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NBRC Exam Preparation: Complete Guide to Passing the TMC and CSE Exams

Written and reviewed by a Registered Respiratory Therapist (RRT-NPS) with 18+ years of bedside experience in NICU, PICU, CVICU, and adult critical care. Last updated August 2026.

If you are preparing for the NBRC board exams right now, you are studying during the single biggest change to respiratory therapy credentialing in a decade. The Therapist Multiple-Choice (TMC) Examination retires at the end of 2026, and a new single Respiratory Therapy (RT) Examination replaces both the TMC and the Clinical Simulation Examination beginning January 2027.

This guide covers exactly what is on each exam, how scoring works, what it costs, and — most importantly — which exam you will actually sit for based on where you are in your program. Every number below comes straight from the NBRC's published Detailed Content Outlines and official FAQs, not from secondhand summaries.

Time-sensitive: The last date applications will be accepted for the TMC Examination is December 15, 2026, and the last day to take it is December 31, 2026. If you are graduating in 2026 and want the TMC pathway, your window is closing.

What this guide covers

The 2026–2027 transition timeline
The TMC Exam: format, content, and cost
The official TMC blueprint (140 scored items)
Cut scores: what actually counts as passing
The Clinical Simulation Exam (CSE)
The new 2027 RT Exam blueprint
Which exam will you take?
How to study for board-style questions
Why candidates fail (and how to avoid it)
Frequently asked questions

The 2026–2027 transition timeline

The dates below are the ones that decide your pathway. Miss one and your route to the RRT credential changes.

July 2026 The first version of the Self-Assessment Examination for the new RT Exam becomes available for purchase at nbrc.org, with a second version following in March 2027.
October 1, 2026 Applications for the new Respiratory Therapy Examination open through the Practitioner Portal at nbrc.org.
December 15, 2026 Final day to submit a TMC Examination application. Applications will not be accepted after this date.
December 31, 2026 Final day to sit for the TMC Examination. The CRT-to-Registry admission policy is also eliminated on this date.
January 4, 2027 The new Respiratory Therapy Examination is administered for the first time.
December 31, 2027 The Clinical Simulation Examination retires. It remains available through this date only for candidates who passed the TMC at the high cut score before December 31, 2026.

Already attempted the TMC or CSE more than once? That history does not follow you. The NBRC has confirmed that the number of attempts previously made on the TMC and CSE Examinations will not count toward attempts on the Respiratory Therapy Examination.

The TMC Exam: format, content, and cost

The Therapist Multiple-Choice Examination is the entry point to the profession. It measures the essential knowledge, skills, and abilities required of respiratory therapists at entry into practice, and it does double duty: it awards the CRT credential and determines whether you become eligible for the Clinical Simulation Exam.

TMC Examination at a glance
Total items	160 multiple-choice items — 140 scored and 20 pretest
Time limit	3 hours
Fee	$190 first attempt / $150 repeat attempt
Attempts	3 attempts with no waiting period, then a minimum 120 days between subsequent attempts
Content outline	TMC Detailed Content Outline, effective January 2020 through December 31, 2026
Where you test	PSI assessment centers — more than 300 nationwide, Monday through Saturday
Results	Pass/fail appears on screen immediately; the full score report is emailed within 24 hours

Those 20 pretest items matter more than most candidates realize. They are unscored questions the NBRC is trialing for future exams, and they are not identified on screen. You cannot tell which ones count. That is why a question that feels bizarre or unfamiliar is not necessarily a question you were supposed to know — and why panicking over one item is wasted energy.

Who is eligible for the TMC

The standard route: be 18 years of age or older, and be a graduate of — and hold a minimum of an associate degree from — an entry-into-practice respiratory therapy education program supported or accredited by CoARC. Alternate CRT-to-Registry routes exist for currently credentialed CRTs, but those expire December 31, 2026.

The official TMC blueprint (140 scored items)

This is the table to build your study plan around. Section III alone is half the exam. If your review time is limited, weight it accordingly.

