NREMT Paramedic 1.4.12 Exam Questions

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81.

How does nitroglycerin relieve ischemic cardiac chest pain?

  • By reducing cardiac preload

  • By increasing cardiac preload

  • By decreasing myocardial oxygen consumption

  • By increasing peripheral vascular resistance

Correct answer: By reducing cardiac preload

Nitroglycerin is a powerful vasodilator that decreases cardiac preload and increases coronary blood flow. The dilation effect, therefore, reduces cardiac preload and increases coronary blood flow.

Nitroglycerin is a vasodilator that increases the size of the peripheral blood vessels. This action reduces the preload that reaches the chambers of the heart. Nitro would need to cause a vasoconstrictive effect to increase the preload. 

Nitroglycerin's powerful vasodilatory effect is not capable of primarily decreasing the oxygen consumption of the heart. It does, however, decrease the preload and eventually workload of the heart. This action would eventually reduce the oxygen consumption of the heart by reducing its workload. 

Peripheral vascular resistance is the pressure at which the arterial blood must pump against to circulate to the organs and tissues of the body. Nitroglycerin's vasodilation would decrease peripheral vascular resistance, not decrease it.

82.

Your adult patient was involved in an accident with a truck hauling organophosphate chemicals. If the patient was exposed to a potentially toxic amount of inhaled organophosphates, which of the following is most likely to occur?

  • Respiratory and heart rate decrease due to cholinergic stimulation

  • Respiratory and heart rate increase due to anticholinergic stimulation

  • Decrease in level of consciousness and pulmonary edema due to fluid shift

  • A decrease in lacrimation, sweating, urination and inability to focus on objects in field of vision

Correct answer: Respiratory and heart rate decrease due to cholinergic stimulation

Organophosphate agents and some nerve agents inhibit the effects of acetylcholinesterase, which causes a cholinergic overdrive or crisis to occur. This disrupts normal nerve transmissions in the central and peripheral nervous system and causes a decrease in heart rate and blood pressure and an increase in tear production and excessive saliva as well as other signs and symptoms.

The cholinergic overstimulation caused by organophosphate poisoning causes a decrease in heart rate and respiratory rate, not an increase. 

A decrease in level of consciousness is possible with low to moderate exposure; however, the patient is not likely to present with pulmonary edema initially. 

Patients exposed to organophosphate agents are likely to experience excessive tear production, saliva, and sweating and increased urination, not a decrease in fluids. They do not often present with visual disturbances other than excessive watery eyes.

83.

What is the normal amount of time for a PR interval?

  • 0.12 - 0.2 seconds

  • Less than 0.12 seconds

  • 0.1 seconds

  • 1 second

Correct answer: 0.12 - 0.2 seconds 

The normal time for the PR interval is 0.12 - 0.2 seconds.

84.

Which of the following conditions is most likely to prevent the sinoatrial node from initiating an electrical impulse needed to begin myocardial depolarization?

  • Hypoxia

  • Hypercapnia

  • Hypovolemia

  • Hyperthyroidism

Correct answer: Hypoxia

When the SinoAtrial (SA) node and the atria cannot generate the electrical impulses needed to begin depolarization because of factors such as hypoxia or ischemia, the AV node or the area surrounding the AV node may assume the role as a secondary pacemaker to initiate the impulse needed to cause depolarization and a myocardial contraction.

Hypercapnia is excessive carbon dioxide content in the patient's blood. This condition is also caused by hypoxic states but does not interfere with the SA node discharge. 

Hypovolemia is not likely to cause the SA node to fail; conditions such as low oxygen and ischemia are more likely to interfere with SA node impulse formation. 

Hyperthyroidism (overactive thyroid) is a condition in which the thyroid gland produces too much of the hormone thyroxine. Thyroxine does not affect impulse formation in the SA node, but it can affect the rate of impulse.

85.

Diastole can be broken down into three phases. In which phase does the pressure between the atria and ventricles become equal?

  • Diastasis

  • Atrial kick

  • Isovolumetric relaxation

  • Rapid filling phase

Correct answer: Diastasis

The phases of diastole are as follows:

  1. Rapid filling phase - when the AV valves are open and blood flows into the ventricles
  2. Diastasis - when the pressure between the atria and ventricles begin to equalize
  3. Atrial kick - when the atria contract and expel what little blood is in the chambers into the ventricles.

Isovolumetric relaxation is a phase in systole.

86.

All emergency vehicle operators may be held liable for traffic incidents that involve excessive speed, improper use of emergency warning equipment, and which of the following?

