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Quiz Session - Attempts With Random Questions

NREMT Paramedic 1.4.12 Exam Questions

Page 6 of 60

101.

The pre-hospital pharmacological treatment of head injury with increased intracranial pressure is controversial. However, some medical control physicians may recommend the administration of which of the following medications to decrease cerebral edema?

  • Mannitol

  • Lidocaine

  • Lorazepam

  • Furosemide

Correct answer: Mannitol

A drug that may be ordered by medical direction to decrease cerebral edema or Decrease Intracranial Pressure (ICP) may include mannitol.

Lidocaine may be effective in reducing ICP during intubation of a patient with a closed head injury but is not considered an appropriate drug to reduce cerebral edema or circulating blood volume. 

Lorazepam and diazepam are benzodiazepines that may help prevent seizures associated with head injury and increased ICP. However, they would not be considered when attempting to reduce cerebral edema or circulating blood volume to reduce intracranial pressure. 

Furosemide is a loop diuretic and indicated for edema.

102.

Your patient has sustained a possible tib/fib fracture. The injury site is deformed with evidence of bruising and swelling. How much blood could be lost internally, if a closed tib/fib fracture is present?

  • 250 to 500 mL

  • 150 to 250 mL

  • 1,000 to 1,500 mL

  • Over 2,000 mL

Correct answer: 250 to 500 mL

It is possible for a patient suffering a closed tib/fib fracture to lose as much as 250 to 500 mL of blood in the compartment around the bone. This is an adequate amount to cause hypovolemia to occur in some patients.

It is more likely that a closed radius fracture would lose approximately 150 to 250 mL of blood. 1,000 to 1,500 mL would be more likely in a closed femur fracture, abdominal injury, or chest injury. A hemorrhage of over 2,000 mL would likely cause death and could only occur in an abdominal or chest injury with major hemorrhage.

103.

You are on scene with a patient in respiratory arrest. After intubating the patient using the endotracheal route, you note the presence of adequate breath sounds on the right side, but you auscultate decreased breath sounds on the left side of the patient's chest.

What should you do at this point in the intervention?

  • Deflate the cuff, pull the ET tube back 2-3 cm, re-inflate the cuff, and reassess breath sounds for presence and quality

  • Deflate the cuff, pull the ET tube out completely, assess the tube for defects, and reattempt visualized intubation with a new tube if needed

  • Deflate the cuff, advance the ET tube 1-2 cm, reinflate the cuff, and reassess breath sounds for presence and quality

  • Inflate the cuff with another 10 mL of air to ensure the cuff does not allow the air to leak around the tube and trachea, reassess breath sounds

Correct answer: Deflate the cuff, pull the ET tube back 2-3 cm, re-inflate the cuff, and reassess breath sounds for presence and quality

If breath sounds are decreased in the left lung compared to the right lung after intubating the patient, it is more than likely caused by the ET tube being advanced too far. This normally causes the tube to end up in the right mainstem bronchus due to its natural slope. The best intervention is to deflate the cuff, pull the ET tube back 2-3 cm, re-inflate the cuff, and reassess breath sounds for presence and quality. If the breath sounds are clear and equal, continue confirmation techniques before securing the tube and beginning ventilations.

It would not be appropriate to deflate the cuff and pull the ET tube out completely if there were breath sounds present in the right lung, and you witnessed the tube passing the vocal cords when it was inserted initially. The presence of right lung sounds indicates the tube is in the right place; it has just been advanced a little too far. 

Never deflate the cuff on an ET tube and advance it further into the lung when right lung sounds are present, but left lung breath sounds are diminished. The unequal breath sounds are likely caused by the tube being advanced too far in the first place. 

It is never appropriate to add more than 10 mL of air to the cuff of an adult ET tube. It could cause the cuff to rupture and become ineffective as a seal, or it could cause tissue necrosis around the site of the balloon cuff.

104.

What is the best airway adjunct to quickly establish a clear means of air entry for a spontaneously breathing patient who has an intact gag reflex?

  • A nasopharyngeal airway (NPA)

  • An oropharyngeal airway (OPA)

  • A laryngeal mask airway (LMA)

  • An esophageal-tracheal Combitube

Correct answer: A nasopharyngeal airway (NPA)

A NasoPharyngeal Airway (NPA) is the least invasive airway adjunct. It does not truly help maintain or establish an open airway, but it does keep a clear passage for air to the hypopharynx. It is useful in conscious or unconscious patients with an intact gag reflex. It is also useful if the patient will possibly require a nasogastric tube inserted. An NPA is the only airway adjunct that does not irritate a patient's gag reflex if it is still intact regardless of whether the patient is conscious.