Content area	Recall	Application	Analysis	Total items
I. Patient Data	15	27	8	50
II. Troubleshooting and Quality Control of Devices, and Infection Control	8	9	3	20
III. Initiation and Modification of Interventions	10	30	30	70
Totals	33	66	41	140

Source: NBRC Therapist Multiple-Choice Examination Detailed Content Outline, effective January 2020.

Two things jump out of that grid. First, only 33 of 140 items are pure recall — roughly three-quarters of the exam asks you to apply or analyze, not remember. Memorizing normal values will not carry you. Second, Section III splits 30/30 between application and analysis, which is where most candidates lose points: the exam wants to know what you would do next, not what a mode is called.

The blueprint also sets age-mix rules. Pediatric items (1 month to 17 years) carry a target of 4 per form with a minimum of 3 and a maximum of 8, and neonatal items (birth to 1 month) target 3 with a minimum of 2 and a maximum of 5. Neonatal and pediatric content is a small slice of the TMC — but it is guaranteed to appear, and it is commonly the slice students skip.

Cut scores: what actually counts as passing

The TMC has two passing standards, not one. If you achieve the low cut score you earn the CRT credential. If you achieve the high cut score you earn the CRT credential and become eligible for the Clinical Simulation Examination, provided you meet the eligibility requirements.

In its guidance for candidates credentialed in Canada, the NBRC states that earning the RRT credential requires passing the TMC at the high cut score, described as 92 or above. Against 140 scored items, that works out to roughly 66%.

An honest note on the low cut score. You will see prep sites confidently publish a low cut score — some say 86, others say 88. The NBRC does not publish that figure alongside the high cut score, and cut scores are set by psychometric standard-setting rather than fixed forever. Anyone quoting you a number as permanent gospel is overreaching. Check the current NBRC Candidate Handbook for the figure in effect when you test, and in the meantime aim well past the high cut score — that is the only target that opens the RRT pathway anyway.

One clarification that saves a lot of anxiety: hitting the high cut score does not automatically make you CSE-eligible. The NBRC is explicit that you must still meet the CSE eligibility requirements regardless of your examination score. And if you already hold the CRT and score below the low cut on a retake, you do not lose your existing CRT credential.

The Clinical Simulation Exam (CSE)

The CSE is the second half of the classic RRT pathway, and it is a fundamentally different animal from the TMC. It consists of 22 problems — 20 scored and 2 pretest — and you are given four hours to complete it. The clinical setting and patient situation for each problem are designed to simulate reality and be relevant to the clinical practice of respiratory care. The fee is $200 for both first and repeat attempts, and like the TMC, you get three attempts before a 120-day wait applies.

How CSE scoring differs

Each branching scenario is scored in two separate categories:

Information Gathering (IG) — what you choose to assess, order, or look at. Selecting too little costs you; selecting everything indiscriminately also costs you, because irrelevant or harmful choices carry negative credit.
Decision Making (DM) — what you actually do with the information. This is where clinical judgment gets measured.

You must pass both categories. Strong DM will not rescue weak IG, which is why candidates who "know their stuff" still fail: they jump to the intervention without gathering the data that justifies it. The exam is modeling a therapist who assesses before acting.

A practical habit worth building now: in every scenario, ask yourself what would I need to see at the bedside before I'd be comfortable doing this? Then select exactly that, and nothing decorative.

AARC members are eligible for a one-time $40 discount when applying for the first time to the CSE, PFT, NPS, SDS, ACCS, or AE-C examinations. Note that the TMC is not on that list, and the discount must be applied at the time you submit your application — it will not be applied retroactively.

The new 2027 RT Exam blueprint

Beginning January 2027, one exam replaces two. The NBRC Board of Trustees voted in April 2022 to transition to a single examination in order to reduce barriers for graduates entering the profession while maintaining the standards associated with the CRT and RRT credentials — a continuation of the 2015 change that removed the second multiple-choice exam from the RRT pathway.

