RRT Clinical Simulations (CSE) – NBRC
Practice Scenarios with Verified
Answers (2024–2025)130+ Questions
with Verified Answers & Rationales
SCENARIO 1 – Post-Operative Respiratory Failure
Initial Information:
A 68-year-old male, 2 hours post abdominal aortic aneurysm repair, is in the ICU. He is
sedated but arousable. Ventilator settings: PC-AC, rate 14, Pi 18 cmH2O, PEEP 5, FiO2 0.50.
ABG: pH 7.28, PaCO2 55, PaO2 78, HCO3 24, BE -2.
Question 1
Which of the following should you recommend FIRST?
A. Increase PEEP to 10 cmH2O
B. Increase respiratory rate to 18
C. Obtain a chest x-ray
D. Suction the ETT
Correct Answer: B – Increase respiratory rate to 18
Rationale: Patient has acute hypercapnic respiratory failure (pH <7.30, PaCO2 >45) likely due
to sedation/post-op hypoventilation. Increasing rate will directly lower PaCO2. PEEP treats
hypoxemia, not hypercapnia. CXR and suction are not first-line for acute hypercapnia
without signs of obstruction.
Question 2
After increasing rate to 18, repeat ABG: pH 7.31, PaCO2 48, PaO2 80. What next?
A. Continue current settings
B. Increase PEEP to 8
C. Change to VCV
D. Perform recruitment maneuver
,Correct Answer: A – Continue current settings
Rationale: pH is improving (7.31) and PaCO2 trending down. Acceptable per NBRC targets
(pH >7.30). No indication for change.
Question 3
Two hours later, SpO2 drops to 88% on FiO2 0.50. Breath sounds decreased on left. What
should you do FIRST?
A. Stat CXR
B. Increase FiO2 to 1.0
C. Manual ventilation with 100% O2 and check tube patency
D. Bronchoscopy
Correct Answer: C – Manual ventilation with 100% O2 and check tube patency
Rationale: Sudden desat with decreased breath sounds suggests mucus plug, ETT
dislodgement, or pneumothorax. Immediate manual ventilation and assessment of tube
patency is priority before imaging.
SCENARIO 2 – Acute Asthma Exacerbation
Initial Information:
A 22-year-old female with known asthma presents to ED with severe dyspnea. RR 32, HR
125, SpO2 88% RA. No wheezing on auscultation, silent chest. ABG: pH 7.25, PaCO2 52, PaO2
60.
Question 4
What is the MOST appropriate initial therapy?
A. BiPAP 10/5 cmH2O
B. Intubation and mechanical ventilation
C. Nebulized albuterol/ipratropium and IV steroids
D. Heliox
Correct Answer: B – Intubation and mechanical ventilation
Rationale: Silent chest + hypercapnia (PaCO2 52) with acidosis indicates near-fatal asthma.
Noninvasive ventilation is contraindicated in severe asthma with altered mental status.
Immediate intubation is required.
Question 5
Post-intubation, which ventilator mode and setting is BEST?
A. VCV, rate 14, Vt 500 mL, flow 60 L/min
B. PCV, rate 12, Pi 18, I:E 1:4, PEEP 0
C. PRVC, rate 20, Vt 6 mL/kg
D. SIMV, rate 16, Vt 450 mL
, Correct Answer: B – PCV, rate 12, Pi 18, I:E 1:4, PEEP 0
Rationale: Asthma requires low rate, prolonged expiratory time (I:E 1:4), low PEEP (or 0) to
prevent auto-PEEP. PCV allows pressure limitation.
Question 6
Peak pressure is 48, plateau 30. What is most appropriate?
A. Increase inspiratory flow
B. Add inline MDI albuterol
C. Decrease rate to 10
D. Change to VCV
Correct Answer: C – Decrease rate to 10
Rationale: High plateau pressure (30) and high peak indicate dynamic hyperinflation.
Decreasing rate allows more expiratory time, reducing auto-PEEP.
SCENARIO 3 – ARDS Management
Initial Information:
A 45-year-old with pancreatitis, intubated for 3 days. PaO2/FiO2 = 150 on PEEP 10, FiO2 0.7.
CXR: bilateral infiltrates.
Question 7
Which of the following is a standard ARDSnet low tidal volume strategy target?
A. Vt 12 mL/kg IBW, plateau < 35
B. Vt 6 mL/kg IBW, plateau < 30
C. Vt 8 mL/kg IBW, plateau < 40
D. Vt 10 mL/kg IBW, plateau < 25
Correct Answer: B – Vt 6 mL/kg IBW, plateau < 30
Rationale: ARDSnet protocol: initial Vt 6 mL/kg PBW, keep plateau ≤ 30.
Question 8
After setting Vt 6 mL/kg, plateau pressure is 32. What next?
A. Increase PEEP to 12
B. Reduce Vt to 5 mL/kg
C. Change to APRV
D. Add prone positioning
Correct Answer: B – Reduce Vt to 5 mL/kg
Rationale: Plateau >30 despite low Vt → further reduce Vt to 5-4 mL/kg, accept permissive
hypercapnia.
