NREMT Paramedic Exam Questions

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1.

Which lead is the most helpful in identifying a ventricular rhythm?

  • Lead V1

  • Lead aVR

  • Lead aVL

  • Lead V6

Correct answer: V1

Lead V1 (also known as MCL) is the best lead to use to search for ventricular rhythms. Left ventricular PVCs will have an upward deflection in V1, while right ventricular PVCs will have a downward deflection in V1. Left ventricular PVCs are more dangerous than right PVCs, so correct identification is crucial. Lead aVR is used for specific information about the right atrial area of the heart and to verify reciprocal changes. 

2.

You are treating and transporting a 40-year-old male involved in an MVA with a possible closed head injury. He is conscious but confused. During your evaluation, you discover the patient is diabetic with a current blood glucose level of 70. He is breathing at 26 respirations per minute and regular with a current SpO2 of 92%; his heart rate is 110, his blood pressure is 90 systolic, and he is complaining of a severe headache.

Which of the following is most appropriate?

  • Administer high-flow oxygen, maintain SpO2 at least 94%, establish a large bore IV at KVO, and withhold glucose

  • Intubate the patient, and ventilate with a BVM with 100% supplemental O2 at 28-30/minute, establish large bore IV x 2 and administer a 1-liter fluid bolus, administer 1 amp of D50 IVP

  • Administer oxygen therapy to maintain SpO2 at > 98%, administer oral glucose, establish an IV, and run glucose-containing fluid at 200 mL/hr

  • Administer ventilation via a rescue ventilator at 30/min, establish IV x 2, and administer D5W at 300 mL/hr

Correct answer: Administer high-flow oxygen, maintain SpO2 at least 94%, establish a large bore IV at KVO, and withhold glucose

Patients with potential closed head injuries and increased intracranial pressure require proper oxygenation to prevent hypoxia at the cellular level and to reduce the associated edema. It is recommended to attempt to maintain blood oxygen at 94%. It is also recommended to withhold large fluid amounts when an IV is in place. The blood pressure range for head injury patients is around 90 systolic. This pressure is enough to continue to maintain perfusion and is not high enough to worsen any associated cerebral hemorrhage. Glucose is contraindicated in patients with closed head injuries with increased intracranial pressure unless they are experiencing adverse signs and symptoms of hypoglycemia.

There is no need to attempt to intubate a conscious trauma patient with potential increased intracranial pressure who is breathing adequately at 26 times a minute with a SpO2 of 93%. The target is 94%, and oxygen therapy should easily accomplish the task. 

Glucose is contraindicated because the patient's blood glucose level is not dangerously low, and he is not showing signs and symptoms of hypoglycemia. A fluid bolus would also be contraindicated when the blood pressure is 90 systolic in a closed head injury patient. O2 saturation should be maintained at 94%, not 98%; also, glucose is contraindicated. IV fluid should not contain glucose for this patient. 

A rescue ventilator would not be recommended for a patient with increased intracranial pressure, even if he were not conscious and breathing adequately.

3.

You are preparing to perform synchronized electrical cardioversion with a biphasic defibrillator on your unstable adult patient who is experiencing supraventricular tachycardia at 160 beats per minute on the monitor. Which of the following initial energy settings would be recommended if he was exhibiting a narrow complex, regular supraventricular tachycardia, in which his palpable carotid pulse matches the rhythm on the monitor?

  • Synchronized cardioversion at your specific device's recommended energy level to maximize first shock success

  • Synchronized cardioversion at 360 joules

  • Defibrillation at 100 joules

  • Defibrillation at 360 joules

Correct answer: Synchronized cardioversion at your specific device's recommended energy level to maximize first shock success 

Performing immediate cardioversion for patients experiencing PSVT with a narrow complex and a regular rate is crucial. Even though the complexes are narrow and the rate regular, the AHA now recommends that cardioversion should be conducted at your specific device's recommended energy level to maximize first shock success. 

It is not appropriate to begin at a higher than recommended energy setting. Delivering any amount of unsynchronized energy to a patient experiencing supraventricular tachycardia with a narrow complex is likely to send the patient into ventricular fibrillation, so defibrillation is contraindicated. It is not appropriate to use unsynchronized energy on a breathing patient with an organized electrical rhythm still somewhat perfusing.

4.

What is the most crucial criterion to identify rhythms started by the sinus node?

  • Matching upright P waves in lead II

  • Matching inverted P waves in lead I

  • Matching QRS complexes in lead II

  • Matching T waves in V1

Correct answer: Matching upright P waves in lead II

Because P waves originate in the sinus node, upright, matching P waves are crucial to identifying sinus rhythm. You look at lead II to examine to P waves. 

