NREMT Paramedic Exam Questions

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21.

Of the following, which patient will require an unsynchronized shock?

  • A 39-year-old female presenting with polymorphic ventricular tachycardia

  • A 78-year-old male presenting with unstable atrial fibrillation

  • A 63-year-old male presenting with monomorphic ventricular tachycardia

  • A 44-year-old female presenting with unstable atrial flutter

Correct answer: A 39-year-old female presenting with polymorphic ventricular tachycardia

According to the AHA, synchronized and unsynchronized shocks are required for stable and unstable tachycardias. Polymorphic ventricular tachycardia requires a high-energy unsynchronized shock. Also, if you are unable to determine whether the rhythm is polymorphic or monomorphic, you must treat it as polymorphic and perform a high-energy unsynchronized shock.

Unstable atrial fibrillation requires a synchronized shock at your device’s specific recommended energy level to maximize the success of the first shock. Monomorphic ventricular tachycardia requires a synchronized shock at your device’s specific recommended energy level to maximize the success of the first shock. Unstable atrial flutter requires a synchronized shock at your device’s specific recommended energy level to maximize the success of the first shock.

22.

Your adult patient is complaining of dyspnea, anxiety, and confusion. The patient is found to have hypertension with reflex bradycardia. The findings and situation lead you to suspect the patient is suffering from acute cyanide poisoning. In which of the following situations would administering a cyanide antidote kit be contraindicated?

  • The patient suffered smoke inhalation from a structure fire

  • The patient was poisoned by inhalation of cyanide gas

  • The patient was intentionally poisoned with cyanide salt added to food

  • The patient was accidentally poisoned with cyanide through direct skin absorption

Correct answer: The patient suffered smoke inhalation from a structure fire

The cyanide kit should not be administered to any patient suspected of smoke inhalation as the cause of the cyanide poisoning. Carbon monoxide from the fire limits the amount of oxygen that hemoglobin can carry. This, coupled with the formation of methemoglobin from the antidote kit, leaves very little or no available hemoglobin to transport the needed O2 molecules.

The cyanide antidote kit is safe for administration to patients who were potentially poisoned by inhaling a cyanide-containing gas, ingesting cyanide salt, and through absorption of the chemical form of cyanide.

23.

Post-Scene

Which of the following is correct regarding this scenario?

  • You can transport the patient to the critical-access hospital six blocks away.

  • This patient should be transported to the specialty pediatric hospital 20 miles away.

  • An air medical response to the scene should be requested.

  • The mother should have taken the child directly to the critical access hospital.

Correct answer: You can transport the patient to the critical-access hospital six blocks away.

This patient had a foreign body airway obstruction that was relieved by the EMS crew. No further interventions would be anticipated, but the child should be transported for evaluation at an emergency department. Transport to the specialty resource hospital 20 miles away is unnecessary. The critical access hospital should be able to evaluate the patient. The child is stable, so there is no need to request air medical response to the scene. Even though she was close to a hospital, this patient needed immediate intervention, and stopping for help at the ambulance garage was a good choice.

24.

What are two consecutive PVCs called?

  • Couplets

  • Bigeminy

  • Trigeminy

  • Fusion beats

Correct answer: Couplets 

Two consecutive PVCs in a rhythm are called couplets.

Bigeminy occurs when every other beat in a rhythm is a PVC. In trigeminy, every third beat is a PVC. Fusion beats occur when electrical impulses from several foci stimulate a ventricular chamber, causing QRS complexes that are very wide, and will look like the merger of a sinus beat with a ventricular beat.

25.

Which of the following would be considered normal respiratory rates?  

Select the three correct answer options.

  • 12-day-old with 52 breaths per minute

  • 6-month-old with 46 breaths per minute 

  • 4-year-old with 26 breaths per minute 

  • 8-year-old with 32 breaths per minute 

Normal pediatric respiratory rates:

  • Neonates (first 28 days of life): 30–60
  • Infant (one month to one year): 30–53
  • Toddler (one to two years): 22–37
  • Preschooler (three to five years): 20–28
  • School-aged child (six to 12 years): 18–20
  • Adolescent (12 to 15 years): 12-22

26.

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.

27.

Your adult diabetic patient has a low blood glucose level and is unconscious. When would it be appropriate to administer glucagon to the patient in an attempt to correct the low blood glucose level?