  • Failure to consider road and weather conditions in the area

  • Failure to comply with posted speed limit for the area

  • Failure to stop at all train crossings

  • Failure to anticipate the actions of other drivers in the area

Correct answer: Failure to consider road and weather conditions in the area

Emergency vehicle operators are obligated by law to operate emergency vehicles with due regard to the safety of others. All emergency vehicle operators may be held liable for traffic incidents that involve excessive speed, improper use of emergency warning equipment, and failure to consider the road and weather conditions in the immediate area. 

Most EMS agencies are allowed to drive slightly above the posted speed limit when in emergency mode. The EMS speed limit for response is typically set forth by the paramedics' supervisors and agency. Therefore, it is not a component of liability. 

It is not a key factor of liability for EMS personnel to not stop at all train crossings when responding to an emergency call. Therefore, it would not be a key element of liability. 

Paramedics cannot be expected to anticipate the actions of other drivers.

87.

When involved in transporting a patient from the hospital (regardless of the destination), which of the following disease processes, along with HIV/AIDS, must be reported to the transporting crew members to prevent the accidental transmission of the disease?

  • Hepatitis and tuberculosis

  • Shingles and pneumonia

  • Syphilis and gonorrhea

  • ARDS and sepsis

Correct answer: Hepatitis and tuberculosis 

The Ryan White Act of 1990 requires that all EMS or healthcare workers who have been exposed to certain communicable diseases be notified and/or warned of the presence prior to contact when possible. These diseases include the following:

  • Hepatitis
  • Tuberculosis
  • HIV/AIDS
  • Bacterial meningitis
  • Rubella

It is part of the Ryan White Act to include non-communicable or infectious disease processes; however, shingles and pneumonia are not considered communicable/infectious disease processes and are not required to be reported to the transporting crew. 

Syphilis and gonorrhea are considered sexually transmitted diseases and are not part of the Ryan White Act. 

ARDS is Adult Respiratory Distress Syndrome and believed to be primarily caused by post-trauma to the respiratory system. Sepsis results from a systemic infection. These are not recognized as communicable infectious diseases and are not part of the Ryan White Act.

88.

You are attempting to perform transcutaneous pacing on a symptomatic bradycardia patient. Which of the following would be appropriate when attempting to gain electrical capture of the patient's heart rhythm?

  • Do not activate pacing mode until a "marker" is located on the oscilloscope screen, the marker should be in front of each and every QRS complex.

  • Set the pacemaker voltage at 70–80 milliamps before initiating non-demand pacing mode.

  • Attach pacing pads, initiate pacing mode at 100 milliamps, and increase the voltage until pacing is adequately producing a heart rate.

  • Attach pads and initiate pacing mode at 100 milliamps and 100 impulses per minute.

Correct answer: Do not activate pacing mode until a "marker" is located on the oscilloscope screen, the marker should be in front of each and every QRS complex.

While attempting to perform transcutaneous pacing on a symptomatic bradycardia patient, it is appropriate to attach electrodes, select pacing mode, select pacing rate (usually 80 beats per minute), select the beginning current starting at zero, and increase slowly until capture is achieved (usually 50 milliamps). Then, activate the pacemaker to initiate the mechanical pacing procedure.

Transcutaneous demand pacing is the preferred method of pacing in the pre-hospital setting, not non-demand. Demand mode is evident by the appearance of "markers" on the oscilloscope screen indicating the location at which the pacing impulse will be delivered. It is not acceptable in most regions and per the American Heart Association (AHA) to set the initial energy setting at 70 to 80 impulse deliveries each minute, even though that level (and higher) may be needed/reached increasing amperage to gain capture. It is not acceptable to initiate the pacing procedure until electrical capture is first achieved. Do not initiate pacing and increase amplitude until electrical and mechanical capture is achieved. Achieve electrical capture first, then initiate pacing procedure. It is not an AHA recommendation to currently begin transcutaneous pacing at 100 milliamps and the intrinsic rate set at 100 beats per minute.

89.

Which of the following is designed to limit the amount of air that enters the chest during the upstroke phase of chest compressions, thereby enhancing negative pressure inside the chest during cardiopulmonary resuscitation efforts?

  • Impedance threshold device (ITD)

  • Automated external defibrillator

  • Mechanical CPR device 

  • Positive end-expiratory pressure (PEEP)

Correct answer: Impedance threshold device (ITD)

An Impedance Threshold Device (ITD) is a class IIB intervention. It has a valve that limits the amount of air allowed to enter the chest during the upstroke of manual chest compressions. It is meant to enhance the negative pressure inside the chest cavity to help increase blood flow through the heart and doubles the systolic blood pressure.

An automated external defibrillator is designed to analyze an unconscious apneic patient's heart rhythm to determine if the patient is exhibiting a shockable rhythm. It is effective in helping return a fibrillating heart to a more normal state of functioning. 

