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Quiz Session - Attempts With Random Questions

BCEN CFRN CTRN Exam Questions

Page 5 of 50

81.

A 66-year-old male with past medical history of diabetes mellitus, hypertension, obesity, and 45-pack years of tobacco use is in transport from a rural area after reporting sudden onset, crushing, 10/10 substernal chest pain of 30 minutes duration. Prior to transport, he chewed 165 mg ASA and self-administered 0.4 mg of sublingual nitroglycerin. ECG shows ST elevations in V3-V6, and point of care troponin level is 14.6 ng/mL.  

What is the most appropriate next step?

  • Thrombolytic therapy followed by transfer to a PCI capable facility 4 hours away

  • Transfer to a PCI-capable facility 4 hours away

  • Thrombolytic therapy followed by a 1 mg/kg unfractionated heparin drip

  • Start the patient on 1 mg/kg low molecular weight heparin drip

Correct answer: Thrombolytic therapy followed by a transfer to a PCI capable facility 4 hours away

Percutaneous coronary intervention (PCI) with or without stent placement is currently the preferred approach to reperfusion in patients with persistent symptoms and STEMI. Pharmacologic reperfusion is accomplished with fibrinolytic therapy, which is improved with adjuvant antiplatelet and antithrombin therapy. ACLS guidelines recommend a treatment goal of ≤ 90 minutes for a patient who arrives at a hospital with PCI capability, or  ≤ 120 minutes for patients arriving at a hospital without PCI capability to account for transfer time. Fibrinolytic therapy should be given within 30 minutes if PCI cannot be accomplished within noted time frames. The concept of “first medical contact to device/balloon time” replaces the “door to needle” or “door to balloon” time. 

Each health system and institution treating ACS patients should develop protocols to drive optimal methods of reperfusion, determining which strategy it prefers, based on available resources and capabilities.

82.

You are preparing to participate in the rapid sequence intubation (RSI) of a patient being transported via medical air transport. All of the following "P's" should be followed to guarantee successful intubation except:

  • Position all patients with a pad behind the shoulders

  • Preoxygenate the patient prior to attempting intubation

  • Prepare by making sure all equipment is in working order

  • Use a paralytic agent during RSI

Correct answer: Position all patients with a pad behind the shoulders

The likelihood of successful endotracheal intubation can be significantly improved through application of the "7 P's for Success."

Preparation: Make sure all the necessary equipment is in working order

Preoxygenate: Administer oxygen via nasal cannula at a rate of 10 to 15 L/minute for 3 to 5 minutes prior to attempting intubation

Pretreatment: Administer medications, if needed, to facilitate intubation (lidocaine, opiates, atropine, or a defasciculating dose of rocuronium or vecuronium)

Paralysis: Provide paralysis prior to intubation through use of an induction agent, a paralytic, and administration of a pain medication

Protect and position: Place a pad behind the shoulder of pediatric patients, position from ear to the sternal notch, use ramps

Placement with proof: Confirm correct endotracheal tube placement visually or through use of capnography or radiography

Post-intubation management: Maintain oxygenation, sedation, and pain control

83.

Which of the following signs and symptoms are classic of preeclampsia?

  • Hypertension, proteinuria, edema

  • Tachycardia, tachypnea, alkalosis

  • Hypotension, seizures, acidosis

  • Hemolysis, elevated liver enzymes, low platelets

Correct answer: Hypertension, proteinuria, edema

Preeclampsia is identified by the previous three signs. While the mechanism of why this occurs is not fully understood, the CFRN/CTRN should be aware that patients with these signs are pre-eclamptic and thus at risk for going into eclampsia which is defined by seizures. 

Tachycardia, tachypnea, and alkalosis are all normal physiological changes the mother goes through while pregnant. Seizures are not present in pre-eclamptic patients. Hemolysis, elevated liver enzymes, and low platelets are HELLP syndrome.

84.

