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NBRC TMC CRT RRT ACTUAL EXAM WITH 300
QUESTIONS AND CORRECT DETAILED SOLUTIONS WITH
RATIONALES LATEST UPDATED VERSION THIS YEAR
Question 1 A 68-year-old patient with a history of COPD presents with increased shortness of breath, productive cough with green sputum, and fever. Arterial blood gas on room air shows: pH 7.28, PaCO₂ 68 mmHg, PaO₂ 52 mmHg, HCO₃ 30 mEq/L. What is the most appropriate interpretation of this ABG? A) Acute respiratory acidosis with hypoxemia B) Chronic respiratory acidosis with acute exacerbation C) Metabolic alkalosis with respiratory compensation D) Mixed metabolic and respiratory acidosis Correct Answer: B Rationale: The pH is acidemic (7.28), PaCO₂ is elevated (68) indicating respiratory acidosis. The HCO₃ is elevated (30) suggesting chronic compensation. The acute drop in pH with elevated PaCO₂ indicates an acute exacerbation on top of chronic respiratory acidosis.
Question 2 A 55-year-old patient is receiving mechanical ventilation with the following settings: Mode SIMV, Rate 12, Vt 500 mL, FiO₂ 0.40, PEEP 5 cm H₂O. Arterial blood gas shows: pH 7.31, PaCO₂ 55 mmHg, PaO₂ 78 mmHg, HCO₃ 26 mEq/L. What is the most appropriate ventilator adjustment? A) Increase the respiratory rate B) Decrease the tidal volume C) Increase FiO₂ D) Decrease PEEP Correct Answer: A Rationale: The ABG shows respiratory acidosis (pH 7.31, PaCO₂ 55). Increasing the respiratory rate will increase minute ventilation and help lower PaCO₂. The PaO₂ is acceptable at 78 mmHg. Question 3 A patient with asthma is receiving continuous albuterol nebulization. The patient's heart rate is 140 bpm and they are complaining of palpitations and tremors. What is the most appropriate action?
Correct Answer: B Rationale: The patient has acute respiratory acidosis (pH 7.32, PaCO₂ 52) with hypoxemia. NPPV can support ventilation and improve oxygenation while avoiding intubation in an awake, alert patient. Question 5 A patient with ARDS is on mechanical ventilation with the following settings: PC-CMV, Pressure Control 18 cm H₂O, Rate 16, FiO₂ 0.60, PEEP 12 cm H₂O. The patient's SpO₂ drops from 94% to 86%. What is the MOST appropriate initial action? A) Increase FiO₂ to 1. B) Increase PEEP C) Increase the pressure control level D) Suction the patient Correct Answer: D Rationale: A sudden drop in SpO₂ should prompt an immediate assessment for an acute problem. The most common cause is mucus plugging or secretion accumulation. Suctioning should be performed first before making ventilator changes.
Question 6 A 45-year-old patient with status asthmaticus is intubated. Ventilator settings: PC-CMV, Rate 14, Pressure Control 25 cm H₂O, FiO₂ 0.50, PEEP 0. The peak inspiratory pressure is 45 cm H₂O and plateau pressure is 32 cm H₂O. What is the most likely cause of the elevated pressures? A) Auto-PEEP due to air trapping B) Mainstem intubation C) Pneumothorax D) Pulmonary edema Correct Answer: A Rationale: In status asthmaticus, air trapping (auto-PEEP) is common due to prolonged expiration. The difference between peak and plateau pressures is 13 cm H₂O (normal <5-10), indicating increased airway resistance. Auto-PEEP management includes allowing more expiratory time, sedation, and bronchodilators. Question 7 A 60-year-old patient with COPD has a baseline PaCO₂ of 55 mmHg. The patient is receiving 2
B) Respiratory acidosis with metabolic compensation C) Metabolic alkalosis with respiratory compensation D) Respiratory alkalosis with metabolic compensation Correct Answer: A Rationale: The pH is acidemic (7.20), HCO₃ is low (10) indicating metabolic acidosis. The PaCO₂ is low (25) indicating respiratory compensation (Kussmaul breathing). This is metabolic acidosis with appropriate respiratory compensation. Question 9 A patient with a history of heart failure presents with dyspnea, orthopnea, and frothy pink sputum. Lung auscultation reveals crackles in both lung bases. What is the most likely diagnosis? A) Pneumonia B) Pulmonary embolism C) Acute cardiogenic pulmonary edema D) COPD exacerbation Correct Answer: C
Rationale: Frothy pink sputum, dyspnea, orthopnea, and crackles in a patient with heart failure are classic signs of acute cardiogenic pulmonary edema. Question 10 A 50-year-old patient is receiving mechanical ventilation. The low-pressure alarm sounds. Which of the following is the most likely cause? A) Patient biting the endotracheal tube B) Secretions in the airway C) Disconnection from the ventilator D) Bronchospasm Correct Answer: C Rationale: A low-pressure alarm indicates decreased airway pressure, most commonly due to a disconnection or leak in the ventilator circuit. Patient biting, secretions, and bronchospasm would cause high-pressure alarms.
C) Pneumonia D) Myocardial infarction Correct Answer: B Rationale: The sudden onset of dyspnea, pleuritic chest pain, hemoptysis, and hypoxia in a post- surgical patient is classic for pulmonary embolism. Question 13 A patient is receiving mechanical ventilation with the following settings: VCV, Rate 12, Vt 450 mL, FiO₂ 0.50, PEEP 8. The patient's plateau pressure is 32 cm H₂O. What is the most appropriate action? A) Decrease the tidal volume B) Increase the tidal volume C) Increase PEEP D) Decrease the respiratory rate Correct Answer: A Rationale: Plateau pressure >30 cm H₂O increases the risk of ventilator-induced lung injury.