  • If the patient has an altered level of consciousness and you are unable to obtain a patent IV line

  • If the patient is experiencing signs and symptoms of diabetic ketoacidosis

  • If the patient is known to have liver disease

  • If the patient's blood glucose levels fall below 70 milligrams per deciliter

Correct answer: If the patient has an altered level of consciousness and you are unable to obtain a patent IV line

If the patient has an altered level of consciousness and an IV line cannot be established, glucagon can be administered to a hypoglycemic patient subcutaneously, intramuscularly, or even intranasally if protocol allows it.

Patients with diabetic ketoacidosis have an elevated blood glucose level due to the lack of insulin to help the glucose enter the cells. Therefore, glucagon would not be indicated for a hyperglycemic event; only conditions that cause hypoglycemia would warrant the administration of glucagon. 

Glucagon is not effective in patients who have liver disease, so it would not be administered to a liver disease patient. 

It is not required that a patient's blood glucose level be below 70 milligrams per deciliter to administer glucagon to the patient. It is only recommended when IV access cannot be initiated because dextrose 50 percent is not recommended to be given by any other route other than intravenously.

28.

Which of the following are management principles for the treatment of a patient with an animal bite? 

Select the 3 answer options which are correct.

  • Irrigate with sterile water to decontaminate if needed

  • Apply a dry, sterile dressing

  • Immobilize the area with a splint if needed

  • Allow the wound to bleed so that any bacteria will be flushed out

The emergency care of a patient with an animal bite should include bleeding control, gross decontamination by irrigating with sterile water before placing a dry, sterile dressing over the wound, and splinting as necessary. After addressing the wounds, provide prompt transport to the ED.

You should not allow the wounds to bleed; this would not flush the bacteria out of the wound and could lead to shock.

29.

The type of cells responsible for initiating depolarization are:

  • Pacemaker cells

  • Myocardial cells

  • Electrical conducting cells

  • Purkinje fibers

Correct answer: Pacemaker cells

Pacemaker cells are responsible for initiating depolarization in the SA node. For this reason, they are considered the powerhouse of the heart. 

Myocardial cells are responsible for contraction of the heart muscle. Electrical conducting cells carry the electric currents created by depolarization to the walls of the heart. Purkinje fibers are electrical conducting cells that innervate the walls of the ventricles.

30.

En-Route

As you are responding to the call in this scenario, which of the following conditions should you give priority consideration to?

  • Exertional heat stroke

  • Classic heat stroke

  • Traumatic brain injury

  • Hemorrhagic shock

Correct answer: Exertional heat stroke

Due to the weather conditions and dispatch information, you should be prepared to treat exertional heatstroke, which occurs when the patient is typically young and healthy and has been performing vigorous activity in very warm conditions.

Classic heatstroke usually affects vulnerable populations such as the very old, or very young in very warm conditions with sustained high temperatures and the patient is predisposed to the condition. There is no indication from the dispatch information that the patient has sustained an injury, so a traumatic brain injury or hemorrhagic shock are not priority considerations.

31.

The Hartford Consensus was produced in response to numerous mass shootings in the United States and recommends prioritized actions in a mass shooting event. Which of the following are correct components of the THREAT mnemonic that identifies those recommended actions?

Select the 3 answer options which are correct.

  • Threat suppression

  • Hemorrhage control

  • Rapid Extrication to safety 

  • Active suppression of threats

The Hartford Consensus recommends prioritized actions in a mass shooting event. These actions include: 

  • Threat suppression 
  • Hemorrhage control
  • Rapid Extrication to safety 
  • Assessment by medical providers 
  • Transport to definitive care

Active suppression of threats is not one of the prioritized actions the Hartford Consensus recommends.

32.

You are unable to control an upper arm hemorrhage from a laceration that is located just above the patient's antecubital fossa on the inner aspect of the patient's upper arm. After all bleeding control measures fail, you decide to apply a tourniquet to control the hemorrhage. 

After the tourniquet is properly applied, the bleeding is controlled, and the tourniquet is secured, what should you do after reassessing the injury site?

  • Note the time the tourniquet was applied

  • Place a second tourniquet below the injury site

  • Tighten the tourniquet one half a turn, and resecure it every fifteen minutes until the hemorrhage is controlled

  • Loosen the tourniquet one turn every fifteen minutes until the bleeding is controlled

Correct answer: Note the time the tourniquet was applied

After applying the tourniquet and controlling the associated hemorrhage, it is important to reassess the patient's injury after securing the tourniquet. Immediately after reassessment, it is important to note the time the tourniquet was applied.