5.

When should the EKG equipment be wiped down?

  • After each patient use

  • At the end of the day

  • At the beginning of the day

  • No cleaning is needed since the EKG is a noninvasive test

Correct answer: After each patient use 

The EKG machine, in addition to all patient equipment, must be cleaned at regular intervals to prevent the transmission of infection. Even though the EKG is a noninvasive test, pathogens still live on the lead cables, and infection can be passed from one person to another.

6.

Your adult chronic hypertension patient calls for help after developing a sudden-onset headache described as "the worst headache I've ever experienced." You note nausea and vomiting and a steady decrease in mental status when the patient begins to experience a tonic-clonic seizure.

Which of the following should you suspect until proven otherwise?

  • Hemorrhagic stroke

  • Drug overdose

  • Ischemic stroke

  • Transient ischemic attack

Correct answer: Hemorrhagic stroke

Patients with hemorrhagic stroke often present with sudden-onset symptoms that include a crushing headache often described as the worst they have ever experienced. As the intracranial pressure begins to increase, the patient often experiences rapid-onset nausea, vomiting, and decreases in mental status. As the pressure increases, the patient may experience seizure activity before becoming comatose, increasingly hypertensive despite the blood loss, bradycardia, and diminished respiratory effort.

Patients who present with a sudden-onset headache, nausea, vomiting, seizures, and signs of increased intracranial pressure are not likely to be experiencing a drug overdose. 

Patients with ischemic strokes will likely present with one-sided weakness and paralysis first. The key finding in ischemic stroke is unilateral symptoms with weakness and facial droop. 

Transient ischemic strokes or attacks often present as ischemic strokes initially with the symptoms then subsiding within a few minutes to a few hours.

7.

After assisting a full-term pregnant patient in the delivery of her newborn, the newborn remains bradycardic with a heart rate of 50 beats per minute and exhibits cyanosis around the mouth, nose, fingers, and toes. The newborn is not responding well and appears lethargic following the five-minute APGAR assessment.

What would be the best initial intervention at this point to increase the newborn's heart rate?

  • Deliver adequate artificial ventilation after ensuring a definitive airway

  • Administer epinephrine 1:10,000 at 0.1 mg/mL intravenously

  • Administer a vasopressor agent intravenously per medical command recommendations

  • "Fast and hard" chest compressions at more than 120 compressions per minute

Correct answer: Deliver adequate artificial ventilation after ensuring a definitive airway

Artificial ventilations should be initiated if a newborn's heart rate stays below 60 beats per minute after the newborn's airway is clear, and oxygenation has been unsuccessful in increasing the heart rate. If positive pressure ventilation fails to increase heart rate, then chest compressions would be indicated; epinephrine may be indicated only after oxygenation, ventilation, and chest compressions fail to improve the patient's heart rate and condition.

Drug therapy is rarely indicated for newborns. As a general rule, medications are only administered when a newborn's heart rate stays below 60 beats per minute after adequate ventilations and chest compressions fail to increase the heart rate. 

Vasopressors are seldom used for the resuscitation of bradycardic newborns. 

Fast and hard compressions should be avoided in a newborn, although fast and hard compressions are appropriate for adults. Newborn chest compressions are administered at 120 per minute regardless if they are intended to treat bradycardia or cardiac arrest.

8.

You are treating a 48-year-old patient who presented with symptomatic narrow-complex supra-ventricular tachycardia that has not responded to vagal maneuvers and adenosine. The patient remains hemodynamically stable and shows no signs of congestive heart failure. He is conscious and denies any other past medical history. The patient refuses to allow electrical cardioversion to convert the rhythm.

What secondary pharmacological agent may be effective in converting the rhythm in this situation?

  • A beta blocker or calcium channel blocker

  • Amiodarone

  • Atropine

  • Lidocaine

Correct answer: A beta blocker or calcium channel blocker

A calcium channel blocker may effectively convert the patient in SVT, as long as the patient remains hemodynamically stable and there are no signs of acute pulmonary edema associated with congestive heart failure. A beta blocker or calcium channel blocker is often reserved for an in-hospital setting for patients with persistent SVT. However, medical command physicians may recommend the administration of beta blockers or calcium channel blockers such as diltiazem, verapamil, or metoprolol. 

