbook nor NBRC's CSE page lists point values for individual options or a fixed passing score. For score-report instructions, use the handbook’s “After You Finish the Examination” section.

What that means for you:

Justify essential steps. Use the clinical findings to identify indicated assessments and actions; the handbook links the cut score to judgments about required positively scored options.
There's no going back. Once you choose an option, the software reveals the result and you can't unselect it.
Keep working through the next problem. The score combines responses across the exam; one difficult case is a reason to refocus, not to infer the final result.

NBRC's free CSE practice, linked from its CSE page, is a single problem meant to teach the software. The handbook says its difficulty doesn't reflect the real exam (p. 13). NBRC doesn't endorse any review program (p. 13).

Information gathering vs decision making: habits that protect points

Before any selection, run the same four-step check: finding → why it matters → indicated action → what you'll reassess. If you can't fill in "why it matters" for an option, identify whether that is a knowledge gap or an unnecessary selection.

Information gathering

Name the decision you're preparing to make. Select information with a clear clinical purpose, not everything you could eventually put in the chart.
Choose tests with a clear indication, even when the result arrives later. A culture can guide antibiotics; it must not delay urgent respiratory support.
Never select anything unsafe for the patient's current state. In these cases, elective exercise testing and a trip to the PFT lab would delay stabilization. An invasive test needs a specific indication.
Don't gather your way past an emergency. If the patient is crashing, the decision that follows needs to be fast.
Use the Simulation History window. Every result you've revealed stays there. Read it before every decision.

Decision making

Treat the immediate threat and follow the relevant emergency algorithm. Assessment and treatment may need to happen together.
Match the intervention to the mechanism. Acidotic COPD exacerbation in an appropriate candidate → bilevel NIV. Cardiogenic edema with acute respiratory failure → CPAP or bilevel after airway and hemodynamic assessment. Unstable tension pneumothorax → emergency decompression. Rapid neuromuscular decline with impaired airway protection → planned intubation.
Use the least invasive therapy that will work. Don't jump to intubation when NIV fits and the patient protects the airway. Don't stay on NIV when the airway isn't protected.
If the software asks for another selection, don't panic. Re-read the scenario and history, find what you missed, and choose again.
Leave a bad choice behind. Use the supplied situation in the next section and apply your reasoning again.

High-yield decision rules by problem type

Problem type	The rule to know	Source
COPD exacerbation	In an appropriate candidate with an acidotic COPD exacerbation and respiratory distress, bilevel NIV supports ventilation; monitor closely and escalate if needed. Hypercapnia alone is not an automatic NIV indication.	ERS/ATS NIV guideline (2017)
Oxygen targets	SpO2 88–92% for COPD; 94–98% for most hospitalized adults in the cited guideline. Apply the patient’s prescribed target and clinical context.	AARC oxygen guideline (2022)
Cardiogenic pulmonary edema	CPAP or bilevel NIV for acute respiratory failure in an appropriate patient; assess airway protection, blood pressure, and response.	ERS/ATS NIV guideline (2017)
ARDS	Tidal volume 4–8 mL/kg PBW; plateau below 30 cm H2O; prone >12 h/day in severe ARDS. The example protocol starts at 6 mL/kg. Choose and monitor PEEP individually.	ATS/ESICM/SCCM guideline (2017); ATS update (2024)
Predicted body weight	PBW in kg: men 50 + 2.3 × (height in inches − 60); women 45.5 + 2.3 × (height in inches − 60)	Institutional ARDSNet protocol, p. 1
Ventilator liberation	Screen → SBT → separate extubation decision. Don't raise FiO2 during an SBT; cough and secretions matter for extubation.	AARC SBT guideline (2024)
Guillain-Barré	Rapidly falling FVC, weak cough, and bulbar dysfunction need urgent ICU assessment; airway protection and the trend can justify planned intubation before hypercapnia appears.	EAN/PNS guideline (2023), PICO 7 and Figure 2
Tension pneumothorax	Clinical diagnosis. Unstable → decompress before imaging, then chest tube.	WSES–AAST guideline (2025)
Severe pediatric asthma	Prompt SABA, ipratropium, oxygen for hypoxemia, and systemic corticosteroid. Poor response or fatigue needs urgent escalation, continued bronchodilation, and consideration of IV magnesium as an adjunct.	GINA 2026, Box 9-6; AARC/PALISI (2025)
Newborn resuscitation	Apneic or persistent HR <100 after initial steps → PPV (21% O2 is a reasonable start at ≥35 weeks); fix ventilation before compressions; HR <60 after 30 s of ventilation moving the chest → compressions 3:1; 100% O2 during compressions is reasonable.	AHA/AAP neonatal guidelines (2025)
Capillary blood gas	pH and PCO2 can be useful with adequate sample quality, perfusion, and clinical agreement; capillary PO2 isn't PaO2	AARC capillary blood gas guideline (2022)

