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Quiz Session - Attempts With Random Questions

NREMT Paramedic 1.4.12 Exam Questions

Page 8 of 60

141.

Determining the electrical axis on a 12-lead ECG can be accomplished using the QRS direction of which two leads?

Select the 2 answer options which are correct.

  • Lead I

  • aVF

  • V1 

  • aVL

A fast and easy way to determine the electrical axis is to use the direction of the QRS complex in leads I and aVF. These two leads are used because they are the only perfectly horizontal and vertical leads, respectively.

V1 and aVL are not used to determine the electrical axis on a 12-lead ECG using the QRS direction.

142.

Which of the following are unpredictable situations that may not be planned for ahead of time while responding to an emergency call?

Select the two answer options which are correct.

  • Inclement weather

  • Stalled vehicles

  • Heavy commuter traffic

  • Blocked train crossings

It is important to become familiar with traffic patterns and roads in your response area in order to plan your response routes to emergency calls, or transport routes to hospitals. Heavy commuter traffic times and railroad crossings can be predicted based on known traffic patterns and train schedules in the response area and can be planned for ahead of time.

It is difficult to plan response routes based on inclement weather or stalled vehicles because these are unpredictable situations.

143.

After intubating your adult patient, you quickly auscultate decreased breath sounds on the left side and breath sounds on the right are clear. Which of the following is most likely to cause this to occur?

  • A right mainstem intubation

  • A left mainstem intubation

  • Tip of the tube against the carina

  • The patient is elderly and likely suffered a pneumothorax during the event

Correct answer: A right mainstem intubation

When an endotracheal tube is advanced too far into the trachea, it will most likely end up in the right mainstem bronchus in adults. This is because of the natural slope involved in the branching of the two main bronchi. This becomes evident when initial breath sounds reveal unequal breath sounds and expansion. The patient can be expected to have decreased breath sounds on the left side of the chest due to the blocking of air entering the lung by the ET tube itself. The patient will have right-sided breath sounds with adequate expansion due to the tube directly ventilating the right lung only.

The tip of endotracheal tubes does not normally end up in the left mainstem bronchus when the tube is initially advanced too far during intubation, but it is possible. The key finding in the event of a left mainstem bronchus intubation is decreased breath sounds on the right side and adequate breath sounds with normal or hyper-expansion on the left side of the chest.

If the tip of the tube is advanced to the point of lying against the carina of the lungs, the patient would most likely present with equal but diminished breath sounds. The key finding is a patient that is hard to bag after intubation with a tube that may be advanced past the 23-cm mark. 

It is not appropriate to initially assume that your newly-intubated patient suffered a pneumothorax during the intubation. Training tells us to confirm the proper placement of an ET tube after intubation as well as any time the patient is moved. Diminished breath sounds should quickly point the paramedic to the probability of a mainstem intubation.

144.

You are on-scene with a 19-year-old who witnesses state began seizing about 15 minutes prior with only one break in the seizure, lasting about 30 seconds. The patient is currently seizing again, making intravenous access virtually impossible at present. However, MCP orders you to administer a benzodiazepine to help suppress the spread of the seizure's focus.

Which of the following medications would be most appropriate in this case?

  • Lorazepam

  • Oxazepam

  • Zolpidem

  • Alprazolam

Correct answer: Lorazepam

The pre-hospital treatment of a patient experiencing a seizure disorder involves stopping the seizure activity by administering anti-convulsant medications. Currently, most MCPs around the country prefer to order benzodiazepines to combat seizure activity in the field. The recommended medications include lorazepam, diazepam, and midazolam; the preferred route is IV. However, when an IV is not possible, lorazepam can be safely administered IM (class IIa). Diazepam and midazolam should be administered IV in the field.

Oxazepam can be administered IV or rectally in the pre-hospital setting. IM administration should not be attempted in the pre-hospital setting. Lorazepam is preferred due to its longer action and its ability to be administered IM if needed. 

Zolpidem is a sedative-hypnotic medication often prescribed for sleep. It is not an effective anticonvulsant medication nor is it a benzodiazepine that can be administered intramuscularly. 

Alprazolam (Xanax) is used to treat panic and anxiety disorders. It is not effective to treat seizure disorders in the pre-hospital environment.

145.

You are on-scene with a cardiac patient who recently had a pacemaker implanted in her chest. It is intended to help produce a myocardial contraction when her heart rate falls below a preset rate. Once on the electrocardiogram, you note the presence of a pacer spike that precedes each QRS complex.

What type of pacemaker do you believe is being utilized in this case?

