Clinical Sims Exam Preparation

Manifesto
 
How to Prepare for (and Pass) the CSE
 
By Respiratory Therapy Zone

Table Of Contents
Introduction
How to Pass the CSE?
About the Clinical Simulations Exam
Clinical Simulations Exam Rules
What are the Admission Requirements for the Clinical Simulations
Exam?
How Much Does it Cost to Take the Clinical Simulations Exam?
What Content Will Be on the CSE?
How Are the Problems Structured on the CSE?
CSE Scoring
What are the Components of a Clinical Simulation Problem?
How to Prepare for the CSE?
What Diseases will be on the CSE?
What is the Structure of the CSE?
Final Thoughts
References

Disclaimer:
 
Medicine and respiratory therapy are continuously changing practices. The
author and publisher have reviewed all information in this report with
resources believed to be reliable and accurate and have made every effort to
provide information that is up to date with the best practices at the time of
publication. Despite our best efforts we cannot disregard the possibility of
human error and continual changes in best practices the author, publisher,
and any other party involved in the production of this work can warrant that
the information contained herein is complete or fully accurate. The author,
publisher, and all other parties involved in this work disclaim all
responsibility from any errors contained within this work and from the
results from the use of this information. Readers are encouraged to check all
information in this book with institutional guidelines, other sources, and up
to date information. Respiratory Therapy Zone is not affiliated with the
NBRC, AARC, or any other group at the time of this publication.

Introduction
 
If you’re reading this right now then it most likely means that you’ve
already passed the TMC Exam. If so, congratulations! That is an amazing
accomplishment and it means that you’re one step closer to becoming a
Registered Respiratory Therapist.
 
I just want to say thank you for choosing Respiratory Therapy Zone as a
way to help prepare for the Clinical Simulations Exam. Our #1 goal is to
help you pass the exam on your very first attempt. And the contents of this
book can set you on the right path to do just that.
 
We’re striving to provide you with the most current information needed to
prepare for the CSE and will give you all the information that you will be
expected to know for the exam by the NBRC.
 
So if you’re ready, let’s go ahead and dive right in!

How to Pass the CSE?

 
First and foremost, in order to pass the Clinical Simulations Exam, it’s
going to take a lot of hard work and dedication from you. There’s no way
around it. This is a mindset that you must adopt early on in the preparation
process.
 
Once you set your mind to the fact that you CAN pass the exam through
hard work and dedication, it makes everything else a whole lot easier.
 
You need a good, reliable CSE Study Guide.
 
In order to learn the most important information, you need to get your
hands on that information. Believe it or not, this is where many students
mess up from the very beginning. And that is exactly why we created our
own  CSE Study Guide  because we were sick and tired of seeing students
fail.
 
Our  CSE Study Guide   is, without question, the best resource on the
market today. But we’ll tell you more about it later on in this book.
 
For now, just know that it’s crucial that you are studying the  right
 information if you want to increase your chances of passing the exam on
your next attempt.

About the Clinical Simulations Exam

 
As I’m sure you already know, the CSE has a much different structure than
the TMC Exam. Yes, the CSE shares the same topical content with the
TMC. The difference is — if you only master the topical content alone, you
will not get you a passing score because the CSE also tests your case-
management abilities.
 
Our goal is to help you master both — the content and the comprehensive
abilities you need to pass the exam.

Clinical Simulations Exam Rules

 
The test is fully computer-based, and you will have four hours to take the
exam.
 
There will be a total of 22 problems on the exam that are selected from 8
different categories. Two of the problems are pretested scenarios that are
individually scored based on the judgment of the NBRC committee.
 
Each problem represents a clinical setting or patient situation that is
designed to simulate real-life situations in the clinical practice of respiratory
care.
 
Keep These Rules in Mind for the Exam:
A pencil and a sheet of scratch paper will be provided for you. No outside notes or books
are allowed. You must return your scratch paper after completing the exam.
No personal belongings are allowed in the testing area. You will need to leave them in
your car.
You may leave the testing area at any time to stretch or use the restroom. Keep in mind,
though, that your test timer will not stop.
Be on time. If you arrive more than fifteen minutes late, you will not be admitted to take
the exam.
You will need to show two forms of identification, with at least one showing a current
photograph. Both forms must be current and must include a signature.
What are the Admission Requirements for
the Clinical Simulations Exam?
 