If a tourniquet fails to control bleeding, a second one can be placed above (proximal to) the first tourniquet and injury. There is no indication this is needed for this patient.

There is no reason to write the patient's name, date, and allergies on the tourniquet. Never retighten or loosen a tourniquet that has proven effective in stopping a hemorrhage after it has been secured unless the hemorrhage begins again in the prehospital setting.

33.

You are on-scene with an adult patient who was found with an extremely altered level of consciousness and a small amount of blood noted on their lips. There are no other obvious signs of trauma during the primary assessment other than a small tongue laceration. After ensuring an adequate airway, you discover the patient's small tongue laceration appears consistent with biting their tongue. The patient also has obviously swollen gums that do not appear to be caused by trauma. Vital signs are found to be within normal limits, and pupils react to light, but the patient's level of consciousness continues to be decreased to painful stimuli only.

With the limited findings, which of the following conditions is most likely to cause the patient presentation?

  • An epileptic seizure is likely responsible for causing the patient's condition

  • A diabetic seizure most likely caused the patient's presentation

  • A cerebrovascular accident is likely the cause of the patient's condition

  • A metabolic coma is likely the cause of the patient's presentation

Correct answer: An epileptic seizure is likely responsible for causing the patient's condition

A patient who has an extremely altered level of consciousness and an apparent tongue wound may have experienced a grand-mal seizure. When a patient has a seizure, it is common for EMS to find them with an altered level of consciousness or postictal. In this phase of the seizure activity, the patient is worn out after the overstimulation and firing of nerves throughout the body. It is also common for seizure patients to bite their tongue during the tonic-clonic phase of the seizure. The probability of epileptic seizure comes from the patient having swollen gums that did not appear to be part of the tongue biting. Swollen gums are the telltale sign of chronic phenytoin therapy. Phenytoin is a common medication in the treatment of epileptic patients.

With the limited findings, a seizure is most likely. However, without a current blood sugar reading indicating hypo or hyperglycemia with the obvious signs of chronic phenytoin therapy, a diabetic seizure is less likely than an epileptic seizure. 

It would not be appropriate for a paramedic to assume the patient is experiencing a stroke rather than a seizure disorder. Stroke patients may have a severely decreased level of consciousness, but they do not often present with tongue bites, swollen gums, and normally responsive pupils. 

A patient experiencing a metabolic coma usually progresses to unconsciousness quickly, and the condition does not cause the patient to bite their own tongue as seizure activity does. Patients with metabolic coma also typically present with pupils unequal but reactive with a brisk response, like this patient. They also tend to have rapid, weak respirations. 

34.

Which of the following are considered critical EMS assessments and actions of out-of-hospital acute stroke care?

Select the three correct answer options.

  • Establish time of symptom onset (last known normal)

  • Triage to most appropriate stroke center

  • Check glucose; treat if indicated

  • Obtain a 12-lead ECG 

Out-of-hospital acute stroke care focuses on critical EMS assessments and actions:

  • Assess ABCs; give oxygen if needed
  • Initiate stroke protocol
  • Perform physical exam
  • Perform validated pre-hospital stroke screen and stroke severity tool
  • Establish time of symptom onset (last known normal)
  • Triage to most appropriate stroke center
  • Check glucose; treat if indicated
  • Provide pre-hospital notification; on arrival, transport to brain imaging suite

12-lead ECG acquisition will most likely occur as part of the assessment, but it is not considered a critical assessment and action of acute stroke care. 

35.

Post-Scene

Based on the information given in the scenario, which of the following treatments should be initiated during the 9-minute transport to the cardiac center if he develops hypotension and becomes lethargic?

  • Dobutamine (Dobutrex) infusion at 5 mcg/min

  • Oxygen via NRB mask at 15 LPM

  • Start CPAP at 5 cm/H2O

  • Administer 0.3mg nitroglycerin sublingually

Correct answer: Dobutamine (Dobutrex) infusion at 5 mcg/min

This patient is exhibiting signs of decompensated cardiogenic shock. The most appropriate treatment for this patient during transport is to start a Dobutamine (Dobutrex) infusion and monitor the patient closely.

Administration of sublingual nitroglycerin or CPAP is contraindicated and may worsen this patient's condition. There is no indication this patient needs more oxygen via NRB mask.

36.

Post-Scene

Which of the following treatments would be most appropriate during the transport to the hospital if the patient remains hypotensive despite initial interventions?