	TMC + CSE (through 2026)	RT Exam (from Jan 2027)
Number of exams	Two	One
Items	160 TMC (140 scored) + 22 CSE problems	185 items — 160 scored, 25 pretest
Time	3 hours + 4 hours	4 hours
Format	Multiple choice + branching simulations	All multiple choice
First-attempt cost	$390 combined	$360 (a $30 saving)
Repeat cost	$350 combined	$300 (a $50 saving)
How credentials are awarded	TMC low cut = CRT; high cut + passing CSE = RRT	Low cut score earns CRT; high cut score earns RRT

Inside the 160 scored items

The RT Exam is built in two portions that are combined into a single form. The Breadth of Knowledge portion contains 100 items and the Depth of Clinical Judgement portion contains 60 items. There is one total score — you do not pass each portion separately.

Breadth of Knowledge — 100 items

Content area	Recall	Application	Analysis	Total
I. Patient Data	6	15	4	25
II. Management of Devices and Patient Safety Procedures	8	12	5	25
III. Initiation and Modification of Interventions	9	25	16	50
Totals	23	52	25	100

Depth of Clinical Judgment — 60 items. This is the portion that absorbs what the CSE used to test. Each item is linked to a patient condition, a clinical judgment type, and a setting, plus a task statement from the Breadth of Knowledge portion, and complexity is limited to the application or analysis cognitive levels.

Patient condition	Items per form
Adults — Chronic lung disease (COPD, asthma, restrictive disease, bronchiectasis, CF)	17
Adults — Medical (infectious disease 5, ARDS 5, other 5)	15
Adults — Cardiovascular	5
Adults — Pre- and post-operative care	5
Adults — Trauma	4
Adults — Neurological or neuromuscular	4
Children — Neonatal (resuscitation 3, RDS 3)	6
Children — Pediatric	4
Total	60

Three further specifications shape every form, and they tell you a great deal about how to prepare:

Judgment type: 20 Information Gathering items and 40 Decision Making items. Two-thirds of this portion asks what you would add, modify, continue, or discontinue.
Setting: 46 items in a hospital and 14 outside a hospital. Home care, outpatient, rehabilitation, and transport are no longer afterthoughts.
Age mix across the whole exam: a minimum of 15 and a maximum of 18 neonatal or pediatric items, with the remainder adult or general.

That last figure is the single biggest shift for students. On the TMC, neonatal and pediatric content targets roughly 7 items. On the RT Exam it is 15 to 18 out of 160 — more than double. If neonatal resuscitation and RDS management have been your weak spot, that gap is no longer survivable.

The content itself has also been refreshed. The 2027 outline explicitly names social determinants of health and barriers to healthcare, trauma-informed and culturally aware care, closed-loop communication, debriefing following adverse patient events, handoffs, antifibrinolytics, biologics for asthma such as dupilumab, and CFTR modulators such as elexacaftor/tezacaftor/ivacaftor. Meanwhile diagnostic chest percussion, which appears in the current TMC outline, is gone. Medical ethics is woven throughout: each minipool carries at least 5 ethics-linked items in the Breadth portion and at least 3 in the Depth portion.

Which exam will you take?

Find yourself below.

Your situation	Your pathway
Graduating and testing before December 31, 2026	TMC, then CSE if you hit the high cut score. Apply by December 15, 2026.
Graduating in 2027 or later	The RT Exam. One sitting decides both CRT and RRT.
Passed the TMC at the high cut score but have not yet passed the CSE	You may sit the CSE through December 31, 2027 — or take the RT Exam and pass at the high cut score to earn the RRT from January 1, 2027.
Passed the TMC at the low cut score only (CRT held)	If you hold an associate degree or higher from a CoARC-supported entry-into-practice program, you are eligible for the RT Exam.
CRT without a CoARC associate degree	CRT-to-Registry routes close December 31, 2026. After that, the CoARC associate degree becomes mandatory. Act now if this is you.

How to study for board-style questions

Content knowledge and exam performance are two different skills. Plenty of excellent students fail these exams, and it is almost never because they did not know enough physiology.