OroPharyngeal Airways (OPA) are useful in unconscious patients or patients in cardiac arrest to help keep the patient's tongue out of the hypopharynx. However, they are not indicated for conscious patients because most conscious patients will have an active gag reflex. 

For an Laryngeal Mask Airway (LMA) to be indicated, the patient must be unresponsive without an active gag reflex. It is often indicated when intubation is needed, but access to the patient or a possible spinal cord injury prevents successful intubation. LMAs are considered supra-glottic airways. 

A Combitube is often used for patients who require ventilatory assistance and airway control. It has two tubes that enter both the esophagus and trachea. Combitube is indicated when intubation is needed but difficult or impossible. However, like most advanced airway control devices, the patient must be unconscious/unresponsive with an absent gag reflex.

105.

You are called to assist a patient who may be experiencing an allergic reaction. On arrival, the patient complains of severe itching with angioedema and shortness of breath but denies the feeling of his tongue or airway swelling. Which of the following medication types would be indicated to improve the patient's alveolar ventilation?

  • Beta-agonists such as albuterol

  • Antihistamines such as diphenhydramine

  • Corticosteroids such as methylprednisolone

  • Antiarrhythmics such as amiodarone

Correct answer: Beta-agonists such as albuterol

During an allergic reaction or anaphylaxis, it is appropriate to administer a beta-agonist, such as albuterol, in an attempt to reverse the bronchospasm and increase the patient's alveolar ventilation.

Antihistamines are given during an allergic reaction or anaphylaxis in an attempt to block the adverse effects of histamine; they are not capable of increasing alveolar ventilation. Corticosteroids are given during an allergic reaction or anaphylaxis in an attempt to reduce the inflammation associated with the reaction. They do not improve alveolar ventilation. Antiarrhythmics are given during an allergic reaction, such as anaphylaxis when cardiac arrhythmias are present due to the reaction. They do not improve alveolar ventilation.

106.

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.

107.

Which of the following is true regarding atrial flutter?

  • The atrial rate will be between 250 and 360

  • P waves are still present

  • PR intervals are shorter

  • The ventricular rate will be between 100-200

Correct answer: The atrial rate will be between 250 and 360 

Atrial flutter is a rhythm that occurs when the atrium fires so rapidly that a fluttery pattern is produced instead of P waves. In atrial flutter, the ventricular rate depends on the conduction ratio, while the atrial rate stays about 250-360 beats per minute. P waves are replaced by fluttery waves, and there are no PR intervals present.

108.

Your patient is currently complaining of lightheadedness and chest palpitations. You hook him up to a 12 lead EKG and see this rhythm. You prepare for which of the following?

  • Cardioversion

  • Defibrillation

  • Cath lab

  • CPR

Correct answer: Cardioversion 

The rhythm pictured is atrial fibrillation which, depending on patient symptoms, can be reversed with cardioversion.

109.

Scene

Which of the following treatments should be performed on scene for the patient in this scenario?

Select the 3 answer options which are correct.

  • Use tepid water to actively cool the patient

  • Administer IV fluid

  • Place an ECG monitor

  • Use ice water to actively cool the patient

  • Administer a vasopressor if hypotension develops

  • Administer a sports drink such as Gatorade

This patient is exhibiting signs and symptoms of heatstroke. Management on scene should include ECG monitoring, the administration of IV fluids, and the use of tepid water or cool packs to cool the patient.

Refrain from using ice water or over cooling the patient as this can cause shivering, which will worsen the condition. Do not give oral fluids to patients with altered mental status. Avoid vasopressors and anticholinergic drugs in patients with heat emergencies. These drugs can inhibit sweating, and produce a hyper-metabolic state in the presence of high environmental temperatures.

110.

What is a painful facial fracture that runs across the face, just below the nose but above the teeth, and presents with epistaxis?

  • Le Fort I fracture

  • Le Fort II fracture

  • Le Fort III fracture

  • Le Fort IV fracture

Correct answer: Le Fort I fracture

A Le Fort I fracture is located on the lower portion of the face. It is usually below the nostrils and above the mouth. It can cause significant signs and symptoms such as epistaxis, pain, and the classic lengthening of the face called donkey face.

A Le Fort II fracture is more dangerous than a Le Fort I fracture. It is characterized by the presence of a fracture line that runs from the mandibular joint laterally across the bridge of the nose to the opposite mandibular joint area. 