Question 9
Practice Scenarios with Verified
Answers (2024–2025)130+ Questions
with Verified Answers & Rationales
SCENARIO 1 – Post-Operative Respiratory Failure
Initial Information:
A 68-year-old male, 2 hours post abdominal aortic aneurysm repair, is in the ICU. He is
sedated but arousable. Ventilator settings: PC-AC, rate 14, Pi 18 cmH2O, PEEP 5, FiO2 0.50.
ABG: pH 7.28, PaCO2 55, PaO2 78, HCO3 24, BE -2.
Question 1
Which of the following should you recommend FIRST?
A. Increase PEEP to 10 cmH2O
B. Increase respiratory rate to 18
C. Obtain a chest x-ray
D. Suction the ETT
Correct Answer: B – Increase respiratory rate to 18
Rationale: Patient has acute hypercapnic respiratory failure (pH <7.30, PaCO2 >45) likely due
to sedation/post-op hypoventilation. Increasing rate will directly lower PaCO2. PEEP treats
hypoxemia, not hypercapnia. CXR and suction are not first-line for acute hypercapnia
without signs of obstruction.
Question 2
After increasing rate to 18, repeat ABG: pH 7.31, PaCO2 48, PaO2 80. What next?
A. Continue current settings
B. Increase PEEP to 8
C. Change to VCV
D. Perform recruitment maneuver
,Correct Answer: A – Continue current settings
Rationale: pH is improving (7.31) and PaCO2 trending down. Acceptable per NBRC targets
(pH >7.30). No indication for change.
Question 3
Two hours later, SpO2 drops to 88% on FiO2 0.50. Breath sounds decreased on left. What
should you do FIRST?
A. Stat CXR
B. Increase FiO2 to 1.0
C. Manual ventilation with 100% O2 and check tube patency
D. Bronchoscopy
Correct Answer: C – Manual ventilation with 100% O2 and check tube patency
Rationale: Sudden desat with decreased breath sounds suggests mucus plug, ETT
dislodgement, or pneumothorax. Immediate manual ventilation and assessment of tube
patency is priority before imaging.
SCENARIO 2 – Acute Asthma Exacerbation
Initial Information:
A 22-year-old female with known asthma presents to ED with severe dyspnea. RR 32, HR
125, SpO2 88% RA. No wheezing on auscultation, silent chest. ABG: pH 7.25, PaCO2 52, PaO2
60.
Question 4
What is the MOST appropriate initial therapy?
A. BiPAP 10/5 cmH2O
B. Intubation and mechanical ventilation
C. Nebulized albuterol/ipratropium and IV steroids
D. Heliox
Correct Answer: B – Intubation and mechanical ventilation
Rationale: Silent chest + hypercapnia (PaCO2 52) with acidosis indicates near-fatal asthma.
Noninvasive ventilation is contraindicated in severe asthma with altered mental status.
Immediate intubation is required.
Question 5
Post-intubation, which ventilator mode and setting is BEST?
A. VCV, rate 14, Vt 500 mL, flow 60 L/min
B. PCV, rate 12, Pi 18, I:E 1:4, PEEP 0
C. PRVC, rate 20, Vt 6 mL/kg
D. SIMV, rate 16, Vt 450 mL
, Correct Answer: B – PCV, rate 12, Pi 18, I:E 1:4, PEEP 0
Rationale: Asthma requires low rate, prolonged expiratory time (I:E 1:4), low PEEP (or 0) to
prevent auto-PEEP. PCV allows pressure limitation.
Question 6
Peak pressure is 48, plateau 30. What is most appropriate?
A. Increase inspiratory flow
B. Add inline MDI albuterol
C. Decrease rate to 10
D. Change to VCV
Correct Answer: C – Decrease rate to 10
Rationale: High plateau pressure (30) and high peak indicate dynamic hyperinflation.
Decreasing rate allows more expiratory time, reducing auto-PEEP.
SCENARIO 3 – ARDS Management
Initial Information:
A 45-year-old with pancreatitis, intubated for 3 days. PaO2/FiO2 = 150 on PEEP 10, FiO2 0.7.
CXR: bilateral infiltrates.
Question 7
Which of the following is a standard ARDSnet low tidal volume strategy target?
A. Vt 12 mL/kg IBW, plateau < 35
B. Vt 6 mL/kg IBW, plateau < 30
C. Vt 8 mL/kg IBW, plateau < 40
D. Vt 10 mL/kg IBW, plateau < 25
Correct Answer: B – Vt 6 mL/kg IBW, plateau < 30
Rationale: ARDSnet protocol: initial Vt 6 mL/kg PBW, keep plateau ≤ 30.
Question 8
After setting Vt 6 mL/kg, plateau pressure is 32. What next?
A. Increase PEEP to 12
B. Reduce Vt to 5 mL/kg
C. Change to APRV
D. Add prone positioning
Correct Answer: B – Reduce Vt to 5 mL/kg
Rationale: Plateau >30 despite low Vt → further reduce Vt to 5-4 mL/kg, accept permissive
hypercapnia.
Question 9
