NBRC TMC Exam Review 2026: 300+ Practice
Questions & Study Guide
SECTION I: PATIENT DATA EVALUATION & RECOMMENDATIONS
Questions 1–35
1. A 68-year-old male with a history of COPD is admitted to the emergency
department with progressive shortness of breath. His initial ABG on room air
reveals: pH 7.29, PaCO₂ 68 mmHg, PaO₂ 52 mmHg, HCO₃⁻ 32 mEq/L. What is the
most appropriate interpretation of this ABG?
A. Acute respiratory acidosis with hypoxemia
B. Chronic respiratory acidosis with acute exacerbation and hypoxemia
C. Metabolic alkalosis with respiratory compensation
D. Acute respiratory alkalosis with metabolic compensation
Correct Answer: B
Rationale: The pH is low (7.29) indicating acidemia. The PaCO₂ is markedly
elevated (68 mmHg) indicating respiratory acidosis. The HCO₃⁻ is elevated (32
mEq/L) above normal (22–26 mEq/L), suggesting renal compensation. The
combination of elevated PaCO₂ and elevated HCO₃⁻ with a pH that is only mildly
acidemic indicates chronic respiratory acidosis with an acute exacerbation (the pH
would be closer to normal if fully compensated). The PaO₂ of 52 mmHg confirms
hypoxemia.
2. A 45-year-old female is receiving mechanical ventilation in the ICU. Her
ventilator settings are: SIMV, rate 12, Vt 500 mL, FiO₂ 0.40, PEEP 5 cm H₂O. The
most recent ABG shows: pH 7.38, PaCO₂ 42 mmHg, PaO₂ 88 mmHg, HCO₃⁻ 24
mEq/L. Which of the following is the correct interpretation?
A. Normal ABG
B. Compensated respiratory acidosis
,C. Compensated metabolic alkalosis
D. Partially compensated respiratory acidosis
Correct Answer: A
Rationale: All values are within normal ranges: pH 7.35–7.45, PaCO₂ 35–45
mmHg, PaO₂ 80–100 mmHg, HCO₃⁻ 22–26 mEq/L. This represents a normal ABG
on the current ventilator settings.
3. A 72-year-old patient with CHF is receiving 40% Venturi mask. ABG results: pH
7.32, PaCO₂ 48 mmHg, PaO₂ 68 mmHg, HCO₃⁻ 24 mEq/L. What is the most
appropriate recommendation?
A. Increase FiO₂ to 50%
B. Add BiPAP
C. Administer sodium bicarbonate
D. Increase the Venturi mask to 60%
Correct Answer: B
Rationale: The patient has acute respiratory acidosis (pH 7.32, PaCO₂ 48) with
hypoxemia (PaO₂ 68) despite 40% oxygen. The elevated PaCO₂ with a normal
HCO₃⁻ suggests acute ventilatory failure. The most appropriate intervention is
noninvasive positive pressure ventilation (BiPAP) to improve ventilation and
reduce work of breathing. Simply increasing FiO₂ will not address the
hypercapnia. Sodium bicarbonate is not indicated for respiratory acidosis.
4. A patient's chest X-ray shows a white-out of the left hemithorax with
mediastinal shift to the left. What is the most likely diagnosis?
A. Left-sided pneumothorax
B. Left-sided pleural effusion
C. Left lung atelectasis
D. Left-sided tension pneumothorax
Correct Answer: C
,Rationale: Complete opacification (white-out) of a hemithorax with mediastinal
shift toward the affected side indicates volume loss, most commonly from
complete atelectasis. A tension pneumothorax or large pleural effusion would
cause mediastinal shift away from the affected side.
5. A 55-year-old patient with asthma is receiving bronchodilator therapy. Which
of the following findings would indicate the patient is not responding
adequately to treatment? (Select all that apply)
A. Increased wheezing
B. Peak expiratory flow rate (PEFR) improving from 200 to 350 L/min
C. Paradoxical abdominal movement
D. Silent chest on auscultation
E. Heart rate decreasing from 110 to 88 bpm
Correct Answers: A, C, D
Rationale:
• A. Increased wheezing — Can indicate worsening bronchospasm or
impending respiratory failure.