Study the blueprint, not the textbook

The Detailed Content Outline is the actual specification the exam is assembled from. Print it and mark every task you could not confidently teach to a first-year student. That list — not the textbook's table of contents — is your study plan.

Practice in the exam's cognitive register

Since roughly three-quarters of TMC items sit at application or analysis level, flashcards alone under-prepare you. Work questions that hand you a scenario and force a decision. When you review, do not stop at "I got it right." Articulate why the three distractors are wrong — that is the reasoning the exam is actually scoring.

Master the recurring patterns

A large share of items reduce to a handful of repeating skills: interpreting an arterial blood gas and naming the acid-base disturbance with compensation, reading a ventilator waveform, deciding whether a problem is a lung problem or a machine problem, choosing the least invasive effective intervention, and recognizing when to stop a therapy. Build genuine fluency in those and you have covered enormous ground. If ABG interpretation is where you slow down, our ABG Interpreter tool is built to drill exactly that pattern.

Take full-length timed exams

Three hours of sustained clinical reasoning is a physical challenge as much as an intellectual one. Sit at least two complete timed practice exams before test day so that fatigue is not a new variable. RRTNOW's full-length practice exams are built to the blueprint proportions above so your practice score means something.

Use the free official resources

The NBRC offers free practice examinations for every credential, including an RT Practice Examination for the January 2027 format, and paid Self-Assessment Examinations through PSI. The official SAEs are the only products that provide the examination committees' own rationale for the best response to each question — that makes them worth the money regardless of what else you use.

Why candidates fail (and how to avoid it)

Studying breadth instead of weight. Section III is 70 of 140 TMC items. Spending equal time on all three sections quietly under-prepares you for half the exam.
Skipping neonatal and pediatric content. It was always guaranteed to appear. On the 2027 exam it is 15 to 18 items.
Answering as an experienced therapist rather than by the book. The NBRC scores guideline-concordant, textbook-correct practice. Your unit's workaround is not the keyed answer.
Acting before assessing. This sinks CSE candidates and will sink Decision Making items on the RT Exam. When an answer choice offers to gather one more critical piece of data, it is often correct.
Second-guessing on strange items. Some questions you see are unscored pretest items. Flag, answer, move on.
Never practicing under time. Untimed practice measures knowledge; timed practice measures readiness.

Frequently asked questions

How many questions are on the NBRC TMC exam?

The TMC Examination contains 160 multiple-choice items — 140 scored and 20 pretest — taken over a three-hour period. The pretest items are unscored and are not identified during the exam.

What score do you need to pass the TMC exam?

The TMC uses two cut scores. The low cut score earns the CRT credential; the high cut score earns the CRT and eligibility for the Clinical Simulation Exam. The NBRC describes the high cut score as 92 or above out of 140 scored items, roughly 66%. The low cut score is not published in the same place, so confirm the current figure in the NBRC Candidate Handbook.

Is the TMC exam being discontinued?

Yes. The final day to apply for the TMC is December 15, 2026, and the final day to take it is December 31, 2026. It is replaced by the Respiratory Therapy Examination beginning January 4, 2027.

What is replacing the TMC and CSE in 2027?

A single Respiratory Therapy (RT) Examination. It consists of 185 multiple-choice items — 160 scored and 25 pretest — over four hours, and costs $360 for new applicants and $300 for repeat applicants. The low cut score earns the CRT credential and the high cut score earns the RRT credential.

How many questions are on the Clinical Simulation Exam?

The CSE consists of 22 problems — 20 scored and 2 pretest — completed within four hours. Each problem is scored separately for Information Gathering and Decision Making, and both categories must be passed.

How much do the NBRC exams cost?

The TMC is $190 first attempt and $150 repeat. The Clinical Simulation Exam is $200 for both first and repeat attempts. The NPS is $250/$220, PFT $200/$170, ACCS $300/$250, SDS $300/$250, and AE-C $350/$250. AARC members receive a one-time $40 discount on first-time application to the CSE, PFT, NPS, SDS, ACCS, and AE-C exams.