While transporting a patient via medical air transport, you and your crew mates determine that the patient's condition has worsened and she required intubation. Using rapid sequence intubation (RSI), you quickly establish an airway and begin to inflate the endotracheal tube (ETT) cuff. Current recommendations on cuff pressure state:

  • No ideal cuff pressure has been defined

  • Inflate the cuff once it is situated 4 to 5 cm above the level of the carina

  • Inflate the cuff to 25 to 35 cm H2O pressure

  • Reassess cuff pressure once the aircraft has reached altitude

Correct answer: No ideal cuff pressure has been defined

Unless using the supraglottic airway (SGA) device the I-gel, both SGAs and endotracheal tubes (ETTs) require the use of an inflated cuff or balloon in keeping the emergency airway in place. The pressure placed on the surrounding tissues of the airway needs to be carefully managed, as even short periods of too high pressure can cause damage to the airway, including tracheal ischemia and fistula formation. Damage to the tracheal mucosa can begin in as little as 14 minutes when cuff pressure is too high.

No ideal cuff pressure has been definitively stated; current recommendations include inflating the cuff to between 20 to 30 cm H2O pressure, with 25 cm H2O being the standard inflation pressure. The ETT should be inserted until the tip of the tube sits 4 to 5 cm above the level of the carina. When transporting patients by air, cuff pressure should be reassessed during both takeoff and landing (ascent and descent), as cuff pressure will increase and decrease in response to the effects described in Boyle's gas law.

85.

You are a CFRN/CTRN caring for an adult patient with the following injuries; bilateral wrist injuries, calcaneus fractures, compression fractures to T12-L1. What do you suspect is the mechanism of injury?

  • A fall greater than 15 ft. 

  • Pedestrian hit by motor vehicle 

  • Head-on collision

  • Side-impact collision

Correct answer: A fall greater than 15 ft.

Adults tend to land on their feet in falls greater than 15 ft. This causes calcaneus (heel) fractures and spinal compression fractures typically seen in the T12-L1 region. Patients usually fall forward after landing on the ground and reach out their hands, causing the wrist fractures.

86.

Which of the following is/are complications associated with administering Fentanyl too rapidly or in too high of a dosage?

  • Chest wall rigidity

  • Hypertension

  • Malignant hyperthermia

  • Tachypnea

Correct answer: Chest wall rigidity 

The critical care transport provider should be mindful of the complication of chest wall rigidity when using fentanyl as a premedication in RSI. Chest wall rigidity can make ventilation impossible.

Administering Fentanyl does not cause malignant hyperthermia. Fentanyl can cause respiratory depression and hypotension when given in large enough doses. 

87.

The medical air transport team is providing care for a patient experiencing severe diabetic ketoacidosis (DKA). The patient is unconscious and must be transported to a level-one trauma center. Which of the following laboratory findings is indicative of this condition?

  • Bicarbonate <15 mmol/L

  • Serum glucose >300 mg/dL

  • Venous pH >7.3

  • Ketonuria

Correct answer: Bicarbonate <15 mmol/L

DKA is a serious complication of diabetes mellitus and an emergency condition that, if left untreated, can have life-threatening consequences. DKA remains the leading cause of morbidity and mortality in children with type I diabetes and is the leading cause of hospital admissions.

It typically presents with the classic triad of symptoms of polyuria, polydipsia, and weight loss with or without polyphagia. Abdominal pain, nausea, and vomiting are also common presenting symptoms. Late signs and symptoms result in mental status changes, leading to coma, Kussmaul respirations, and fruity sweet-smelling breath.

DKA occurs as a relative or absolute insulin deficiency and is diagnosed with ketonemia/ketonuria plus:

  • blood glucose greater than 200 mg/dL
  • venous pH less than 7.3
  • bicarbonate less than 15 mmol/L

88.

A Mallampati score of class II indicates which of the following?

  • The soft palate, uvula, and fauces are visible.

  • Only the base of the uvula and soft palate are visible.

  • The soft palate, uvula, fauces, and tonsillar pillars are visible.

  • Only the hard palate is visible.

Correct answer: The soft palate, uvula, and fauces are visible.

The Mallampati score describes the ability to see structures in the oropharynx. It is a simple scoring system that relates the amount of mouth opening to the size of the tongue and provides an estimate of space available for oral intubation by direct laryngoscopy (DL). Intubation is typically not difficult in class I (soft palate, uvula, fauces, and tonsillar pillars are visible) and II (the tonsillar pillars disappear, but the soft palate, uvula, and fauces are visible) airways. 