To be eligible to take the CSE, you must have obtained the CRT credential
by successfully passing the TMC Exam (Therapist Multiple-Choice
Examination) with the high-cut score.
 
This is the basic qualification for most students, although there are others
that can be found on the  NBRC website .
 
Be aware of the 3-year time limit!
 
You must pass the Clinical Simulations Exam within three years after
graduating for a CoARC accredited Respiratory Therapy Program.
 
If you do not pass it within this time limit, you will be required to retake
(and pass) the TMC Exam again at the high-cut score to regain eligibility.
 
Outside of the three-year time frame, any previous passing performance to
earn the RRT credential is nullified — so please be aware of this.
How Much Does it Cost to Take the
Clinical Simulations Exam?
 
The exam costs $200 for both new and repeat applicants. I realize that this
is a significant investment, which is why it is our goal to help you pass the
exam on your next attempt.
 
This is another reason why it’s so critical to use a  CSE Study Guide  that
can truly prepare you for the exam. Otherwise, there’s a good chance that
you’ll have to retake the exam, which means you’ll have to pay that exam
fee again.
 
We see this far too often with students.
 
The good news it, if you put in the work by studying and preparing well,
you can pass the exam on your first (or next) attempt, and you’ll only have
to pay the fee once.

What Content Will Be on the CSE?

 
As we’ve already discussed, the same content that was on the TMC Exam
will be on the CSE as well. They just ask it to you in a totally different way.
 
Not to worry — we will cover it all inside of our  CSE Study Guide . A big
focus of the CSE will be on Pathology. You absolutely must how to
differentiate and treat the different diseases and what to recommend for
these specific patients on a case by case basis.
 
That is the major focus of the CSE — like it or not.
 
The NBRC put out a detailed content outline of exactly what to look for on
the CSE. I highly recommend that you take a look over it and you can do so
by visiting  this link .

How Are the Problems Structured on the

CSE?
 
The CSE is designed to evaluate your patient management skills and ability
to evaluate ongoing treatment, recommend changes, and adapt to
circumstances and events.
 
So in order to accomplish this, they have laid out the problem in a
completely different way compared to the traditional multiple-choice layout
that we’re all accustomed to.
 
Here’s an example of how the problems will be structured on the
computer screen:
 
 Photo example by the  NBRC .
 
As you can see,  3 windows  will appear on the screen at all times during
the exam.
1) There is a window with the  “Scenario”  at top of the screen, and your
picture will be displayed in the upper right-hand corner of this window.
 
Each simulation begins with a brief paragraph in this window that provides
preliminary information about the patient. The following sections will
contain information about the changing patient situation in this window as
well.
 
Each Scenario Window will also provide you with specific instructions
about whether to “CHOOSE ONLY ONE” response in the section or to
“SELECT AS MANY” responses as appropriate to gather information.
 
It is super-important that you follow these directions!
 
2) The  “Options”   window is displayed in the lower left portion of the
screen. This window contains all options, choices, or possible responses
that you can choose from.
 
You select an option by clicking the check box next to the option.
 
3) The  “Simulation History”   window is displayed as the lower right
portion of the screen. This window shows the options chosen in the current
section and the results for each choice are displayed in this window.
 
It also shows the “Simulation History” from all previous sections as well as
the options chosen.
 
Basically, it helps you see the results that you selected already, in case you
forgot.
When you are finished with a particular section, you can hit the “Go To
Next Section” button at the bottom left of the screen to continue to the next
section.
 
A box will pop up requesting that you confirm your wish to continue to the
next section. Be sure to only click the “Yes” button when you are 100%
ready to proceed to the next section, because you can’t go back.
 
A timer button is shown in the lower right portion of the screen and
displays the time remaining for the exam. You may hide the time remaining
button if you wish, simply by clicking it.

CSE Scoring
 
There will be a total of 22 problems on the exam that are selected from 8
different categories.
 
Two of the problems are pretested scenarios that are individually scored
based on the judgment of the NBRC committee. The total points scored on
these will be added to your results at the end.
 
Each version of the exam will be different which means that each version
will have a minimum passing score. Of course, this is decided by the testing
committee for each exam.