How many times can you retake the TMC exam?

You may attempt the TMC and CSE three times without waiting, after which a minimum of 120 days is required between subsequent attempts. The same policy applies to the new RT Examination, and attempts on the TMC or CSE do not count toward attempts on the RT Exam.

Do I lose my CRT if I fail a retake?

No. The NBRC confirms that scoring below the low cut score on a retake does not affect the status of a CRT credential you already hold, and you may retake as many times as needed to earn the RRT.

How long does it take to get NBRC exam results?

Your pass/fail result appears on screen immediately after you finish, and the full score report is emailed within 24 hours.

What is the hardest section of the TMC exam?

By weight and cognitive demand, Section III — Initiation and Modification of Interventions. It carries 70 of 140 scored items and splits 30 application and 30 analysis, meaning almost none of it can be answered by recall alone.

Sources

All examination specifications on this page are taken from official National Board for Respiratory Care publications: the Therapist Multiple-Choice Examination Detailed Content Outline (effective January 2020), the Respiratory Therapy Examination Detailed Content Outline (effective January 2027), and the NBRC Resources and Examinations FAQ pages. Verify current figures at nbrc.org/resources before applying, as fees, dates, and standards are set by the NBRC and may change. RRTNOW is an independent educational publisher and is not affiliated with or endorsed by the NBRC. CRT, RRT, and related designations are registered trademarks of the National Board for Respiratory Care.

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Complete DIGITAL NPS Study Bundle | Neonatal Pediatric Specialist – 440 Total Pages

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NPS Exam & Cardiac Care Study | Advanced Ventilation Modes | RRTNOW

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NBRC Exam Preparation: Complete Guide to Passing the TMC and CSE Exams

The 2026–2027 transition timeline

The TMC Exam: format, content, and cost

Who is eligible for the TMC

The official TMC blueprint (140 scored items)

Cut scores: what actually counts as passing

The Clinical Simulation Exam (CSE)

How CSE scoring differs

The new 2027 RT Exam blueprint

Inside the 160 scored items

Which exam will you take?

How to study for board-style questions

Study the blueprint, not the textbook

Practice in the exam's cognitive register

Master the recurring patterns

Take full-length timed exams

Use the free official resources

Why candidates fail (and how to avoid it)

Frequently asked questions

How many questions are on the NBRC TMC exam?

What score do you need to pass the TMC exam?

Is the TMC exam being discontinued?

What is replacing the TMC and CSE in 2027?

How many questions are on the Clinical Simulation Exam?

How much do the NBRC exams cost?

How many times can you retake the TMC exam?

Do I lose my CRT if I fail a retake?

How long does it take to get NBRC exam results?

What is the hardest section of the TMC exam?

Sources

Collection: Neonatal Pediatric Specialist-NPS

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NBRC Exam Preparation: Complete Guide to Passing the TMC and CSE Exams

The 2026–2027 transition timeline

The TMC Exam: format, content, and cost

Who is eligible for the TMC

The official TMC blueprint (140 scored items)

Cut scores: what actually counts as passing

The Clinical Simulation Exam (CSE)

How CSE scoring differs

The new 2027 RT Exam blueprint

Inside the 160 scored items

Which exam will you take?

How to study for board-style questions

Study the blueprint, not the textbook

Practice in the exam's cognitive register

Master the recurring patterns

Take full-length timed exams

Use the free official resources

Why candidates fail (and how to avoid it)

Frequently asked questions

How many questions are on the NBRC TMC exam?

What score do you need to pass the TMC exam?

Is the TMC exam being discontinued?

What is replacing the TMC and CSE in 2027?

How many questions are on the Clinical Simulation Exam?

How much do the NBRC exams cost?

How many times can you retake the TMC exam?

Do I lose my CRT if I fail a retake?

How long does it take to get NBRC exam results?

What is the hardest section of the TMC exam?

Sources