  • A ventricular demand pacemaker

  • A fixed rate or asynchronous pacemaker

  • An atrial and ventricular demand pacemaker

  • An atrial synchronous ventricular pacemaker

Correct answer: A ventricular demand pacemaker

A pacemaker designed to fire when the patient's own heart rate falls below a preset limit is known as a demand pacemaker. There are different types of demand pacemakers depending on the impulse needed. When a pacemaker spike is present and precedes a QRS complex, it is called a ventricular demand pacemaker. If each spike produces a QRS complex, it has mechanical capture and is initiating a viable myocardial contraction.

A fixed rate or asynchronous pacemaker is seldom used today, but they are still in use in many patients who had them implanted years ago. So it is important for the paramedic to recognize the possibility when pacemaker spikes are present and equal regardless of capture, whether they elicit a complex and contraction. They are not likely to produce pacer spikes that precede each QRS complex as seen with a demand ventricular pacemaker. 

An atrial and ventricular demand pacemaker would produce both an atrial and ventricular pacer spike when it detects the need for an impulse. Therefore, there would be two pacer spikes per QRS complex when the need arises. 

An atrial synchronous ventricular pacemaker paces both chambers at the same time to provide an atrial kick. There would not be a single pacer spike for each QRS complex when the pacer detects the need for an impulse.

146.

 Which of the following are contraindications for using a supraglottic airway such as a King LT or LMA?

Select the three correct answer choices.

  • The patient has a gag reflex

  • The patient has known esophageal disease

  • The patient has ingested a caustic substance

  • Intubation attempts have failed

  • The patient is apneic

Having an intact gag reflex or known esophageal disease are contraindications for all supraglottic airway devices. Ingestion of caustic substances is also a known contraindication of King Airways.

An apneic patient or failed intubation are indications for using a supraglottic device such as a King LT (laryngeal tube) or LMA (laryngeal mask airway).

147.

Identify the following rhythm.

  • Sinus bradycardia

  • Normal sinus rhythm

  • Type 1 AV block

  • Atrial flutter

Correct answer: Sinus bradycardia 

The rhythm pictured is sinus bradycardia, or a sinus rhythm that is less than 60 bpm. It is slower than normal sinus rhythm, which has a rate of 60-100.

A type 1 AV block is an arrhythmia that affects the PR interval. Atrial flutter is an arrhythmia that will show a fluttery pattern instead of P waves. Bradycardia is considered a sinus rhythm that is slower than normal.

148.

Your adult trauma patient has sustained a blunt force injury to the lateral aspect of their neck when they were struck by a baseball bat. The patient is conscious and alert, denies loss of consciousness and dyspnea. The patient's vitals are within normal limits, and there are no other obvious injuries. The patient is breathing well, and there are no signs of deformity, airway swelling, or compromise. The only obvious injury is that the patient has a large hematoma over the injury site, leading you to suspect a venous injury may be present.

Why is it important to transport the patient supine or in the slight Trendelenburg position?

  • To potentially prevent pulmonary embolus from occurring

  • To prevent hypotension from occurring

  • To prevent a pneumothorax from occurring

  • To prevent the hematoma from spreading

Correct answer: To potentially prevent pulmonary embolus from occurring

It is important for a paramedic to transport any patient, who has sustained a blunt force injury to the neck, with full Spinal Motion Restriction (SMR) due to the mechanism of injury alone regardless if the patient denies neck or back pain. In this case, the patient has a venous injury to the neck capable of causing an embolus to form and enter the general circulation. From there, it can pass through the heart and end up in the lungs, forming a pulmonary embolus. Transporting the patient supine or with the legs slightly elevated will help potentially prevent the formation of an embolus from the injury.

The supine or slight Trendelenburg position is not the position of choice for trying to prevent worsening hypotension. To help prevent hypotension, the paramedic would utilize the full Trendelenburg position. In this case, there is no reason to assume hypotension may occur. 

Transporting this patient in the slight Trendelenburg or supine position will not prevent a pneumothorax from occurring or prevent the spread of the hematoma.

149.

Using the Hs and Ts mnemonic helps paramedics remember possible reversible causes of cardiac arrest in adult patients. All the following are included in the Hs and Ts mnemonic except:

  • Hyperthermia

  • Tension pneumothorax

  • Hypovolemia

  • Thrombosis

Correct answer: Hyperthermia 

The Hs and Ts include:

  • Hypovolemia
  • Hypoxia
  • Hydrogen ion (acidosis)
  • Hypo/hyperkalemia
  • Hypothermia
  • Tension pneumothorax
  • Tamponade (cardiac)
  • Toxins
  • Thrombosis

150.

Which great vessel returns deoxygenated blood to the right atrium from the upper body?