Amiodarone is not an effective medication for patients suffering from SVT. Amiodarone is indicated for pulseless ventricular tachycardia and/or ventricular fibrillation. Atropine is not indicated for treating SVT. It is indicated for sinus bradycardia. Lidocaine is not an effective antidysrhythmic for the treatment of SVT. Lidocaine is an antidysrhythmic that effectively suppresses ventricular tachycardia.

9.

Post-Scene

Which of the following positions should you place the mother during transport to the hospital?

Select the 2 answer options which are correct.

  • Knee-to-chest

  • Modified Trendelenburg

  • Left lateral recumbent

  • Semi-Fowler

In cases of a prolapsed cord, the mother should be placed in the knee-to-chest position or a modified Trendelenburg position. This helps to relieve pressure on the cord and reduce the risk of umbilical cord compression, which can compromise blood flow to the baby. The knee-to-chest position involves the mother lying on her side with her knees drawn up towards her chest, while the modified Trendelenburg position involves the mother lying flat on her back with her legs elevated higher than her head. Elevate her hips as high as you can with pillows. Both positions can help alleviate pressure on the cord until arrival at the hospital.

The left lateral recumbent position is used for pregnant patients who are not in labor. The Semi-Fowler position is used to transport most patients but is not the position recommended for a woman in labor with a prolapsed cord.

10.

You are on-scene with a six-year-old who is unconscious and unable to protect his own airway. He is of average height, and his estimated weight is 23 kg. Which of the following endotracheal tube sizes would be most appropriate for this patient?

  • 5.5-millimeter uncuffed endotracheal tube

  • 5-millimeter cuffed endotracheal tube

  • 7-millimeter cuffed endotracheal tube

  • 4-millimeter uncuffed endotracheal tube

Correct answer: 5.5-millimeter uncuffed endotracheal tube

The EndoTracheal Tube (ETT) size formula, (age/4) + 3.5 is used for cuffed ETT, or the formula (16+age)/4 or (age/4) + 4 to calculate the uncuffed pediatric ETT size.

The appropriate size endotracheal tube for a 23-kg, six-year-old child would be a 5- to 5.5-mm internal diameter tube. However, since the child is six, he has a natural narrowing around the cricoid cartilage and does not require the use of a ballooned or cuffed endotracheal tube. A cuffed endotracheal tube may not correctly seal this patient's airway due to the narrowing or cause mucosal injury. Uncuffed ETT should be used in patients under 8 years of age. 

A 5-mm cuffed ET tube would more appropriate for a very small adult or child who is over the age of eight. At eight years old, the natural narrowing of the cricoid cartilage expands to normal dimensions. Cuffed tubes should be used on all patients over age eight. 

A 7-mm cuffed ET tube would be used on an average weight and height adult patient. It would not be appropriate for use on a 23-kg, six-year-old child. 

A 4-mm uncuffed ET tube would be appropriate for use on a 10- or 11-kg toddler, not a six-year-old, 23-kg child.

11.

Which of the following conditions is characterized by the local or diffuse changes in muscle tone that cause painful muscle spasms, unusual movement patterns, and fixed postures?

  • Dystonia

  • Muscular dystrophy

  • Parkinson's disease

  • Dementia

Correct answer: Dystonia

The term dystonia refers to the local and diffuse muscle tone changes. It may cause painful muscle spasms, unusually fixed postures, and movement patterns.

Muscular dystrophy is an inherited muscle disorder with unknown origin. The disease is marked by a slow, progressive degeneration of muscle fibers. It does not refer to muscle tone changes with painful muscle spasms, unusually fixed postures, and movement patterns. Parkinson's disease begins with hand shaking that progresses to the arms and legs in later stages. It causes stiffness, weakness, and muscle tremors. It is not similar to dystonia. Dementia is the slow progression of loss of awareness.

12.

You are on-scene with an unconscious 23-year-old female who has a possible closed head injury after a motorcycle accident. During your assessment, you determine the patient's blood pressure is elevated, her heart rate is slow, her pupils are reactive, and she is exhibiting Cheyne-Stokes-type respirations. The patient reacts only to painful stimuli.

Your assessment findings lead you to believe there is damage in what area of the brain?

  • Brainstem

  • Midbrain region

  • Frontal lobe

  • Medulla oblongata

Correct answer: Brainstem

As the pressure within the skull begins to rise, the increase in intracranial pressure can cause significant neurological and functional injuries and/or damage to the brain. As the pressure initially begins to rise, it causes the blood pressure also to begin to increase while the pulse rate decreases. At this point, the pupils remain reactive to light, and the patient may begin to develop Cheyne-Stokes-type respirations. At this level of pressure, the patient will typically try to localize and remove the source of the painful stimuli but will eventually withdraw from pain, and flexion will likely occur. At this stage of increased intracranial pressure, all deficits are reversible.