A Le Fort III fracture is the worst facial fracture. It runs laterally across the face through both eye sockets and temporal bones. 

There is no classification titled Le Fort IV fracture.

111.

Which of the following airway procedures are contraindicated for use when a patient has a potential basilar skull fracture?

  • Nasotracheal intubation

  • Orotracheal intubation

  • Laryngeal mask airway (LMA)

  • Optical intubation

Correct answer: Nasotracheal intubation

Nasotracheal intubation is contraindicated in patients who are apneic, who have midface or nasal fractures, or who are suspected of having a basilar skull fracture. The fracture may allow the tip to enter the cranial vault.

Orotracheal intubation is the approved route of intubation when patients with suspected basilar skull fracture need definitive airway control. Caution should be used and ventilation kept at a slow, even rate. Hyperventilating the patient can worsen the cerebral edema while hyperoxygenation can reduce edema. 

A  Laryngeal Mask Airway (LMA) is approved for advanced airway control when orotracheal intubation cannot be accomplished after two attempts. It is safe to use on patients who have potential head injuries when proper stabilization is provided. 

Optical intubation is the premier method of intubation. It uses video and cameras to optimize visualization of the cords and tube passing through them. It is safe for the orotracheal intubation of basilar skull fracture patients, but its use in the pre-hospital setting is still very rare.

112.

What is the difference between wandering atrial pacemaker and multifocal atrial tachycardia?

  • Heart rate

  • Heart rhythm

  • The shape of the P waves

  • The shape of the QRS complexes

Correct answer: Heart rate

Wandering atrial pacemaker (WAP) and multifocal atrial tachycardia (MAT) are both atrial rhythms with inconsistent P waves and irregular rhythms. The difference is the heart rate; WAP fires at a slower rate, while MAT fires at a rapid rate.

113.

Which of the following is true regarding premature ventricular contractions (PVCs)?

  • It is a regular but interrupted rhythm

  • It only occurs at a rate above 150

  • It contains wide, bizarre P waves

  • The PR interval is greater than  0.12 seconds

Correct answer: It is a regular but interrupted rhythm 

Premature ventricular contractions are regular but interrupted rhythms. They can occur at any rate and contain no P waves or PR interval. They contain wide, bizarre QRS complexes that are greater than 0.12 seconds.

114.

Select the correct cardiac conduction pathway:

  • Sinus node → interatrial tracts → atrium → internodal tracts → AV node → bundle of His → bundle branches → Perkunje fibers → ventricle

  • Sinus node → internodal tracts → atrium → interatrial tracts → AV node → Bundle of His → bundle branches → Perkunje fibers → ventricle

  • Sinus node → interatrial tracts → atrium → internodal tracts → AV node → Perkunje Fibers → bundle branches → Bundle of His → ventricle

  • Ventricle → interatrial tracts → atrium → internodal tracts → AV node → bundle of His → bundle branches → Perkunje fibers → sinus node

Correct answer: Sinus node → interarterial tracts → atrium → internodal tracts → AV node → bundle of His → bundle branches → Perkunje fibers → ventricle

 Above is the correct pathway of electrical conduction through the heart. 

115.

While applying direct pressure to a right mid-thigh injury with profuse bleeding, your initial bulky dressing becomes soaked with blood. Which of the following should you do at this point?

  • Apply a tourniquet above the level of the bleeding and place a clean, dry dressing on top of the blood-soaked dressing

  • Replace the blood-soaked dressing with a clean, dry dressing, and apply a pressure dressing

  • Remove the blood-soaked dressing, and apply a tourniquet to the right upper thigh, tightening until the bleeding stops

  • Place a tourniquet directly over the blood-soaked dressing, and tighten until the bleeding stops

Correct answer: Apply a tourniquet above the level of the bleeding and place a clean, dry dressing on top of the blood-soaked dressing

Profuse bleeding that involves major arteries can be difficult to control. The first attempt to control the bleeding is to apply direct pressure with a clean, dry, bulky dressing. If the dressing becomes blood-soaked, apply a tourniquet. EMS providers may go straight to the use of a tourniquet for severe arterial bleeding.

Once direct pressure is applied, it cannot be released until it is under control. Never replace a blood-soaked dressing with a clean dressing. It will disrupt the clotting process that is likely beginning. Simply place the clean dressing over the old one while continuing pressure. Never remove a blood-soaked dressing once it is applied, even if a tourniquet is to be applied within proximity to the dressing. It is not considered appropriate to apply a tourniquet directly over the wound itself.