 
Exam Hint:  More than half of the total possible points will come from the
selections you make in the Information Gathering sections.
 
That is why it’s a major focus throughout this book.

 
If your final score exceeds the minimum passing score, that means you will
have passed the exam.
 
On average, you will need to score roughly a 72% in order to pass the CSE.
 
That doesn’t sound so bad, right?

Now let’s talk about the actual physical points that you can get for each
selection you make.
 
The scoring scale runs from –3 points up to 3 points. That’s right, folks.
You can earn up to 3 points or you can lose up to 3 points, depending on the
selections that you make.
Usually, there will be one best available answer that gives
maximum points.  (+3)
It is necessary for proper care and not doing it would cause harm
to the patient.
 You can earn  (+2)  points for selecting very important information
for good patient care.
You can get  (+1)  for information that is helpful.
You get  0   points for the selections you make that are neither
helpful nor harmful to the patient.
Now here’s where it gets dicey!
You lose a point  (–1)  for selecting something that is counterproductive.
You lose two points  (–2)  for making a selection that is very counterproductive.
You lose three points  (–3)  for making a selection that is detrimental to the patient.
This includes any selection that could result in harming the patient, or worse.
Obviously, it goes without saying, you want to make selections that earn
you points and avoid those that take points away.

What are the Components of a Clinical

Simulation Problem?
 
There are (3) components of each CSE problem, and they are:
Scenario  – This establishes the setting and general parameters of the patient and (you)
the Respiratory Therapist.
Information Gathering   – This section provides information about the patient that is
normally obtained in chart review or diagnostic testing, such as vital signs, ABG results,
etc.
Decision Making   – This is the decision point that you will need to recommend what
happens next for the patient.
After being given the  Scenario , you use the  Information Gathering
 section to access the patient and make an analysis and evaluation according
to the information that is provided. Then, in  Decision Making , you must
decide what type of therapy or response is best for the particular problem of
the patient.
 
We will discuss each of these 3 components in more detail below.

How to Prepare for the CSE?

 
We’ve already touched on this earlier, but now, let’s dive a little bit deeper.
 
In order to increase your chances of passing the exam, you need to be
prepared for the unique exam structure. As we said, the CSE covers much
of the same topical content as the TMC Exam, they just ask it in a totally
different way.
 
You have to take what you know and apply it to a real-life situation in order
to make a decision to help the patient — just as if it were in a real hospital.

 
Exam Hint:  Here’s a little “hack” that I always recommend for students.
Now that you have completed the TMC Exam, you can take the results
score report and use it as a guide to prioritize what you should focus on for
the CSE.
 
Is there a section that you didn’t do so hot? You may want to dedicate some
extra time looking back over that section.

 
By the way, these little “Exam Hint” boxes are included all throughout our 
CSE Study Guide . They contain some of the most important tips, tricks,
and insights that all students must know in order to pass the exam.
 
This is one of the many perks of using our  CSE Study Guide .

What Diseases will be on the CSE?

 
Now let’s talk about all the different diseases that you must know for the
exam.
 
As you now know, Cardiopulmonary Pathology is super-important in regard
to the Clinical Simulations Exam! It’s what you should spend most of your
time on when preparing for the exam.
 
We cover each disease in detail in our  CSE Study Guide , but for now,
let’s familiarize your brain with all the possible disease cases that you need
to know.
 
Here are the 8 disease categories that you should focus on when
preparing for the CSE:
 
Disease # of
Examples
Category Cases

Chronic
Bronchitis,
COPD
2 Emphysema,
(Management)
Asthma, and
Bronchiectasis.

COPD Mechanical
(Critical Care) 2 Ventilation and
  NIV management.

Head or Chest
Injury,
Adult Trauma Pneumothorax,
3
  Burns, Drowning,
Smoke Inhalation,
and Hypothermia.

CHF, Pulmonary
Edema, Heart
Cardiovascular attack, Coronary
3
Diseases Artery Disease,
and Valvular Heart
Disease.

Neuromuscular 2 Guillain-Barre
Diseases Syndrome,
Myasthenia
Gravis, Muscular
 Dystrophy, Stroke,
and Drug
overdose.

Croup, Epiglottitis,
Asthma,
Bronchiolitis,
Pediatric Foreign-body
Diseases 2 aspiration, toxic
  substance
ingestion, and
Bronchopulmonary
Dysplasia.