Decreasing tidal volume will lower plateau pressure while maintaining adequate minute ventilation. Question 14 A patient with asthma is receiving albuterol via small-volume nebulizer. The patient's heart rate is 110 bpm, respiratory rate is 28/min, and SpO₂ is 92% on 2 L/min nasal cannula. What is the most appropriate action? A) Continue current treatment and reassess B) Increase oxygen to 4 L/min C) Add ipratropium to the nebulizer D) Initiate noninvasive ventilation Correct Answer: C Rationale: Adding ipratropium (an anticholinergic) to albuterol provides additional bronchodilation in acute asthma exacerbations, especially in patients not responding adequately to beta-agonists alone.
C) Reduce the cuff pressure to 20-30 cm H₂O D) Increase the cuff pressure to 40 cm H₂O Correct Answer: C Rationale: The recommended endotracheal tube cuff pressure is 20-30 cm H₂O to prevent aspiration while maintaining mucosal perfusion. A pressure of 35 cm H₂O exceeds this and may cause tracheal ischemia. Question 17 A 62-year-old patient with a 40-pack-year smoking history presents with a chronic cough, hemoptysis, and weight loss. Chest X-ray shows a hilar mass. What is the most likely diagnosis? A) Tuberculosis B) Lung cancer C) Sarcoidosis D) COPD Correct Answer: B Rationale: A hilar mass in a patient with a significant smoking history, hemoptysis, and weight loss is highly suspicious for lung cancer.
Question 18 A patient on mechanical ventilation has the following settings: VCV, Rate 14, Vt 600 mL, FiO₂ 0.40. ABG shows: pH 7.48, PaCO₂ 32 mmHg, PaO₂ 95 mmHg, HCO₃ 24 mEq/L. What is the most appropriate adjustment? A) Decrease the respiratory rate B) Decrease the tidal volume C) Decrease FiO₂ D) No change needed Correct Answer: A Rationale: The ABG shows respiratory alkalosis (pH 7.48, PaCO₂ 32). Decreasing the respiratory rate will lower minute ventilation and increase PaCO₂ toward normal. Question 19 A 35-year-old patient presents with acute shortness of breath, pleuritic chest pain, and a feeling of "impending doom." The patient has a history of a recent long flight. SpO₂ is 90% on room air. What is the most appropriate next step?
Rationale: Patient-ventilator asynchrony with tachypnea often requires sedation to improve synchrony and reduce work of breathing. Sedation should be the initial step before making ventilator changes. Question 21 A patient with Guillain-Barré syndrome is being evaluated for respiratory function. The patient's vital capacity is 12 mL/kg. What is the most appropriate recommendation? A) Continue monitoring in the general ward B) Initiate NPPV C) Intubate and mechanically ventilate D) Perform pulmonary function testing Correct Answer: C Rationale: In neuromuscular disease, a vital capacity <15 mL/kg is an indication for intubation and mechanical ventilation to prevent respiratory failure. Guillain-Barré can progress rapidly, and early intubation is recommended.
Question 22 A patient on mechanical ventilation has a peak inspiratory pressure of 40 cm H₂O and a plateau pressure of 28 cm H₂O. Which of the following is the most likely cause? A) Increased airway resistance B) Decreased lung compliance C) Patient-ventilator asynchrony D) Auto-PEEP Correct Answer: A Rationale: The difference between peak and plateau pressures reflects airway resistance. A normal difference is 5-10 cm H₂O. Here the difference is 12 cm H₂O (40-28), indicating increased airway resistance. Question 23 A patient with COPD is being discharged home with oxygen therapy. The patient asks about smoking while using oxygen. What is the most appropriate response? A) "It's safe as long as you keep the oxygen at 2 L/min or less." B) "Smoking while using oxygen is extremely dangerous due to fire risk."
Rationale: The symptoms of dyspnea, orthopnea, leg edema, and crackles indicate acute decompensated heart failure. Diuretics are the mainstay of treatment to reduce fluid overload. Question 25 A patient with a history of asthma is being discharged. The patient asks when to seek emergency care. Which of the following is a sign that the patient should go to the emergency room? A) Using the rescue inhaler more than twice a week B) Peak flow between 50-80% of personal best C) Peak flow below 50% of personal best D) Nighttime awakenings from asthma twice a month Correct Answer: C Rationale: A peak flow below 50% of personal best indicates a severe exacerbation requiring emergency care. Peak flow between 50-80% indicates a moderate exacerbation requiring prompt treatment.
Question 26 A 45-year-old patient is receiving mechanical ventilation. The patient's SpO₂ drops from 94% to 85% after suctioning. What is the most appropriate action? A) Suction again immediately B) Administer a bronchodilator C) Manually ventilate with 100% oxygen D) Increase the FiO₂ Correct Answer: C Rationale: Desaturation after suctioning is common but significant drops require intervention. Manual ventilation with 100% oxygen will re-oxygenate the patient and allow recovery. Suctioning again may worsen the problem. Question 27 A patient is receiving noninvasive ventilation (NIV) for acute hypercapnic respiratory failure. The patient is becoming increasingly agitated and pulling off the mask. What is the most appropriate next step? A) Restrain the patient and continue NIV