As the intracranial pressure continues to rise, it will reach the midbrain. Once here, the paramedic can expect to see a widened pulse pressure, bradycardia increases, and pupils sluggish to react and eventually unreactive to light. Neurogenic hyperventilation often ensues at this point. 

Frontal lobe injuries do not produce Cheyne-Stokes respirations. 

As intracranial pressure continues to rise, it will reach the medulla oblongata. At this point, the patient often has a blown (fixed and dilated) pupil on the same side as the injury. The pulse remains slow but is progressively irregular, and ataxic respirations are likely. Patients become flaccid at this stage with varying blood pressure readings.

13.

Cardioversion treatment for atrial fibrillation should occur within what time frame of the onset?

  • 48 hours

  • 72 hours

  • 36 hours

  • Never

Correct answer: 48 hours

Current guidelines support the clinical practice that patients who present with atrial fibrillation (AF) of less than 48 hours duration should be considered for cardioversion.

14.

You have a 70-year-old female patient in cardiac arrest. Your partner begins compressions, and another paramedic on-scene begins ventilating with an OPA and BVM. You look over to the fridge and find the patient's DNR orders that state the patient does not want any life-saving procedures, and it looks to be signed and valid. There is no family on-scene.

What are the next steps that you should take?

  • Discontinue all resuscitation measures, and take the next steps of notifying your dispatch and/or local medical coroner or medical control as laid out by protocol

  • Continue basic CPR and airway control, and transport to the hospital so they can determine whether to continue resuscitation

  • Follow full ACLS protocols for at least two minutes to assess whether the patient can be resuscitated

  • Continue basic resuscitation, and attempt to get in contact with the family to determine whether you should discontinue

Correct answer: Discontinue all resuscitation measures, and take the next steps of notifying your dispatch and/or local medical coroner or medical control as laid out by protocol

DNR orders are a legal document, in which a patient and doctor have determined that it is the patient's wish to not have resuscitation attempted. In the end, it has been determined that the patient does not wish for actions to be taken, and EMS is there for the patient.

This can be an incredibly difficult and stressful situation, but by either continuing CPR and transporting the patient or initiating full resuscitative measures, you are going directly against the patient's wishes and could be tried for assault. This is also why it is not appropriate to continue CPR while attempting to contact the family, as this is the patient's decision, not the family's. 

However, if the family is on-scene and asking you to attempt resuscitation, depending on local protocol, you may continue basic procedures and contact your supervisor or medical control to determine how to handle the situation. 

Refusing to continue treatment in a situation that is already extraordinarily stressful may escalate the situation, so make sure all attempts have been made to determine the best course of action.

15.

While treating a patient with a closed head injury and a major bleeding wound to the inner thigh, you suspect the presence of hypovolemia due to the patient's blood pressure of 66 systolic and a heart rate of 120. However, your evaluation also reveals signs and symptoms of increased intracranial pressure.

Which of the following would medical command most likely recommend in this case?

  • Crystalloid fluid boluses in an attempt to maintain the blood pressure at 90 systolic

  • Hypertonic saline administration to reduce ICP

  • Colloid solution boluses in an attempt to increase the blood pressure to 100 systolic

  • The administration of vasopressors to raise the blood pressure to greater than 100 systolic

Correct answer: Crystalloid fluid boluses in an attempt to maintain the blood pressure at 90 systolic

In this case, the hypovolemia is usually more immediately life-threatening than the head injury. As a rule, hypotension in the presence of a closed head injury should initially be managed with crystalloid fluid boluses to maintain a blood pressure of at least 90 systolic.

Hypertonic saline would be contraindicated because the patient is in hypovolemic shock. It is also generally not available in the prehospital setting. 

Colloid solutions are not generally used in the pre-hospital setting and would not be indicated for the treatment of a closed head injury patient with possible increased intracranial pressure. 

Vasopressors are not indicated when attempting to correct hypovolemia from an open injury in the pre-hospital setting, especially when the patient may have an increased intracranial pressure from another injury.

16.

Your adult epileptic patient experienced a seizure lasting several minutes per the bystanders and family. The patient is now postictal and unable to answer your questions. A family member informs you the patient has been on a prescribed medication for the seizures for a long time but is not sure what the name of the medication is or where the container is located.

What is the paramedic's best way to check the patient for chronic phenytoin therapy?