116.

You are on-scene with a 55-year-old cardiac history patient who suddenly collapsed during dinner with her family. She is found to be pulseless and apneic with her family performing adequate CPR on arrival. Her husband is distraught and hands you a legal DNR order signed by her physician. He states that she does not have a terminal illness and begs you to ignore the legal order and "do everything in your capabilities to save her!"

Which of the following would be most appropriate in this situation?

  • Abide by the DNR and contact medical control immediately

  • Provide palliative care only and transport

  • Advise the family to stop CPR and to leave the room

  • Take over CPR until you reach the ambulance, then stop all resuscitation efforts as per the legal order

Correct answer: Abide by the DNR and contact medical control immediately

In some situations, the family members may disagree with the DNR order and insist that you begin resuscitation. In these situations, avoid any hostile encounters while carrying out the patient's wishes to the best of your ability. Contact medical control in confusing situations involving resuscitation questions. The medical control physician can be a valuable resource in this situation.

The 2020 American Heart Association (AHA) guidelines recommend all EMS providers do not initiate resuscitation of any patient in the following scenarios:

  • Situations where attempts to perform CPR would place the rescuer at risk of serious injury or mortal peril
  • Overt clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, decomposition)
  • A valid advanced directive, a Physician Order for Life-Sustaining Treatment (POLST) form indicating that resuscitation is not desired, or a valid Do Not Attempt Resuscitation (DNAR) order

Palliative care is only indicated in DNR patients who are not in cardiac arrest. The DNR order does not give EMS permission to simply "walk away" and do nothing for the patient. 

It is important not to be deceptive with the patient's family. You must be honest and provide the facts. Do not ask them to leave the room during this time. The medical control physician may want to speak to the spouse.

Do not take over CPR and then cease resuscitation efforts once in the ambulance. This is dishonest and unethical.

Nationally, most EMS agencies have protocols in place that are in line with the American Heart Association (AHA), the National Association of EMS Physicians (NAEMSP), the American College of Surgeons (ACS), and the American College of Emergency Physicians (ACEP) guidelines. 

117.

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.

118.

You are called to assist a twenty-three-year-old patient complaining of nausea and vomiting. On arrival, the patient reports that they became nauseated and then began vomiting after the sudden onset of lower abdominal pain earlier in the day. The patient states the pain is now in the lower right abdominal quadrant and worsening and rates the pain at ten on the pain scale. The patient's skin is somewhat hot and dry but pale.

Which of the following abdominal conditions is most likely to cause these signs and symptoms?

  • Appendicitis

  • Peritonitis

  • Cholecystitis

  • Pancreatitis

Correct answer: Appendicitis

Appendicitis patients often report the presence of sudden onset lower abdominal pain that usually (but not always) begins with gradual onset and moves to the right lower quadrant once the severe pain begins. Nausea and vomiting are often present and begins when the pain intensifies.

Peritonitis pain normally involves the entire epigastric region. The pain is often diffuse and severe. It is not often related to the right lower quadrant and pain that can be pinpointed to a specific region. 

Cholecystitis presents with severe, unrelenting pain in the right upper quadrant of the abdomen. 

Pancreatitis normally presents with dramatic sudden onset in the right upper quadrant of the abdomen.

119.

Which of the following ECG leads are considered lateral leads?

  • V6

  • V1

  • V3

  • V4

Correct answer: V6

Lateral leads include leads I, V5, and V6. Leads V1 and V2 are septal, and V3 and V4 are anterior leads.

120.

Your unconscious closed head injury patient presents with a widened pulse pressure and bradycardia. Her pupils are sluggish to react, and she is exhibiting abnormal extension posturing. Her signs and symptoms lead you to believe she is experiencing increased intracranial pressure from the injury.

What area of the brain is most likely impacted by the increase in pressure?

  • Midbrain

  • Cortex

  • Pons

  • Upper brainstem 

Correct answer: Midbrain

Patients with increased intracranial pressure at the level of the middle brainstem will likely present with a widened pulse pressure, bradycardia, and abnormal posturing (extension).

Patients with increased intracranial pressure at the level of the cortex and Pons, or upper brainstem, often present with an increase in BP while the pulse rate falls, and Cheyne-Stokes respirations may be present. The patient will likely withdraw from pain at this point. 

Patients who have an increased intracranial pressure at the level of the medulla will likely present with blown pupils, ataxic respirations, irregular pulse, and fluctuating blood pressure. They are not likely to survive.

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