A 14-day CSE plan

This plan assumes about 2 hours a day and a recent TMC pass: 28 hours across 14 days. That is a suggested workload, not a minimum or a promise of readiness. If you have four weeks, spend two days on each block from Days 2–9 and add a second round of retries. If your exam is sooner, keep Days 1, 2–3, 4–5, 10, and 11–12 and shorten the rest.

Day	Focus	Do this	You're done when
1	Format	Read the CSE sections of the Candidate Handbook and take NBRC's free one-problem CSE practice from its CSE page.	You can explain "select as many" vs "choose only one" in your own words.
2–3	Chronic airways (7 problems on the exam)	COPD and asthma exacerbations, NIV vs intubation, ventilator liberation, outpatient and discharge planning, diagnosis. Work Problems 1 and 8.	You've logged every missed or guessed choice.
4–5	Medical/surgical (5)	ARDS ventilation, pneumonia and infection control, CF and bronchiectasis airway clearance, shock, immunocompromised patients. Work Problem 5.	You can calculate PBW and a 6 mL/kg tidal volume without notes.
6	Cardiovascular (2)	Heart failure, PE, pulmonary hypertension, arrhythmia recognition. Work Problem 3.	You can name the findings that separate cardiogenic edema from COPD.
7	Trauma (1) + neuro/neuromuscular (1)	Chest trauma, head injury and ventilation, myasthenia gravis, Guillain-Barré, overdose. Work Problems 2 and 4.	You can state when to act before imaging and when to intubate electively.
8	Pediatrics (2)	Asthma, bronchiolitis, croup vs epiglottitis, chronic lung disease of prematurity. Work Problem 6.	You can describe how to escalate when a child isn't responding.
9	Neonatal (2)	Delivery-room resuscitation, RDS, surfactant, CPAP, capillary vs arterial gases. Work Problems 7 and 9.	You can recite the heart-rate thresholds and what each one triggers.
10	Timed practice	Close the explanations and work all nine problems here in a 90-minute practice block. Spend 30 minutes comparing your selections with the explanations.	You have recorded missed, unnecessary, or guessed choices. The 90 minutes is a study budget, not official exam timing.
11–12	Repair	Add every missed or unnecessary choice to your error log, then re-study the weakest category. Retry those problems here without opening the answers.	Each error has a written "clue I missed."
13	Mixed retry	Work the nine problems in this order: 9, 4, 1, 7, 3, 8, 2, 6, 5. Keep explanations closed for a 90-minute block, then spend 30 minutes explaining why each alternative does not fit.	Your error log shows which habits still slip. Remembering these answers is review, not an independent test of readiness.
14	Light review	Re-read the decision rules table and your error log. Rest.	—

Your error log

Write down every choice you missed and every one you guessed right. A lucky guess is still a gap.