• C. Paradoxical abdominal movement — Indicates severe respiratory
muscle fatigue and impending respiratory failure.
• D. Silent chest — Indicates severe airway obstruction with minimal air
movement; a critical sign of impending respiratory arrest.
• B. PEFR improving — Actually indicates improvement.
• E. Heart rate decreasing — Typically indicates improvement as work of
breathing decreases.
6. A patient with acute respiratory distress syndrome (ARDS) is on mechanical
ventilation. Which of the following ventilator strategies is recommended to
reduce ventilator-induced lung injury?
, A. High tidal volume (10–12 mL/kg) with low PEEP
B. Low tidal volume (6 mL/kg ideal body weight) with high PEEP
C. High respiratory rate with low PEEP
D. Pressure support ventilation with high FiO₂
Correct Answer: B
Rationale: The ARDSnet protocol recommends low tidal volume ventilation (6
mL/kg ideal body weight) with plateau pressures ≤30 cm H₂O and higher PEEP to
recruit alveoli and prevent atelectasis. This lung-protective strategy reduces
ventilator-induced lung injury (VILI) and mortality.
7. A patient's pulmonary artery catheter shows: CVP 14 mmHg, PAOP 22 mmHg,
cardiac index 1.8 L/min/m², SVR 1800 dynes·sec·cm⁻⁵. What is the most likely
diagnosis?
A. Cardiogenic shock
B. Hypovolemic shock
C. Septic shock
D. Distributive shock
Correct Answer: A
Rationale: Elevated PAOP (>18 mmHg) with low cardiac index (<2.2 L/min/m²)
and elevated SVR indicates cardiogenic shock with left ventricular failure. The
elevated CVP also suggests right-sided volume overload.
8. A 60-year-old patient with emphysema is on 2 L/min nasal cannula. The ABG
reveals: pH 7.28, PaCO₂ 70 mmHg, PaO₂ 58 mmHg, HCO₃⁻ 32 mEq/L. What is the
most appropriate INITIAL action?
A. Increase nasal cannula to 4 L/min
B. Initiate BiPAP
C. Administer nebulized albuterol
D. Intubate and initiate mechanical ventilation
Correct Answer: C
Questions & Study Guide
SECTION I: PATIENT DATA EVALUATION & RECOMMENDATIONS
Questions 1–35
1. A 68-year-old male with a history of COPD is admitted to the emergency
department with progressive shortness of breath. His initial ABG on room air
reveals: pH 7.29, PaCO₂ 68 mmHg, PaO₂ 52 mmHg, HCO₃⁻ 32 mEq/L. What is the
most appropriate interpretation of this ABG?
A. Acute respiratory acidosis with hypoxemia
B. Chronic respiratory acidosis with acute exacerbation and hypoxemia
C. Metabolic alkalosis with respiratory compensation
D. Acute respiratory alkalosis with metabolic compensation
Correct Answer: B
Rationale: The pH is low (7.29) indicating acidemia. The PaCO₂ is markedly
elevated (68 mmHg) indicating respiratory acidosis. The HCO₃⁻ is elevated (32
mEq/L) above normal (22–26 mEq/L), suggesting renal compensation. The
combination of elevated PaCO₂ and elevated HCO₃⁻ with a pH that is only mildly
acidemic indicates chronic respiratory acidosis with an acute exacerbation (the pH
would be closer to normal if fully compensated). The PaO₂ of 52 mmHg confirms
hypoxemia.
2. A 45-year-old female is receiving mechanical ventilation in the ICU. Her
ventilator settings are: SIMV, rate 12, Vt 500 mL, FiO₂ 0.40, PEEP 5 cm H₂O. The
most recent ABG shows: pH 7.38, PaCO₂ 42 mmHg, PaO₂ 88 mmHg, HCO₃⁻ 24
mEq/L. Which of the following is the correct interpretation?
A. Normal ABG
B. Compensated respiratory acidosis
,C. Compensated metabolic alkalosis
D. Partially compensated respiratory acidosis
Correct Answer: A
Rationale: All values are within normal ranges: pH 7.35–7.45, PaCO₂ 35–45
mmHg, PaO₂ 80–100 mmHg, HCO₃⁻ 22–26 mEq/L. This represents a normal ABG
on the current ventilator settings.