In a class III airway (only the soft palate and base of the uvula are visible), DL is predicted to be moderately difficult. In a class IV airway (where only the hard palate is visible), DL is unlikely to be successful. 

89.

The essential components of the Emergency Medical Transport and Active Labor Transport Act (EMTALA) include all the following, except: 

  • Facilities that provide higher levels of care must always accept a patient from a referring facility.

  • All patients who present to an ED must receive a nondiscriminatory medical screening.

  • A patient with a medical emergency must be stabilized within the capabilities of the transferring hospital. 

  • If a patient is transferred for further care, the referring hospital must send all copies of medical records. 

Correct answer: Facilities that provide higher levels of care must always accept a patient from a referring facility.

EMTALA furnishes guidelines, regulations, and penalties that govern patient transfer and transport. It requires all patients who present to an ED to receive a nondiscriminatory medical screening to determine whether a medical emergency is present. The referring facilities must stabilize the patient before transport to the best of their ability, and receiving facilities must have an accepting physician and a place for the patient before transport (they do not always have to accept the patient). 

Qualified medical personnel must determine and document that the transfer and transport benefits outweigh the risks of transport, and copies of medical records, diagnostic studies, and informed consent documents must be sent to the transfer hospital. 

90.

The medical air transport crew is traveling at altitude with a patient. All of the following statements about the risks associated with travel at altitude are true except:

  • Risk of injury due to weather is greatest when traveling at altitude

  • Your patient will be at increasing risk of hypothermia with increasing altitude until the tropopause is reached

  • Your patient will experience the greatest amount of pressure changes when the aircraft is closest to sea-level

  • Negative patient outcomes are greatest at cold, dry, high altitudes

Correct answer: Risk of injury due to weather is greatest when traveling at altitude

Every member of the medical air transport team is at risk of negative effects when traveling at altitude, and these risks are greatest when the team travels at cold, dry, high altitudes. As the greatest amount of pressure changes take place closest to sea-level, your patient is at increased risk of barotrauma injuries when traveling at or through low altitude. The risk of experiencing negative outcomes due to temperature change increases with an increase in the aircraft altitude, as temperature drops by 2 degrees Celsius with each 1,000 foot increase in elevation. Once the tropopause has been reached, temperature-related risks cease to increase with altitude; the tropopause is the point where temperature has reached its lowest possible point and then remains fixed at that level. 

Weather related concerns which can complicate air travel, posing risk of injury, occur at any altitude; crew members should always be prepared to encounter weather.

91.

An elderly male patient residing at a skilled nursing facility was found lying on the floor of his bedroom at the facility with a large contusion noted to the occipital area of his skull. Which of the following statements regarding the subdural hematoma in the elderly population is most accurate?

  • Cerebral atrophy may contribute to the delay in subdural hematoma symptom development in the elderly population

  • Symptoms of subdural hematoma typically develop rapidly in the elderly population even when the subdural hematoma is small

  • The presence of a subdural hematoma may be discovered in the elderly population due to retinal hemorrhaging

  • Even small subdural hematomas may cause the development of a shock-like state in the elderly population

Correct answer: Cerebral atrophy may contribute to the delay in subdural hematoma symptom development in the elderly population

Both the elderly and infants (and young children) are at an increased risk for the development of a subdural hematoma due to the fragility of the intracranial vessels. But while symptoms of subdural hematoma may develop quite rapidly in an infant and as a result of comparatively small hemorrhage, the elderly individual who sustains a larger subdural hematoma may demonstrate a delay in symptom manifestation due to cerebral atrophy. Cerebral atrophy lends itself to a gradual increase in the subdural space, allowing for greater blood loss into this area before symptoms become apparent. Infants who sustain subdural hematoma (often through shaken baby syndrome) will also often sustain retinal hemorrhaging and may succumb to a shock-like state as a result of large amounts of intracranial bleeding.

92.

In which of the following patients should a nasopharyngeal airway not be utilized?