Problem / section	What I chose	The clue I missed	Why the better choice fits	What I'll check next time
Problem 5, Section 2	Tidal volume from actual weight (576 mL)	The patient's height; tidal volume uses predicted body weight	6 × 54.7 kg ≈ 330 mL protects the lung	Calculate PBW before touching tidal volume
Blank error-log entry

Exam-day pacing and logistics

Pace: 4 hours for 22 problems averages about 11 minutes per problem. Problems vary in length, so check the clock every few problems rather than after each one.
Breaks: Allowed, but the clock keeps running (Candidate Handbook, p. 12).
Calculator: Built into the exam software. You can't bring your own (pp. 12, 14).
ID: Two current forms of ID, one with a photo, both showing your current name and signature (p. 11).
Arrival: More than 15 minutes late and you won't be admitted (p. 11).
Results: NBRC's CSE page says you'll receive score information at the test center, and the handbook says your score report is emailed (p. 12). If the emailed report has not arrived within 24 hours, follow the handbook’s instructions to contact PSI.

Can you still take the CSE?

Your situation	What NBRC allows
You passed the TMC at the high cut score on or before Dec. 31, 2026 and meet CSE eligibility	You can take the CSE through Dec. 31, 2027. (NBRC CSE page)
You're thinking of switching to the new Respiratory Therapy (RT) Examination instead	An NBRC notice, republished by Indiana's licensing agency (Sept. 10, 2026), says that once you apply for the RT Exam, you can no longer apply for the CSE. Confirm with NBRC before you apply.
You have not passed the TMC at the high cut by Dec. 31, 2026	The CSE route closes for you. From 2027 the Registered Respiratory Therapist (RRT) credential comes from the high cut score on the RT Exam, first offered Jan. 4, 2027. Check the NBRC RT page for the new route and admission requirements.
You qualify only through the CRT-to-Registry provision	NBRC ends that admission policy on Dec. 31, 2026. Confirm your 2027 CSE eligibility with NBRC (913-895-4900, info@nbrc.org) before planning around it. (NBRC notice)

A high cut score alone doesn't make you eligible; you still need to meet the CSE admission requirements. And keep your application active. The handbook describes inactivation after a year without being scheduled or indicating an intent to attempt the exam; the CSE FAQ says an inactive record nullifies a passing TMC performance toward the unfinished RRT. (Candidate Handbook, p. 10; CSE Record Retention FAQ.)

If you don't pass: retakes and the 2027 deadline

You can take the CSE three times without waiting. After the third attempt, you must wait at least 120 days between each later attempt (Candidate Handbook, p. 13). The standard repeat fee is $200, and you can reapply online two business days after an exam.

Because the CSE ends on December 31, 2027, that waiting period matters:

For a planning illustration, subtracting 120 elapsed days from December 31, 2027 gives September 2, 2027. This is arithmetic, not an NBRC-confirmed last eligible date or an available appointment. Confirm your assigned date with NBRC and leave time to book.
Once an application is accepted, you have 90 calendar days to test (p. 8), and appointments are first-come, first-served. That testing window cannot extend CSE availability beyond December 31, 2027. Book early rather than counting on a late-December seat.

If you can't finish the CSE in time and meet the Respiratory Therapy Examination's admission requirements, you can still earn the RRT through its high cut score: 185 items (160 scored), 4 hours, $360 for a first attempt (NBRC RT page). Its depth-of-clinical-judgment section is built around the same elements as the CSE (patient types, settings, patient ages, information gathering and decision making), but as independent multiple-choice items instead of branching simulations (NBRC 2027 changes). Remember the route-switch rule in Can you still take the CSE? before you apply.

For your next eligible attempt date, check with NBRC; the CSE FAQs and Candidate Handbook give the published rules.

CSE questions people ask

How do I get the AARC discount? AARC members get a one-time $40 discount on their first CSE application. You must register through AARC and start the NBRC application from the link in AARC's email; it isn't applied afterward (NBRC CSE page).

Do I have to retake the TMC if I fail the CSE? No, as long as your NBRC eligibility record stays active. The inactive-record rule concerns a year without being scheduled or indicating an intent to attempt—not a blanket one-year expiration for every TMC pass. NBRC’s CSE FAQ says an inactive record nullifies a passing TMC result toward the unfinished RRT. Confirm your own record with NBRC. (Candidate Handbook, p. 10; CSE FAQ.)