  • Superior vena cava

  • Inferior vena cava

  • Aorta

  • Pulmonary artery

Correct answer: Superior vena cava 

The superior vena cava is the great vessel that returns deoxygenated blood to the heart. It transports blood from the head, neck, upper chest and arms.

The inferior vena cava transports deoxygenated blood from the lower half of the body. The pulmonary artery carries deoxygenated blood to the lungs from the right ventricle. The aorta carries oxygenated blood to the systemic circulation from the left ventricle. 

151.

You are preparing to initiate rapid sequence intubation on a pediatric patient who is exhibiting a borderline hypotensive state. Which medication would be indicated as the first paralytic given, following sedation of the patient for the procedure?

  • Succinylcholine

  • Ketamine

  • Lidocaine

  • Atropine

Correct answer: Succinylcholine

Succinylcholine is a powerful paralytic usually administered as the first medication following sedation to paralyze the conscious patient's airway and gag reflex to make intubating the patient possible without a laryngeal spasm.

Ketamine is a sedative often used to sedate patients who are about to be intubated. It is often the medication of choice when the patient’s blood pressure may be lower than normal, as it achieves sedation without lowering the blood pressure. 

Lidocaine is not a paralytic agent; it is given during rapid sequence intubation to help prevent an increase in intracranial pressure. 

Atropine is not a paralytic but is administered in some cases before the administration of a paralytic or neuromuscular blocking agent to prevent bradycardia.

152.

All the following are indications that artificial ventilation is adequate except: 

  • ETCO2 levels are above 45 cm/H2O

  • The pulse returns to a normal rate

  • Adequate chest rise and fall

  • SpO2 rises from 88% to 94%

Correct answer: ETCO2 levels are above 45 cm/H2O

ETCO2 levels can be an indicator of adequate ventilations. Normal ETCO2 levels are 35–45 cm/H20, so a level above 45 would most likely indicate that ventilations are not adequate. 

Artificial ventilations are indicated for a patient with insufficient breathing. Using a bag-valve mask is the most effective way to deliver artifical ventilations. Indications that ventilations are effective include adequate chest rise and fall, oxygen saturation level increases, and the pulse returning to a normal rate. Another indication would be if lung sounds can be auscultated during ventilations. 

153.

Which of the following would not increase the FiO2 level on a non-breathing, ventilated patient?

Select the 3 answer options which are correct.

  • Increase the rate of ventilation

  • Decrease expiratory time

  • Decrease respiratory rate

  • Increase oxygen flow rate

Changing the ventilation rate, inspiratory time, or expiratory time will not affect the FiO2.

FiO2 levels stands for Fraction of Inspired Oxygen. The most effective way to increase the amount of oxygen inspired is to increase the oxygen flow rate on a ventilator. If you need to increase oxygen saturation on a ventilated patient, increasing the FiO2 may be necessary.

154.

Which of the following is true regarding hip dislocations? 

Select the two answer options which are correct.

  • Most hip dislocations involve posterior dislocation

  • The leg on the affected side of a posterior hip dislocation will be shortened and internally rotated

  • The leg on the affected side of a posterior hip dislocation will be lengthened and externally rotated.

  • Most hip dislocations involve anterior dislocation

Over 90% of all hip dislocations involve posterior dislocation. The leg on the affected side of a posterior hip dislocation is typically found in flexion, internally rotated, and noticeably shorter.  

The leg on the affected side of an anterior hip dislocation usually presents abducted and externally rotated.

155.

You are treating a 32-year-old patient that presents with chest pain, altered mental status, and hypotension. The cardiac monitor reveals a polymorphic wide complex tachycardia. Which of the following would be the most appropriate initial treatment?

  • Unsynchronized high-energy shock

  • Synchronized cardioversion at 100 joules (monophasic)

  • Unsynchronized cardioversion at 50 joules (monophasic)

  •  Synchronized low-energy shock

Correct answer: Unsynchronized high-energy shock

Patients who present with a polymorphic wide complex tachycardia, such as Torsades de Pointes, will usually not permit synchronization. Treat as VF with high-energy unsynchronized shocks (defibrillation doses). For dosing, follow your specific device’s recommended energy level to maximize the success of the first shock.

Synchronized cardioversion at 100 joules (monophasic) is recommended for regular wide complex tachycardias.

Unsynchronized cardioversion at 50 joules (monophasic) is not recommended for regular narrow complex tachycardias or irregular wide complex tachycardias.

A low-energy unsynchronized shock is not recommended for polymorphic wide complex tachycardia. It would be recommended for regular, stable, narrow complex tachycardia.

156.

Identify the artifact.

