NBRC RRT Clinical Simulation Exam (CSE) Prep |
Complete Practice Cases, Clinical Scenarios & Expert
Rationales 2026/2027
QUESTION 1 A 45-year-old male with ARDS is on volume-controlled
ventilation: Tidal Volume 450 mL (6 mL/kg PBW), Rate 24, PEEP 14
cmH2O. ABG: pH 7.28, PaCO2 55 mmHg, PaO2 58 mmHg, SaO2 88%.
The patient is hemodynamically stable. What is the most appropriate
next step?
• A. Increase tidal volume to 8 mL/kg
• B. Increase respiratory rate to 30
• C. Increase PEEP to 16 cmH2O and monitor compliance
• D. Initiate permissive hypercapnia protocols and check for trigger
synchrony
• Correct Answer: C. Increase PEEP to 16 cmH2O and monitor
compliance.
• Detailed Rationale: In ARDS, the priority is oxygenation (PaO2).
The patient is hypoxemic on 14 cmH2O of PEEP. Increasing PEEP is
the standard "open lung" strategy, provided hemodynamics
remain stable. Permissive hypercapnia is appropriate for the
acidosis, but the primary concern is the hypoxemia.
QUESTION 2 A patient with COPD is failing a spontaneous breathing
trial (SBT). HR has increased from 88 to 135 bpm, RR from 18 to 35, and
the patient is using accessory muscles. What should you do?
, • A. Increase the level of pressure support
• B. Immediate re-initiation of mechanical ventilation
• C. Administer a sedative to decrease respiratory drive
• D. Suction the airway
• Correct Answer: B. Immediate re-initiation of mechanical
ventilation.
• Detailed Rationale: The patient is demonstrating clear signs of
respiratory distress and failure of the SBT (tachycardia, tachypnea,
accessory muscle use). Delaying support in a patient with COPD
exacerbation risks cardiac arrest.
QUESTION 3 You are performing an assessment on a post-operative
patient. The ventilator pressure-time waveform shows a "scooped out"
inspiratory phase, and the patient appears anxious. What is the most
likely cause?
• A. Auto-PEEP
• B. Patient-ventilator flow starvation
• C. A circuit leak
• D. Excessive PEEP
• Correct Answer: B. Patient-ventilator flow starvation.
• Detailed Rationale: A "scooped out" (or concave) appearance on
the inspiratory pressure waveform indicates the patient is
demanding more flow than the ventilator is providing (flow
starvation). The solution is to increase inspiratory flow or switch to
a flow-cycled mode (e.g., Pressure Support).
,QUESTION 4 A 6-year-old child presents with a "barking" cough, stridor
at rest, and steeple sign on neck X-ray. What is the most appropriate
initial treatment?
• A. Racemic epinephrine and dexamethasone
• B. Humidified oxygen and heliox
• C. Immediate intubation
• D. Nebulized albuterol
• Correct Answer: A. Racemic epinephrine and dexamethasone.
• Detailed Rationale: The clinical presentation (barking cough,
steeple sign) is classic for croup (laryngotracheobronchitis).
Racemic epinephrine provides rapid relief of upper airway edema,
and steroids reduce inflammation.
QUESTION 5 During a simulation scenario, a patient on a chest tube
drainage system experiences a sudden increase in the amount of air
bubbling in the water-seal chamber. What should you evaluate first?
• A. The suction pressure in the wall regulator
• B. The chest tube insertion site for a loose dressing
• C. The patient for signs of a new pneumothorax
• D. The drainage tubing for loose connections
• Correct Answer: D. The drainage tubing for loose connections.
• Detailed Rationale: Sudden increased bubbling in the water-seal
chamber usually signifies an air leak. Before checking the patient,
rule out the most common and easily fixable cause: a
disconnected or loose tube in the external system.
, QUESTION 6 A 28-week gestation neonate is struggling to breathe. ABG:
pH 7.20, PaCO2 65, PaO2 45. CXR shows "ground-glass" appearance and
air bronchograms. You recommend:
• A. ECMO
• B. Exogenous surfactant replacement therapy
• C. High-frequency oscillation
• D. Chest physiotherapy
• Correct Answer: B. Exogenous surfactant replacement therapy.
• Detailed Rationale: The presentation (preterm, acidosis, ground-
glass CXR) is classic for RDS (Respiratory Distress Syndrome).
Surfactant replacement is the definitive treatment to decrease
surface tension and improve compliance.
QUESTION 7 A patient with massive trauma is suspected of having a
tension pneumothorax. You see tracheal deviation to the right and
decreased breath sounds on the left. The patient is hypotensive. What
is the priority intervention?
• A. Obtain a STAT CXR
• B. Place a chest tube in the right 5th intercostal space
• C. Needle decompression in the left 2nd intercostal space
• D. Increase ventilator PEEP
• Correct Answer: C. Needle decompression in the left 2nd
intercostal space.