Meconium
aspiration, Apnea,
Delivery Room
Neonatal
Management,
Diseases 2
Resuscitation,
 
RDS, and
Congenital Heart
Defect.

Head and Neck

surgery, Thoracic
Adult Medical surgery, Carbon
4
or Surgical Monoxide
Poisoning, and
AIDS.
 
Again, we cover each of these diseases in more detail inside of our  CSE
Study Guide , so definitely check that out if you’re interested. But for now,
let’s talk more about the structure of the exam.

What is the Structure of the CSE?

 
Again, we already talked about this some earlier. But now, let’s dive deeper
into the  Scenario ,  Information Gathering , and  Decision Making .
 
Scenario
 
This will describe the physical setting for the patient and you as the
Respiratory Therapist. This could include the hospital or clinic type, the
home, Med-Surg unit, ICU, time or day, etc.
 
This is also where you will find out the general information about the
patient, including their: age, sex, general appearance, and general
presenting conditions.

 
You will also learn about the patient’s history and a brief history of the
patient’s active illness or event.

 
Exam Hint:  While reading the Scenario, the first thing you want to do is
interpret if the situation is an emergency! If it is, you must take immediate
action to help the patient.
If you determine that the situation is not an emergency, then you can
proceed to gather more information in order to make a clinical decision.
 

 
Information Gathering
 
This is the section that you will be directed to in order to find out more
about the patient.
 
They will list out 15-20 parameters for you to choose from.
For example, you will see vital signs, ABG, PFT, and various lab studies.
 
You must select ONLY those that are important for this patient at this
particular time given what you know.
 
Avoid selecting anything that could be dangerous for the patient. Also, of
course, avoid selecting anything that you know is unnecessary for the
patient at this time.
 
Select only the desired information!
 
Once you click an option to make a selection, it will reveal that results of
what you clicked on the screen.
 
For example, if you select that the patient needs an ABG, as soon as you
click that option, it’s going to show you the patient’s ABG results on the
screen.
You can then act immediately, for example, if their results were to show that
they are in respiratory failure. If that were the case, what would you do?
 
 
Of course, you know this — you would want to recommend intubation and
mechanical ventilation.

 
Exam Hint:  This is important, so remember this. During the Information
Gathering, if you can already tell that the situation is a medical emergency,
you should act right then to help the patient.
 
If it’s not an emergency, you can proceed to gather more information.
 

 
Order of Progression when making your selections:
 
When your list of choices is available, there is a specific order that you
should go through when making your selections. I’m going to share that
with you now:
 
Visual
 
First and foremost, you should go through the list a select the visual things
first — meaning the thing you can see.
 
For example, general appearance, appearance of the chest, respiratory rate,
respiratory pattern, posture, sensorium, and color.
 
These are the things that you can literally see with your eyes. Choose all of
these first. Then ask yourself, “Is there an emergency?” If not, then move
on to the bedside choices.
 
Bedside
 
Now you can go through the list and select the choices that can be
performed at the bedside. These should all still be relatively easy to obtain.
 
For example, pulse, temperature, chest percussion, breath sounds, blood
pressure, heart sounds, tracheal position, and capnometry, etc.
 
These are the things that can literally be done/checked at the patient’s
bedside. After you’ve gone through the choices, is there an emergency? If
no, move on to the basic lab tests.
 
Basic Lab Tests
 
Now you can select any lab tests that are necessary for this patient.
Examples include ABG, CBC, 12-lead EKG, Electrolytes, and/or Chest X-
ray.
 
These are your basic tests that still aren’t difficult to perform but are only
necessary if indicated for some patients. Still no emergency? Move along to
the special tests.
 
Special Tests
 
Now you can select any special test that is indicated for the patient. These
are very specific and should only be selected if it’s necessary for this
patient’s case.
 
Examples include lab tests like blood culture, PFTs, imaging studies like
MRIs, CT scans, bronchoscopy, ICP, hemodynamic monitoring, and
specific tests like sweat chloride test for CF, Apgar score, V/Q scan, etc.
 
These tests are very specific for specific patient situations.
 
After making all necessary selections, you should interpret the data and
make proper decisions in the next section.