  • Dopamine (Intropin) IV infusion

  • Norepinephrine (Levophed) IV infusion

  • Epinephrine (Adrenaline) IV infusion

  • Heparin (Panheparin) IV infusion

Correct answer: Dopamine (Intropin) IV infusion

If the patient remains hypotensive despite atropine and transcutaneous pacing (TCP), dopamine (Intropin) infusion would be the most appropriate treatment during the transport to the cardiac center.

Epinephrine IV infusion may be used in the management of bradycardia, but dopamine would be the preferred treatment in this case, as it would not increase myocardial oxygen demand as much. Norepinephrine (Levophed) IV infusion is not indicated in cardiogenic shock due to bradycardia. Pre-hospital providers do not initiate heparin (Panheparin), which would not be indicated for hypotension but for blood clots.

37.

Scene

Based on the information in the given scenario, what treatments are the most appropriate for this patient while at the scene?

Select the 3 answer options which are correct.

  • IV fluid bolus

  • Analgesic pain medication

  • Antiemetic medication

  • Oxygen administration

  • Vasopressor medication

  • Vasodilator medication

This patient is exhibiting signs and symptoms consistent with cholecystitis. Treatment on the scene should include:

  • Inserting a peripheral IV and administering fluid
  • Analgesic pain medication
  • Antiemetic medication
  • Transport in a position of comfort

This patient is not exhibiting signs of respiratory compromise or hypoxia, so oxygen is not indicated. Vasopressor medications are only indicated in shock. Vasodilator medication would be indicated in suspected acute coronary syndrome or hypertensive crisis. This patient is not exhibiting signs and symptoms of acute coronary syndrome, shock, or hypertensive crisis.

38.

After intubating an apneic adult patient, you quickly auscultate decreased breath sounds on the left side. Which of the following is most likely to cause this abnormal finding?

  • The ET tube has entered the right mainstem bronchus

  • The ET tube has entered the left mainstem bronchus

  • The tip of the ET tube is against the carina

  • The patient may be experiencing a left-sided pneumothorax

Correct answer: The ET tube has entered the right mainstem bronchus

If breath sounds are decreased or absent in the left lung, the ET tube may have passed into the right mainstem bronchus effectively bypassing the origin of the left main bronchus.

If the ET tube enters the left mainstem bronchus, it would occlude the right lung and cause decreased breath sounds on the right side, not the left. Also, the natural shape of the bronchus will usually cause the tube to enter the right lung, not the left. 

If left lung sounds are diminished, it is not likely that the tube is against the carina of the lungs. If this were the case, bilateral lung sounds would be diminished, and the patient would be difficult to ventilate. 

Left-sided diminished breath sounds are common when the tube is advanced too far. It is much more likely that this is the case rather than a pneumothorax.

39.

Your patient has taken approximately 25 tablets of fluoxetine (Prozac) in a suicide attempt. You should expect to find which of the following signs and symptoms?  

Select the three correct answer options. 

  • Dilated pupils  

  • Tachycardia 

  • Heavy sweating 

  • Pinpoint pupils

  • Pale, dry skin 

  • Bradycardia 

Serotonin syndrome occurs as a result of toxic levels of serotonin from an overdose of SSRI medications. Signs and symptoms include:

  • Muscle rigidity
  • Heavy sweating
  • Rapid heart rate and high blood pressure
  • Agitation or restlessness
  • Confusion
  • Dilated pupils
  • Loss of muscle coordination or twitching muscles
  • Diarrhea

Pinpoint pupils, dry skin, bradycardia, and hypotension are not present in serotonin syndrome. Pinpoint pupils are more likely to be found in opioid overdoses. 

40.

Which of the following relates to increased intracranial pressure (ICP)? 

  • Monro-Kellie doctrine

  • Fick Principle

  • Bernoulli's Principle

  • Frank-Starling Law

Correct answer: Monro-Kellie doctrine

The cranial vault is 100% filled by the brain, cerebrospinal fluid (CSF), and blood. In response to an expanding intracranial mass, the body attempts to reduce ICP by expelling CSF and venous blood from the cranial vault. During the early stages, this mechanism successfully creates more space for the mass and keeps ICP within normal limits.

The Fick Principle applies to cardiac output. The Bernoulli Principle states that an increase in the speed of fluid occurs simultaneously with a decrease in pressure or a decrease in the fluid's potential energy. The Bernicke Principle has no relationship to neurology. The Frank-Starling Law pertains to myocardial contractility and states that the stretch of the left ventricle will increase with rising volume.