  • A 27-year-old female with suspected head injury due to a fall

  • An 8-year-old male with severe stridor due to croup

  • A comatose 35-year-old pregnant female

  • A 71-year-old male with congestive heart failure

Correct answer: A 27-year-old female with suspected head injury due to a fall

The nasopharyngeal airway is an acceptable means of establishing and maintaining an airway in patients requiring one. If the patient's airway reflexes are intact, they may demonstrate considerable gagging, vomiting, or develop laryngospasm as a result of placing either a nasopharyngeal or oral airway. When placing a nasopharyngeal airway in a pediatric patient, care must be taken to ensure the appropriate sized airway is utilized, and that the airway is liberally lubricated prior to insertion attempts in order to prevent damage to potentially hypertrophied adenoids, and subsequently, bleeding into the airway. The nasopharyngeal airway may also be used in patients who are comatose or who are stuporous and who require only minimal assistance with airway maintenance. 

Nasopharyngeal airways should not be placed in patients who are suspected of having sustained head injury, or who have obvious facial trauma.

93.

What is considered to be the most dangerous component of a helicopter? 

  • The tail rotor 

  • The main rotor blades

  • The landing skids

  • The rotor mast

Correct answer: The tail rotor 

The most obvious component of the helicopter that presents a risk is the rotor system, and the tail rotor is potentially the most hazardous component of the helicopter. It becomes nearly invisible when in motion, with speeds greater than 2000 rpm. A safety person should be designated at all unsecured landing sites to ensure that no one inadvertently walks near the tail rotor. 

All individuals who approach the helicopter must do so in full view of the pilot and should not proceed under the rotor disk without the pilot's permission. The safety approach zone for most helicopters is from the sides (at the 3 o'clock or 9 o'clock position). 

94.

A 15-year-old male who completed a motorcycle education class and earned a legal license to drive a motorcycle in his state of residence was involved in a motorcycle crash, sustaining a handlebar fracture of both femurs. The medical transport crew called to assist at the scene of the crash should be prepared for significant blood loss as a result of single isolated femur fracture, in the amount of:

  • 1 liter to 2 liters

  • 500 mLs to 750 mLs

  • 250 mLs to 500 mLs

  • 1.5 liters to 3 liters

Correct answer: 1 liter to 2 liters

Isolated skeletal orthopedic injuries and fractures, while not typically considered an emergency, can result in the development of life-threatening complications due to the potential for significant blood loss and hemorrhage as a result of the injury. In addition, if adjacent organs or soft tissues are also injured in the trauma, the potential for significant injury, disability, and death goes up exponentially. And isolated skeletal fracture carries with it the risk of hemorrhage due to the vascular nature of the bone itself, as well as the potential for damage to the nearby vessels. 

Rib fractures can result in up to 125 mLs of blood loss, fractures of the forearm bones (radius and ulna) can result in a blood loss between 250 mLs to 500 mLs, bleeding from a humerus fracture can range between 500 mLs to 750 mLs, an isolated single femur fracture can result in a blood loss between 1 liter to 2 liters, and a pelvic fracture typically results blood loss greater than 1 liter. The transport crew responding to the scene of isolated skeletal fractures should be prepared to both assess for and manage signs of potential hemorrhage and prevent the development of hemorrhagic shock, in addition to managing the orthopedic injury.

95.

Which of the following is associated with Kehr’s sign?

  • Splenic rupture

  • Colon rupture

  • Bladder rupture 

  • Cardiac tamponade

Correct answer: Splenic rupture

Kehr’s sign is referred pain felt in the left shoulder. This pain is felt from blood filling the peritoneal cavity. Out of the answers provided, only a splenic rupture would cause significant amounts of blood in the peritoneum.

96.