Mechanical CPR devices perform chest compressions and do not limit air that enters the lungs. Some have suction-type plungers that help the chest recoil fully, which does help ventricular filling. 

Positive End-Expiratory Pressure (PEEP) is the pressure in the lungs (alveolar pressure) above atmospheric pressure (the pressure outside of the body) that exists at the end of expiration.

90.

You are on-scene with an adult who was possibly exposed to an inhaled vapor that contains a high concentration of organophosphate material. Which of the following medications may help block the adverse effects of the potential poisoning by antagonizing the actions of acetylcholine?

  • Atropine

  • Diazepam

  • Naloxone

  • Amyl nitrate

Correct answer: Atropine

Atropine reverses the muscarinic effects of moderate to severe organophosphate and carbamate poisonings. The muscarinic effects cause bradycardia, hypotension, miosis, and increased secretions. Atropine competitively antagonizes the actions of the neurotransmitter acetylcholine. This reduces smooth muscle hyperactivity. 

Diazepam is a benzodiazepine given to organophosphate poisoning patients to prevent the onset of seizure activity. It does not help block the adverse effects of the muscarinic receptors, such as bradycardia and hypotension, seen in organophosphate poisoning. 

Naloxone is a narcotic antagonist; it is given in times of suspected or confirmed narcotic overdose. It is not indicated for the treatment of organophosphate poisoning. 

Amyl nitrate is an inhalant medication for the treatment of angina pectoris or other cardiac condition that causes chest pain. It is not indicated for the treatment of organophosphate poisoning.

91.

Which of the following are part of the EMS branch within the Incident Management System? 

Select the three correct answer options.

  • Triage

  • Treatment 

  • Transportation

  • Public Information Officer

  • Logistics

  • Rescue 

The EMS branch of the Incident Management System generally consists of triage, treatment, and transportation. Each group will have a leader who reports to the command. 

The Public Information Officer (PIO) would be a part of the command branch, not the EMS. Logistics would be a component of the incident command. Rescue is a group found in the operations branch. 

92.

Scene

Which of the following ALS treatments was most likely performed in this scenario?

  • Removal of a foreign body with a laryngoscope and Magill forceps

  • Removal of a foreign body with a blind finger sweep

  • 30 chest compressions and an attempt to ventilate

  • 10 abdominal thrusts and then finger sweep

Correct answer: Removal of a foreign body with a laryngoscope and Magill forceps

This child most likely has a foreign body airway obstruction. The immediate basic life support (BLS) for this patient is 30 chest compressions and an attempt to ventilate. If you are unable to ventilate the patient after 30 chest compressions and cannot see the object, advanced life support (ALS) interventions are to attempt removal with a laryngoscope and Magill forceps. If you can see the object in the mouth, remove it with a finger sweep.

Never perform blind finger sweeps of a child's mouth; you may lodge the object further. Abdominal thrusts are used on conscious children and adults, back slaps and chest thrusts are used on infants. Finger sweeps, abdominal thrusts, and chest thrusts are all BLS interventions.

93.

Which of the following are correct steps in placing an orogastric tube in an unresponsive patient that has been intubated? 

Select the 3 answer options which are correct.

  • Position the head in a slightly flexed position 

  • Lubricate the tube with water-soluble gel 

  • Measure from mouth to ear to xiphoid process

  • Position the head in a chin down position

The steps for placing an orogastric tube in an unresponsive patient are as follows:

  1. Position the head in a slightly flexed position
  2. Measure from mouth to ear to xiphoid process
  3. Lubricate the tube with water-soluble gel and introduce the tube at the midline; advance it gently into the oropharynx, continuing into the stomach
  4. Confirm placement
  5. Apply suction to the tube
  6. Secure the tube in place

The chin down position may be helpful in placing the nasogastric tube, not an orogastric tube, in a conscious patient. 

94.

Scene

Based on the information given in this scenario, what would this patient's initial Glasgow Coma Score be?

  • 14

  • 13

  • 12

  • 15

Correct answer: 14

The Glasgow Coma Score is used to evaluate mental status. It assigns a point value to eye-opening (1-4), verbal response (1-5), and motor response (1-6). This patient would receive a 3 for eye-opening, a 5 for a verbal response, and a 6 for a motor response, for a total of 14.

If his eyes were open spontaneously, his score would have been 15. Because he can follow commands and his speech is normal, a score of 12 or 13 would be too low.

95.

Which of the following is not a cause of shock?

  • Increased systemic vascular resistance

  • Inadequate cardiac output

  • Decreased systemic vascular resistance

  • Inability of RBCs to deliver oxygen to the tissues

Correct answer: Increased systemic vascular resistance

Shock can result from inadequate cardiac output, decreased (not increased) systemic vascular resistance, and the inability of RBCs to deliver oxygen to the tissues.

