NREMT Paramedic Exam Questions

Cystic fibrosis is a genetic disorder that affects the lungs and can cause crackles or wheezes. A tension pneumothorax occurs when air in the pleural cavity displaces the lung and results in an absence of breath sounds on the affected side. A hemothorax is an accumulation of blood in the pleural space and results in diminished or absent lung sounds on the affected side. 

A pulmonary embolism is a clot or obstruction of a pulmonary blood vessel and does not affect lung sounds. 

Heatstroke signs and symptoms include:

• A core body temperature of 104 °F (40 °C) or higher
• Altered mental state or behavior
• Alteration in sweating
• Nausea and vomiting
• Flushed skin
• Tachypnea
• Tachycardia
• Headache

Bradycardia would not be a sign of classic heat stroke; it may be the result of a toxicological or cardiovascular emergency. 

Correct answer: Premature atrial complexes (PACs)

PAC is a regular rhythm interrupted by a premature atrial beat. Atrial fibrillation and wandering atrial pacemakers are irregular rhythms. Supraventricular tachycardia is a regular rhythm.

Correct answer: Exercise-induced asthma attack; administer beta agonist via nebulizer

This patient is exhibiting signs and symptoms of an exercise-induced asthma attack. The treatment for an asthma attack is to administer a beta-agonist medication such as Albuterol via a nebulizer.

Assisting ventilations with a bag-mask device is not indicated for this patient at this time, but could be if the patient's breathing becomes ineffective. A pneumothorax would present with chest pain and absent lung sounds, not wheezing. Anaphylaxis would cause a rash, hypotension, and difficulty breathing, and there is no evidence of the patient being stung by an insect.

Correct answer: 0.04 seconds

Each small square on the EKG strip represents 0.04 seconds. Each large square contains five small squares, which adds up to 0.2 seconds.

Correct answer: When the patient also exhibits a left bundle branch block (LBBB) on the electrocardiogram

A patient who has a new or existing Left Bundle Branch Block (LBBB) is likely to experience repolarization issues that will make the ST-segment measurements invalid when trying to determine the presence of ST-segment elevation during a possible infarction.

A higher than normal potassium level (hyperkalemia) may alter the appearance of the T wave somewhat (if the level is high enough). Patients with confirmed hyperkalemia may present with tall, tented T waves. However, it is not likely to interfere with the associated S wave, so ST-elevation measurements remain relevant when determining the possibility of an acute myocardial infarction in the prehospital setting.

Patients who have had a myocardial infarction in the past will likely have evidence of the infarction on their electrocardiogram tracing. However, it is still appropriate to evaluate the patient for ST-elevation when a STEMI is suspected. 

Taking nitroglycerin will not change the ST segments; therefore, it is appropriate and useful to assess ST-elevation for the determination of a STEMI in patients who have received nitroglycerin therapy in the past few hours.

Occlusive dressings are used when it is important to keep air or fluid from entering the wound. Examples include penetrating wounds to the great vessels of the neck and penetrating wounds to the chest, trachea, or mediastinum.  

An abdominal evisceration should be covered with a moist, sterile dressing. An avulsion to the finger would not be managed with an occlusive dressing but with sterile gauze and dressings.

Correct answer: A loss of pulmonary surfactant

One effect of toxic smoke inhalation, even in the absence of acute airway burns, is the destruction of pulmonary surfactant. Pulmonary surfactant is a thin film made by the alveolar cells. The purpose of this fluid is to allow the alveoli to expand and contract as needed during ventilation without collapsing. The absence of surfactant can often be heard as a grating sound during auscultation, similar to a pleural rub. Medical control may order CPAP if the patient exhibits signs of respiratory failure. 

Edema can be caused by airway burns and toxic smoke inhalation. However, this is heard as wet lung sounds during auscultation. Breath sounds, such as rales and rhonchi, are common with pulmonary edema. 

Bronchoconstriction can be caused by airway burns and toxic smoke inhalation. However, this would be evident by wheezing, use of accessory muscles, and other signs and symptoms of a narrowed airway. 

There is no reason to assume a rib fracture exists in a patient who does not complain of associated trauma based solely on the presence of grating sounds heard during respiration and shortness of breath.

Correct answer: "We should transport him to the cardiac center, unless we cannot keep him stable."