  • Assess the patient's mouth for the presence of swollen gums

  • Assess the patient's pupils for a sluggish response

  • Assess the patient's blood glucose level

  • Assess the patient's fingers for clubbing

Correct answer: Assess the patient's mouth for the presence of swollen gums

If the seizure medication is not known, a paramedic may check an epileptic patient's mouth for the presence of gingival hypertrophy (swollen gums), as this is a good indicator of chronic phenytoin therapy. About 50% of patients on long-term phenytoin therapy have gingival hypertrophy.

Assessing the pupils of a postictal patient is likely to return a sluggish response to light, as this is common in postictal patients and cannot be used as a good indicator of chronic medication administration of any type. 

Assessing a postictal patient's blood glucose level may be appropriate by local protocol but is not an indicator of chronic medication administration. 

Finger clubbing is a sign of chronic hypoxemia and not chronic anti-epileptic medication administration.

17.

Simply put, shock is a state of hypoperfusion due to several causes. Which of the following types of shock would be considered distributive shock?

  • Anaphylactic shock

  • Cardiogenic shock

  • Hypovolemic shock

  • Hemorrhagic shock

Correct answer: Anaphylactic shock

Distributive shock occurs when peripheral vasodilation causes a fall in systemic vascular resistance. The most common causes of distributive shock are anaphylactic shock, septic shock, and neurogenic shock.

Cardiogenic shock that develops from extrinsic factors, such as cardiac tamponade, tension pneumothorax, or pulmonary embolus, is known as obstructive shock. 

Hypovolemic shock occurs from a loss of circulating blood volume. It is not a form of distributive shock or obstructive shock. 

Hemorrhagic shock is a form of hypovolemic shock caused by blood loss.

18.

You are on-scene with an adult patient suspected of having either a myocardial infarction or an aortic dissection due to the patient's history and assessment. Which of the following findings would lead you to believe an aortic dissection is causing his signs and symptoms?

  • Significant blood pressure differences between the right and left arms

  • The pain associated with aortic dissection has "crescendo" pain characteristics

  • The pain radiates to the shoulder and jaw, often left-sided

  • The peripheral pulses are present and equal

Correct answer: Significant blood pressure differences between the right and left arms

Differentiating the pain associated with myocardial infarction and aortic dissection can be difficult in the pre-hospital setting. However, some differences can help the paramedic determine the existence of an aortic dissection. Differences in blood pressure between the right and left arms of greater than 15 mmHg are indicative of an aortic dissection and not a myocardial infarction.

The pain associated with aortic dissection does not have the "crescendo" pain characteristics often seen with myocardial infarction (MI) patients. The pain associated with aortic dissection does not radiate to the shoulder and jaw or left side. However, the pain experienced during an MI does radiate in this manner. Patients who are experiencing an aortic dissection will have a significant difference in right- or left-sided pulses or differences between the arms and the legs. MI patients present with present and equal pulses.

19.

The National Model EMS Clinical Guidelines indicate all the following considerations regarding head injuries except:

  • Hyperventilation with a bag valve mask to raise the PaO2

  • Continuous waveform capnography and ETCO2 measurement with a moderate to severe head injury

  • Supraglottic airway or endotracheal intubation if bag-mask ventilation is inadequate

  • Severe head injury with signs of herniation. Hyperventilation to target ETCO2 level of 30–35 mmHg. This is a short-term option, and it is only indicated for patients with severe head injury.

Correct answer: Hyperventilation with a bag valve mask to raise the PaO2

Hyperventilation is not implemented to raise the PaO2. Hyperventilation is recommended in patients with severe head injuries or when herniation is suspected. 

The National Model EMS Clinical Guidelines from the National Association of State EMS Officials indicate the following considerations regarding head injury:

  • Moderate to severe head injury: Continuous waveform capnography and ETCO2 measurement if available.
  • Supraglottic airway or endotracheal intubation only if bag-mask ventilation is inadequate. Target ETCO2 level is 35 to 40 mmHg.
  • Severe head injury with signs of herniation: Hyperventilation to target ETCO2 level of 30–35 mmHg. This is a short-term option, and it is only indicated for patients with a severe head injury.

20.

Broken recording, a type of artifact, is caused by:

  • A broken wire

  • Electrical interference

  • A low battery

  • A patient breathing too deeply

Correct answer: A broken wire

A broken recording is caused by a frayed or broken wire. Somatic tremors are caused by patient tremors or anything that shakes the electric wires. Baseline sways are related to a patient’s breathing pattern. A 60 cycle interference is caused by electrical interference.