  • Failure to fire

  • Loss of capture

  • Oversensing

  • Undersensing

Correct answer: Failure to fire

This artifact is failure to fire, evidenced by the lack of pacemaker spikes and QRS complexes.

Oversensing is a cause of failure to fire, not an artifact itself.

157.

Identify the rhythm.

  • Ventricular pacing

  • Atrial pacing

  • Dual chamber pacing

  • Cardioversion

Correct answer: Ventricular pacing

The rhythm is being depolarized by a ventricular pacemaker, as evidenced by the spike followed by the wide QRS complex.

In atrial pacing, a spike precedes a P wave. Both of these spikes occur in dual chamber pacing. Cardioversion is used when a patient is in acute atrial flutter/atrial fibrillation.

158.

Post-Scene

Which of the following medications will be used to manage the patient in this scenario during transport to the hospital?

  • Epinephrine

  • Sodium bicarbonate

  • Lidocaine

  • Atropine

Correct answer: Epinephrine

This patient is in a non-shockable rhythm, for which epinephrine is indicated.

Sodium bicarbonate might be administered if severe metabolic acidosis is present, but it's typically not routinely given and should be used cautiously. There is no indication it should be used for this patient. Lidocaine is used in the treatment of ventricular fibrillation or pulseless ventricular tachycardia. It is not indicated for the patient in this scenario, who is in a PEA rhythm. Atropine is indicated for bradycardia but is not used in cardiac arrest.

159.

Why is procainamide effective in converting supraventricular tachycardia that is refractory to adenosine and vagal maneuvers?

  • It prolongs the Q-T interval

  • It shortens the P-R interval

  • It reduces the Q-T interval

  • It acts directly on pacemaker cells

Correct answer: It prolongs the Q-T interval

Procainamide may be effective in converting supraventricular tachycardia that is refractory to adenosine and vagal maneuvers. It may be effective because it prolongs the Q-T interval, which lengthens the absolute refractory period. During this prolonged refractory period, the re-entry stimulus that has been refractory to other therapy may be effectively blocked. During the absolute refractory period, the heart muscle cannot be stimulated to contract (beat), no matter how powerful the focus that is attempted to stimulate the cells.

Procainamide does not affect the P-R interval of the heart. If it did, it would essentially shorten the time it takes for the stimulus to travel through the atria, AV node, and the bundle of His causing a direct increase in heart rate and impulse formation, not a decrease. Neither procainamide nor any other medication can stimulate or block the re-entry focus early in the Q-T interval. Early in the Q-T interval, the myocardium enters a stage/period of absolute refractory, meaning no stimulus, no matter how strong, can stimulate the heart to contract during this time.

Procainamide does not act directly on pacemaker cells.

160.

Your 20-year-old patient has reportedly been ill for three days with a high fever, chills, nausea, and vomiting. Her skin is cool and pale and has a delayed skin turgor response. Her heart rate is accelerated while her respirations are shallow and fast. Her blood pressure is borderline hypotensive, and she has a decreased level of consciousness.

Suspecting dehydration, which of the following IV fluid would be most appropriate to administer to this patient?

  • Isotonic solution

  • Hypotonic solution

  • Hypertonic solution

  • Nonelectrolyte solution

Correct answer: Isotonic solution

IV fluid therapy is based on hypertonic, hypotonic, and isotonic properties. When an isotonic solution is infused in a dehydrated patient, it is intended to replace the loss of circulating blood/fluid that was lost through bleeding or vomiting. In fact, an isotonic solution is indicated for any patient suspected of losing equal amounts of both sodium and chloride as seen in most forms of dehydration. Isotonic fluids include 0.9% normal saline and Lactated Ringers solution (common EMS fluids).

In hypotonic solutions, when infused in a normally hydrated patient, water is drawn from the solution into the cells by osmotic pressure. The net movement of water is more likely to cause the cell to swell and burst from the pressure increase. Hypotonic solutions are intended to deliver needed calories and prevent dehydration but are not good choices for a dehydrated, vomiting patient on the verge of hypotension. The net influx of water would likely cause cell destruction.

Hypertonic solutions have a higher concentration of solute molecules than found in the normal human cell. So, when a hypertonic solution is administered intravenously, it draws water from the cells into the vascular space. It is mostly used in hospital patients with an increased intracranial pressure. It is given in hopes of reducing the pressure within the extracellular space within the cranium. It is also used to treat metabolic acidosis in the form of bicarbonate. It would not be the ideal solution to administer to the prehospital patient showing signs and symptoms of dehydration.

Nonelectrolyte solutions are solutions such as glucose and urea. They are not intended to be used as intravenous therapy solutions; it would not be administered to a patient in need of fluid in the prehospital environment.

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