 
Exam Hint:  There are a few options that you should Always select when
they are available. These are quick to obtain and usually always helpful in
identifying the patient’s problem.
 
Here are some examples:  Color/general appearance, respiratory rate, heart
rate, SpO2, blood pressure (if the problem deals with the heart), body temp
(only if an infection is involved), level of consciousness, breath sounds, and
history of present illness.
 

 
We cover this stuff in more detail inside of our  CSE Study Guide .
 
You should only make selections if they are appropriate for the situation at
hand.
 
For example, you probably don’t need the check any PFT results for a
patient with ARDS.
 
Not every test should be selected for every patient. Only those that are
pertinent to their situation. Are you following me here? If so, good — let’s
keep moving!
 
Here are some general tips in regard to Information Gathering:
Recommend an ABG to assess the patient’s acid-base balance,
oxygenation, or ventilation.
 Assess the tracheal position to identify atelectasis or a
pneumothorax. Remember that is shifts away from the affected
side for a pneumothorax, and it shifts towards the affected side
with atelectasis.
Assess percussion to identify a pneumothorax or pneumonia.
Select an MIP/NIF to assess the patient’s respiratory muscle
strength for weaning.
Select Vital Capacity to check respiratory muscle strength for
neurological disorders, and also for weaning.
Select the VE and RSBI to check for the adequacy of ventilation
for weaning.
Assess the patient’s sputum to check for an infection.
Select certain PFT tests to check to see if the disease is obstructive
or restrictive.
Again, always select blood pressure for a patient that has a
cardiovascular disorder.
Select only certain laboratory tests that would be necessary for the
patient’s specific situation. For example, you would select to
assess the WBC count if the patient has an infection. That would
be necessary in that situation, etc.
The same applies for x-rays and imaging tests. Only select them
when they would help diagnose the patient. For example, a neck x-
ray would be helpful to identify croup or epiglottitis or to check for
a foreign body aspiration, etc.
Recommend to check the Intracranial Pressure for a patient with a
head or brain injury.
If the patient is unconscious, a Glasgow Coma Scale would be
necessary.
Never select Urinalysis. Just skip it unless you really just want to
lose points. 
I hope that these tips were helpful for you. These are just a few of the many
tips that we share inside of our  CSE Study Guide , where we go into much
more detail.
Now let’s keep moving along and talk about Decision Making.
 
Decision Making
 
After you have made your selections in the Information Gathering section,
you will then be directed to the Decision Making section.
 
This is where you must take what you know from the information given and
make the best possible decision for the patient.
 
Usually, you will be asked to select the best of 4–5 options.
 
Keep in mind, sometimes you will have to make the Best Available
selection if the most desired option is not listed.
 
Once you make the selection, it will usually say: “Physician Agrees. Done.”

 
Exam Hint:   However, it could possibly say, “Physician Disagrees. Make
another selection.”
 
Don’t Panic!
 
Just because it says this does not necessarily mean you are wrong. Proceed
to pick the next best option using the information that you have available.
 

 
After you’ve made your decision, you will be taken to the next scenario.
You must then evaluate how the patient responded to the decisions you
previously made.
 
This pattern between Information Gathering and Decision Making usually
cycles back and forth about 4–5 times for each problem.
 
You take what they give you, gather the necessary information, then make
the best decision possible for the patient.
 
Boom, easy peasy!
 
I hope this simplifies things for you! It’s not as bad as people make it out to
be. You just have to take it one step at a time.
 