• Detailed Rationale: In the setting of hemodynamic instability
(tension pneumothorax), needle decompression is a life-saving,
Complete Practice Cases, Clinical Scenarios & Expert
Rationales 2026/2027
QUESTION 1 A 45-year-old male with ARDS is on volume-controlled
ventilation: Tidal Volume 450 mL (6 mL/kg PBW), Rate 24, PEEP 14
cmH2O. ABG: pH 7.28, PaCO2 55 mmHg, PaO2 58 mmHg, SaO2 88%.
The patient is hemodynamically stable. What is the most appropriate
next step?
• A. Increase tidal volume to 8 mL/kg
• B. Increase respiratory rate to 30
• C. Increase PEEP to 16 cmH2O and monitor compliance
• D. Initiate permissive hypercapnia protocols and check for trigger
synchrony
• Correct Answer: C. Increase PEEP to 16 cmH2O and monitor
compliance.
• Detailed Rationale: In ARDS, the priority is oxygenation (PaO2).
The patient is hypoxemic on 14 cmH2O of PEEP. Increasing PEEP is
the standard "open lung" strategy, provided hemodynamics
remain stable. Permissive hypercapnia is appropriate for the
acidosis, but the primary concern is the hypoxemia.
QUESTION 2 A patient with COPD is failing a spontaneous breathing
trial (SBT). HR has increased from 88 to 135 bpm, RR from 18 to 35, and
the patient is using accessory muscles. What should you do?
, • A. Increase the level of pressure support
• B. Immediate re-initiation of mechanical ventilation
• C. Administer a sedative to decrease respiratory drive
• D. Suction the airway
• Correct Answer: B. Immediate re-initiation of mechanical
ventilation.
• Detailed Rationale: The patient is demonstrating clear signs of
respiratory distress and failure of the SBT (tachycardia, tachypnea,
accessory muscle use). Delaying support in a patient with COPD
exacerbation risks cardiac arrest.
QUESTION 3 You are performing an assessment on a post-operative
patient. The ventilator pressure-time waveform shows a "scooped out"
inspiratory phase, and the patient appears anxious. What is the most
likely cause?
• A. Auto-PEEP
• B. Patient-ventilator flow starvation
• C. A circuit leak
• D. Excessive PEEP
• Correct Answer: B. Patient-ventilator flow starvation.
• Detailed Rationale: A "scooped out" (or concave) appearance on
the inspiratory pressure waveform indicates the patient is
demanding more flow than the ventilator is providing (flow
starvation). The solution is to increase inspiratory flow or switch to
a flow-cycled mode (e.g., Pressure Support).
,QUESTION 4 A 6-year-old child presents with a "barking" cough, stridor
at rest, and steeple sign on neck X-ray. What is the most appropriate
initial treatment?
• A. Racemic epinephrine and dexamethasone
• B. Humidified oxygen and heliox
• C. Immediate intubation
• D. Nebulized albuterol
• Correct Answer: A. Racemic epinephrine and dexamethasone.
• Detailed Rationale: The clinical presentation (barking cough,
steeple sign) is classic for croup (laryngotracheobronchitis).
Racemic epinephrine provides rapid relief of upper airway edema,
and steroids reduce inflammation.
QUESTION 5 During a simulation scenario, a patient on a chest tube
drainage system experiences a sudden increase in the amount of air
bubbling in the water-seal chamber. What should you evaluate first?
• A. The suction pressure in the wall regulator
• B. The chest tube insertion site for a loose dressing
• C. The patient for signs of a new pneumothorax
• D. The drainage tubing for loose connections
• Correct Answer: D. The drainage tubing for loose connections.
• Detailed Rationale: Sudden increased bubbling in the water-seal
chamber usually signifies an air leak. Before checking the patient,
rule out the most common and easily fixable cause: a
disconnected or loose tube in the external system.
, QUESTION 6 A 28-week gestation neonate is struggling to breathe. ABG:
pH 7.20, PaCO2 65, PaO2 45. CXR shows "ground-glass" appearance and
air bronchograms. You recommend:
• A. ECMO
• B. Exogenous surfactant replacement therapy
• C. High-frequency oscillation
• D. Chest physiotherapy
• Correct Answer: B. Exogenous surfactant replacement therapy.
• Detailed Rationale: The presentation (preterm, acidosis, ground-
glass CXR) is classic for RDS (Respiratory Distress Syndrome).
Surfactant replacement is the definitive treatment to decrease
surface tension and improve compliance.
QUESTION 7 A patient with massive trauma is suspected of having a
tension pneumothorax. You see tracheal deviation to the right and
decreased breath sounds on the left. The patient is hypotensive. What
is the priority intervention?
• A. Obtain a STAT CXR
• B. Place a chest tube in the right 5th intercostal space
• C. Needle decompression in the left 2nd intercostal space
• D. Increase ventilator PEEP
• Correct Answer: C. Needle decompression in the left 2nd
intercostal space.
• Detailed Rationale: In the setting of hemodynamic instability
(tension pneumothorax), needle decompression is a life-saving,