Where do I find pass rates? NBRC publishes yearly pass rates for new and repeat candidates in its Exams in Review sheet.

For the full CRT and RRT credential path and the 2027 exam routes, see respiratory therapist certification.

Sources

Official NBRC sources (checked October 29, 2026)

NBRC: Clinical Simulation Examination (CSE) — eligibility, end date, problem count, time, fee, AARC discount, retakes, record inactivation, free practice link
NBRC Candidate Handbook, Rev. 09/03/2026 — pretest problems (p. 4), fees and 90-day eligibility period (p. 8), record inactivation (p. 10), exam-day rules (pp. 11–12), CSE scoring (p. 12), retake table and practice exam (p. 13), CSE software (pp. 14–15)
NBRC: CSE Detailed Content Outline, effective January 2020–December 31, 2027 — content headings and Test Form Assembly Specifications
NBRC: Respiratory Therapy Examination — first test date, admission requirements, fees, length
NBRC: Examination Changes Coming in 2027 — RT Exam structure and CSE availability
NBRC: CRT-to-Registry Admission Policy Expires in December 2026
Indiana Professional Licensing Agency: Respiratory Care announcements — Sept. 10, 2026 republication of NBRC's notice on applying for the RT Exam

Clinical sources used for the practice problems

Global Initiative for Chronic Obstructive Lung Disease. GOLD 2026 Report, v1.3. Chapter 4, pp. 104–108. (Problem 1)
Rochwerg B, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J. 2017;50:1602426. (Problems 1, 3)
Piraino T, et al. AARC Clinical Practice Guideline: Management of Adult Patients With Oxygen in the Acute Care Setting. Respir Care. 2022;67(1):115–128. (Problems 1, 3)
Fan E, et al. ATS/ESICM/SCCM guideline on mechanical ventilation in adult ARDS. Am J Respir Crit Care Med. 2017;195(9):1253–1263. (Problem 5)
NIH ARDSNet Ventilator Protocol, institutional copy — undated University of Colorado protocol, pp. 1–2. Used as the explicitly ordered example in Problem 5, including its PBW formula and table.
Qadir N, et al. An Update on Management of Adult Patients with ARDS: An Official ATS Clinical Practice Guideline. Am J Respir Crit Care Med. 2024;209:24–36. Abstract Results and Conclusions. (Problem 5)
Roberts KJ, et al. AARC Clinical Practice Guideline: Spontaneous Breathing Trials for Liberation From Adult Mechanical Ventilation. Respir Care. 2024. doi:10.4187/respcare.11735. (Problem 8)
Van Doorn PA, et al. European Academy of Neurology/Peripheral Nerve Society Guideline on diagnosis and treatment of Guillain–Barré syndrome. 2023. PICO 7 and Figure 2, pp. 3656–3658. (Problem 4)
WSES–AAST thoracic trauma guideline. 2025. Diagnosis and Pleural injuries. (Problem 2)
Al-Rawas N, et al. Expiratory time constant for determinations of plateau pressure, respiratory system compliance, and total resistance. Critical Care. 2013;17:R23. Introduction, pressure equations. (Problem 2)
Global Initiative for Asthma. GINA 2026 Strategy Report. Chapter 9, pp. 184–189, especially Box 9-6. (Problem 6)
White BR, et al. AARC and PALISI Clinical Practice Guideline: Pediatric Critical Asthma. Respir Care. 2025;70:593–609. Table 1 and Recommendations 1 and 4. (Problem 6)
American Heart Association and American Academy of Pediatrics. Part 5: Neonatal Resuscitation, 2025 Guidelines. (Problem 7)
Evans DL, et al. AARC Clinical Practice Guideline: Capillary Blood Gas Sampling for Neonatal and Pediatric Patients. Respir Care. 2022;67(9):1190–1204. (Problem 9)

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Last verified: October 29, 2026 (cited NBRC policies, format, scoring, dates, fees, and the clinical guidance used in these cases).

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