If there is a disturbance in the transportation of oxygen and the removal of carbon dioxide, then dangerous waste products will build up, leading to cellular death and eventually death to an entire organ.

96.

You are treating a 68-year-old cardiac history patient experiencing chest pain. If it is determined at the hospital that he experienced an acute myocardial infarction of the septal wall, which of the coronary arteries was most likely occluded?

  • Left main coronary artery

  • Right main coronary artery

  • Circumflex artery

  • Posterior descending artery

Correct answer: Left main coronary artery

If an occlusion is in the left main coronary artery, the result is a likely infarction in the anterior, lateral, or septal walls of the myocardium.

Right main artery occlusion normally causes an inferior left ventricle infarction. The circumflex artery is often involved in inferior wall ventricular infarctions. Posterior wall myocardial infarctions are common with occlusion of the posterior descending artery.

97.

You are called to stage at a mass casualty incident involving exposure to possible chemical agents during the event. Knowing you will likely transport one or more patients from the scene who have been grossly decontaminated in the decontamination section, what measures can you take to minimize the possible contamination of your unit during the patient care/transport encounter?

  • Use disposable equipment as much as possible; remove all equipment that will not likely be needed during transport

  • Cover the patient with sheets and blankets and administer oxygen via a non-rebreather mask to prevent the spread of toxins

  • Transport the patient on stretcher and treat appropriately; decontamination has taken place so no further danger of contamination exists

  • Patient should be transported in a full hazmat suit after gross decontamination to prevent infecting EMS and ER staff

Correct answer: Use disposable equipment as much as possible; remove all equipment that will not likely be needed during transport

Contamination of the ambulance and equipment can be minimized by preparing the vehicle for the transport of a partially contaminated patient prior to transport. This involves removing non-essential equipment and supplies. 

Covering a patient with sheets and blankets and applying a non-rebreather mask will not prevent the spread of any possible contamination from a hazmat scene. It would likely cause ER and ambulance contamination that would require a complete decontamination procedure to be considered clean. 

Gross decontamination at the scene is not considered adequate to be considered completely clean. The patient remains somewhat contaminated, and protection procedures must be in place to protect the crew, ER, and public. 

It is not necessary to transport a grossly decontaminated patient to the hospital in a full hazmat suit. It is not likely that they would still possess the contamination to require such a response.

98.

Scene

Which of the following treatments will have the greatest effect on improving this patient's condition?

  • Norepinephrine (Levophed) infusion

  • Epinephrine (Adrenaline) infusion

  • Oxygen administration

  • Normal saline fluid bolus

Correct answer: Norepinephrine (Levophed) infusion

This patient is exhibiting signs and symptoms of sepsis, which meningitis is frequently associated with in children. This patient is critically ill and needs immediate vasopressor support. Norepinephrine (Levophed) is the preferred vasopressor for septic shock. A fluid bolus must accompany the infusion for optimal results.

While all the listed treatments are acceptable for pediatric sepsis, norepinephrine will have the greatest impact on this patient's condition.

99.

Polymorphic ventricular tachycardia with a prolonged QT interval is known as:

  • Torsades de Pointes

  • SVT

  • VFIB

  • Asystole

Correct answer: Torsades de Pointes

Polymorphic ventricular tachycardia with a prolonged QT interval is known as Torsades de Pointes, which means "twisting of the points". The rhythm has a twisting appearance around the isoelectric line.  SVT is supraventricular tachycardia and has a narrow or shortened QT interval. VFIB is ventricular fibrillation, and the QT interval is often not discernable. Asystole is the absence of electric impulse in the heart.

100.

You are performing triage on the patients at a mass-casualty incident when you encounter a conscious and alert 20-year-old male with a respiratory rate of 22 breaths/min. What should you do next?

  • Assess radial pulses, tag the patient appropriately, and move on to the next patient

  • Auscultate the patient's lung sounds

  • Tag the patient as red and move on to the next victim

  • Administer oxygen therapy via a non-rebreather mask at 15 liters/minute

Correct answer: Assess radial pulses, tag the patient appropriately, and move on to the next patient

A responsive and alert patient who has respirations considered normal should have his carotid or radial pulses assessed quickly before moving on. Appropriately tag the patient after ensuring equal radial pulses and move on to the next victim.

During the initial triage event at a mass casualty incident, it is not appropriate to auscultate breath sounds, administer oxygen, or provide any treatment other than opening an airway that may be compromised.

You need to evaluate the pulse before you can assign a color to this patient. Assigning him red before checking his pulse rate would not be appropriate, as he meets the yellow criteria so far.