The medical transport team is transporting an adult patient who sustained burns as a result of a chemical explosion at the plant where he was employed. As part of the medical crew, you are attempting to estimate the depth of his thermal burns and know that all of the following components play into determination of depth of a thermal burn, except:

  • The anatomical site which was contacted by the burning agent

  • The temperature of the burning agent which contacted the patient

  • The duration of time the patient was exposed to the burning agent

  • The conduction ability of the patient's tissue

Correct answer: The anatomical site which was contacted by the burning agent

Estimations of burn depth and extent are made through use of the "rule of nines" and the Lund and Browder burn chart for calculating the percentage of burned body surface area. Pediatric burn assessment is most accurately completed by use of the Lund and Browder method, while burns on adult patients may be accurately estimated using either method. Three major factors play a role in determination of the depth of a thermal burn. These include the temperature of the burning agent with which the patient was in contact; the length or duration of time the patient was exposed to the burning agent; and the conductive ability of the tissue which came into contact with the burning agent. The medical transport provider will be unlikely to establish an accurate estimate of the true extent (depth) of the burn injuries sustained by the patient during transport.

97.

The medical transport team is preparing to retrieve a patient experiencing thyroid storm for air transport. The patient appears agitated, is talking incoherently, and abruptly stops talking at times and starts another topic, and her skin is hot and dry. Which of the following disorders may a patient experiencing thyroid storm be erroneously diagnosed with due to overlapping symptoms?

  • Psychosis

  • Neuroleptic malignant syndrome

  • Sepsis

  • Anxiety

Correct answer: Psychosis

When patients who experience thyroid storm, a severe, potentially life-threatening complication of hyperthyroidism (or thyrotoxicosis), present for emergency care, their symptoms are frequently mistaken for those of psychosis (or an acute mania), causing a delay in appropriate treatment. Many of the symptoms of thyroid storm are neurological in nature due to the intrinsic role the thyroid hormones play in supporting healthy nervous system function. Patients experiencing thyroid storm often present with symptoms of confusion, anxiety, agitation, talking incoherently, tremor or disorders of movement, among others. Non-neurological symptoms include hot, dry skin, complaint of palpitations, weight loss, exophthalmos, tachycardia or tachydysrhythmias, hyperthermia, and signs of heart failure.

98.

What is the most common type of shock experienced by children?

  • Hypovolemic

  • Distributive

  • Cardiogenic

  • Obstructive 

Correct answer: Hypovolemic

Hypovolemic shock is the most commonly experienced type of shock in children; it develops when the intravascular volume is insufficient to maintain tissue perfusion. The decrease in intravascular volume results in a decreased preload, which decreases cardiac output, leading to an increase in SVR and increased capillary refill. 

Sources of volume loss include vomiting; diarrhea; osmotic diuresis; capillary leak from sepsis; and intraabdominal processes with third space losses such as pancreatitis, intussusception, appendicitis, burn injuries, hemorrhage, inadequate fluid intake, or insensible losses. 

99.

A patient with Mallory-Weiss syndrome is being packaged for transport from the referring facility. All of the following potential complications of Mallory-Weiss syndrome may occur as a direct result of medical air transport, except:

  • Mediastinitis

  • Gastric pneumonitis

  • Hemopneumothorax

  • Alterations in gas exchange

Correct answer: Mediastinitis

Mallory-Weiss syndrome, while dangerous due to the nature of esophageal rupture and subsequent bleeding, is typically not considered to be life-threatening, and often may resolve without intervention. If bleeding does not resolve spontaneously, the esophageal rupture should be managed in the same manner as esophageal varices. Mediastinitis may occur as a result of leaking of gastric contents into the chest cavity. With medical air transport, as a result of altitude pressure changes, patients may also experience complications such as gastric pneumonitis, hemopneumothorax, and alterations in gas exchange.

100.

You are caring for a pregnant woman who was involved in a motor vehicle accident. The sending facility drew labs and determined that the patient's blood type was A negative. What medication should you administer?

  • Rhogam

  • Type O positive blood

  • Pitocin

  • Steroids

Correct answer: Rhogam

Rhogam is always administered to Rh negative mothers who are either at 28 weeks gestation or have suffered traumatic injury suspected to cause bleeding. Rhogam is given to prevent the mother from producing Rh antibodies in the event the infant is Rh positive. If the mother develops antibodies, Hemolytic Disease of the Newborn occurs.

Type O positive blood is contraindicated due to the mother being Rh negative. Pitocin is used to either induce labor or to help stop postpartum bleeding. Steroids are used to promote fetal lung development. 

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