3. A 72-year-old patient with CHF is receiving 40% Venturi mask. ABG results: pH
7.32, PaCO₂ 48 mmHg, PaO₂ 68 mmHg, HCO₃⁻ 24 mEq/L. What is the most
appropriate recommendation?
A. Increase FiO₂ to 50%
B. Add BiPAP
C. Administer sodium bicarbonate
D. Increase the Venturi mask to 60%
Correct Answer: B
Rationale: The patient has acute respiratory acidosis (pH 7.32, PaCO₂ 48) with
hypoxemia (PaO₂ 68) despite 40% oxygen. The elevated PaCO₂ with a normal
HCO₃⁻ suggests acute ventilatory failure. The most appropriate intervention is
noninvasive positive pressure ventilation (BiPAP) to improve ventilation and
reduce work of breathing. Simply increasing FiO₂ will not address the
hypercapnia. Sodium bicarbonate is not indicated for respiratory acidosis.
4. A patient's chest X-ray shows a white-out of the left hemithorax with
mediastinal shift to the left. What is the most likely diagnosis?
A. Left-sided pneumothorax
B. Left-sided pleural effusion
C. Left lung atelectasis
D. Left-sided tension pneumothorax
Correct Answer: C
,Rationale: Complete opacification (white-out) of a hemithorax with mediastinal
shift toward the affected side indicates volume loss, most commonly from
complete atelectasis. A tension pneumothorax or large pleural effusion would
cause mediastinal shift away from the affected side.
5. A 55-year-old patient with asthma is receiving bronchodilator therapy. Which
of the following findings would indicate the patient is not responding
adequately to treatment? (Select all that apply)
A. Increased wheezing
B. Peak expiratory flow rate (PEFR) improving from 200 to 350 L/min
C. Paradoxical abdominal movement
D. Silent chest on auscultation
E. Heart rate decreasing from 110 to 88 bpm
Correct Answers: A, C, D
Rationale:
• A. Increased wheezing — Can indicate worsening bronchospasm or
impending respiratory failure.
• C. Paradoxical abdominal movement — Indicates severe respiratory
muscle fatigue and impending respiratory failure.
• D. Silent chest — Indicates severe airway obstruction with minimal air
movement; a critical sign of impending respiratory arrest.
• B. PEFR improving — Actually indicates improvement.
• E. Heart rate decreasing — Typically indicates improvement as work of
breathing decreases.
6. A patient with acute respiratory distress syndrome (ARDS) is on mechanical
ventilation. Which of the following ventilator strategies is recommended to
reduce ventilator-induced lung injury?
, A. High tidal volume (10–12 mL/kg) with low PEEP
B. Low tidal volume (6 mL/kg ideal body weight) with high PEEP
C. High respiratory rate with low PEEP
D. Pressure support ventilation with high FiO₂
Correct Answer: B
Rationale: The ARDSnet protocol recommends low tidal volume ventilation (6
mL/kg ideal body weight) with plateau pressures ≤30 cm H₂O and higher PEEP to
recruit alveoli and prevent atelectasis. This lung-protective strategy reduces
ventilator-induced lung injury (VILI) and mortality.
7. A patient's pulmonary artery catheter shows: CVP 14 mmHg, PAOP 22 mmHg,
cardiac index 1.8 L/min/m², SVR 1800 dynes·sec·cm⁻⁵. What is the most likely
diagnosis?
A. Cardiogenic shock
B. Hypovolemic shock
C. Septic shock
D. Distributive shock
Correct Answer: A
Rationale: Elevated PAOP (>18 mmHg) with low cardiac index (<2.2 L/min/m²)
and elevated SVR indicates cardiogenic shock with left ventricular failure. The
elevated CVP also suggests right-sided volume overload.
8. A 60-year-old patient with emphysema is on 2 L/min nasal cannula. The ABG
reveals: pH 7.28, PaCO₂ 70 mmHg, PaO₂ 58 mmHg, HCO₃⁻ 32 mEq/L. What is the
most appropriate INITIAL action?
A. Increase nasal cannula to 4 L/min
B. Initiate BiPAP
C. Administer nebulized albuterol
D. Intubate and initiate mechanical ventilation
Correct Answer: C