Here are some general tips in regard to Decision Making:
Always select the ‘ Best ‘ option that is available to you, even
though the absolute correct answer may not be listed.
Only select more than one choice if you’re prompted to do so.
Be sure to read all of the responses carefully.
Don’t select any unfamiliar actions. If you do not know what it
means, it’s probably a bad idea to choose that one unless you can
100% rule out the other choices.
If the patient is wheezing, remember that there could be 3 different
causes that require 3 different selections.
Recommend a bronchodilator for bronchospasm.
For wheezing with CHF, recommend diuretics.
A child could have wheezing caused by a foreign body aspiration
— in this case, you would recommend a bronchoscopy.
For stridor, remember that you should recommend cool mist or
racemic epinephrine.
If you found rhonchi or tactile fremitus while gathering
information, this means that there are secretions in the large
airways and the patient needs bronchial hygiene therapy or
suctioning.
A dull percussion note means that there is consolidation — in this
case, recommend lung expansion therapy.
Does the patient have a weak cough? Then they likely can’t cough
out secretions properly. In this case, you should recommend
bronchial hygiene therapy or suctioning.
Is the patient’s secretions yellow, green, or colored? This means
that the patient likely has an infection and you should recommend
antibiotics.
Does the patient have frothy secretions? If so, you automatically
should know it’s pulmonary edema and you should recommend
BiPAP or NPPV for this patient.
ABG interpretation is also important! You passed the TMC Exam,
so I know you already know how to do so. Here are things to keep
in mind when interpreting ABGs for the CSE:
A really low pH with a high CO2 and normal HCO3 means acute
ventilatory failure. Recommend mechanical ventilation.
A normal pH with high CO2 and high HCO3 means chronic
ventilatory failure. Recommend low-flow oxygen and avoid
intubation if possible.
A high pH with a normal CO2 and a high HCO3 means acute
metabolic alkalosis. Recommend either potassium or chloride,
depending on what is needed.
A low pH with a normal CO2 and a low HCO3 means acute
metabolic acidosis. You should increase the ventilation and treat
the underlying cause.
If the patient has a PaO2 > 60 on an FiO2 < 60%, this is moderate
hypoxemia (V/Q imbalance). You should recommend oxygen
therapy and treat the underlying problem.
If the patient has a PaO2 < 60 on an FiO2 > 60%, this is severe
hypoxemia (shunting). You should recommend oxygen therapy
with PEEP/CPAP and treat the underlying cause.
Again, these are just a few of the basic things I want you to remember to get
the juices flowing in your brain.
For more tips and insights, check out our  CSE Study Guide .

Final Thoughts
 
So there you have it! That wraps up this little eBook on how to prepare for
(and pass) the clinical simulations exam. I truly hope that this information
was helpful for you.
 
This wasn’t meant to teach you everything you need to know in order to
pass the CSE. We couldn’t possibly fit all of that information into one small
book such as this one.
 
However, this information can definitely set you on the right path to
learning exactly what you need to know so that you can pass the exam and
earn your RRT credentials.
 
If you enjoyed what you just read, then you’ll definitely get even more out
of our  CSE Study Guide . We created it to specifically help students pass
the CSE on their very next attempt. 
 
We’re very fortunate to help so many Respiratory Therapy Students around
the world and it brings me great joy that our study guide is already helping
students pass the exam.
 
So if you’re ready to pass the CSE on your next attempt as well,  Click
Here to Learn More .
 
Thanks again for reading and I wish you the best of luck. And as always,
breathe easy my friend.

References
 
1. AARC Clinical Practice Guidelines, (2002-2019) Respirator
Care. www.aarc.org.
 
2. Egan’s Fundamentals of Respiratory Care. (2010) 11th Edition.
Kacmarek, RM, Stoller, JK, Heur, AH. Elsevier.
 
3. Mosby’s Respiratory Care Equipment. Cairo, JM. (2014) 9th
Edition. Elsevier.
 
4. Pilbeam’s Mechanical Ventilation. (2012) Cairo, JM.
Physiological and Clinical Applications. 5th Edition. Saunders,
Elsevier.
 
5. Ruppel’s Manual of Pulmonary Function Testing. (2013)
Mottram, C. 10th Edition. Elsevier.
 
6. Rau’s Respiratory Care Pharmacology. (2012) Gardenhire, DS.
8th Edition. Elsevier.
 
7. Perinatal and Pediatric Respiratory Care. (2010) Walsh, BK,
Czervinske, MP, DiBlasi, RM. 3rd Edition. Saunders.
 
8. Wilkins’ Clinical Assessment in Respiratory Care (2013) Heuer,
Al. 7th Edition. Saunders. Elsevier.
 
9. Clinical Manifestations and Assessment of Respiratory Disease.
(2010) Des Jardins, T, &  Burton, GG. 6th edition. Elsevier.
 
10. Neonatal and Pediatric Respiratory Care. (2014) Walsh, Brian
K. 4th edition. RRT. Elsevier.
 
11. Clinical Application of Mechanical Ventilation (2013) Chang,
David W. 4th edition. Cengage Learning.
 
 
 
 
 
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