It is recommended that patients with a heart attack have PCI within 120 minutes of first medical contact, and patients should be transported directly to a hospital capable of performing PCI whenever possible. Taking the patient to the closest hospital may delay PCI if he has acute coronary syndrome (ACS). You can determine the destination after your assessment on scene, and bypass the critical access hospital to the cardiac center capable of PCI.

There is no need to contact air medical for this patient. It would only complicate the scene, cause unnecessary extra response to the scene to establish an LZ, and add significant expense. It would not save any time, which is the primary consideration when deciding on the utilization of air medical services.

Correct answer: Pulmonary vein

The pulmonary vein is the only artery that carries oxygenated blood. It sends blood from the right ventricle to the lung bases for carbon dioxide exchange.

The pulmonary artery carries deoxygenated blood from the body, and the superior and inferior vena cavae send deoxygenated blood to the heart from the body.

Correct answer: Cuffed 6.0–6.5 mm endotracheal tube

At times, nasotracheal intubation may be the preferred method of airway control. This may be the case in patients who have spontaneous respirations, when laryngoscopy is determined too difficult due to anatomy or laryngospasm or when the motion of the cervical spine must be very limited. Conscious patients tolerate a nasal tube better; they cause less tracheal trauma. The best nasal tube for intubating an average height and weight adult would be a tube that is one size smaller than the optimal tube size for endotracheal intubation and cuffed.

When performing nasal intubation, it is important to choose a tube that is cuffed and one size smaller than the optimal endotracheal tube for the patient. Therefore, using an uncuffed tube of any size would not allow the paramedic to seal the air from escaping from around the tube, making the tube useless. 

Using a 7–8 mm cuffed ET tube for nasally intubating an average height and weight adult would likely be too large a diameter to fit into the nostrils without causing unneeded trauma. Remember, the optimal nasal tube is cuffed, and one size smaller than the appropriate endotracheal tube would have been. 

A 7.0–7.5 mm cuffed ET tube is considered the correct size for orotracheal intubation of an average height and weight adult patient.

Correct answer: Defibrillation

Cardioversion, adenosine, and carotid massage are all treatments for atrial flutter. Defibrillation is a treatment for ventricular fibrillation or ventricular tachycardia.

Correct answer: Use a short, 14-gauge IV catheter with a short macro-drip infusion set with warm fluid

The flow of fluid through a catheter is related directly to its diameter and adversely related to its length. Therefore, a catheter with a large diameter, such as a 14-gauge (largest in EMS for IV therapy), will allow more fluid to flow quicker than a smaller diameter catheter will (such as 16, 18, 20, 22, 24 gauges). This same concept applies to the length of the catheter. Shorter catheters allow more fluid to flow than a longer catheter, and shorter tubing sets will deliver more fluid quicker than a long tubing set will. Macro-drip sets have a larger diameter than micro-drip sets do. It is recommended to use warm IV fluid when administering volumes larger than 500 mL unless you are attempting to actively cool the patient. Also, warmer fluid will always flow better than colder fluid. Therefore, the fastest available infusion would occur with the short, 14-gauge IV catheter with a short macro-drip infusion set and warm fluid. 

10-gauge catheters are reserved for chest decompression and emergency cricothyroidotomy in the pre-hospital setting. 14-gauge IV catheters are the largest for IV infusion in EMS. Short macro-drip tubing will not flow as quickly as a short macro-drip infusion set and warm fluid. 

A short 24-gauge is one of the smallest IV catheters in use today and will deliver fluid very slowly. They are used most commonly for pediatric patients and in small veins when a small amount of medication may be needed and are not appropriate for an infusion in an adult. 

A short 14-gauge would allow fluid to flow faster than a longer 16-gauge catheter would. The 14-gauge has a larger internal diameter. A short macro-drip set would allow fluid to flow faster than a micro-drip set would. Macro-drip tubing sets pass only 10 drops (gtts) for every mL while it takes 60 drops to allow a single mL of fluid to pass through the micro-drip set. Also, warm fluid flows better and faster than cool fluid due to viscosity.

Correct answer: Pulmonary embolus

Pulmonary Embolus (PE) during or shortly after childbirth is a significant cause of maternal death. An embolus often results from a blood clot in the pelvic circulation that breaks loose and travels to the lungs.. The patient often presents with the classic signs and symptoms associated with a pulmonary embolus. These include sudden-onset sharp focal chest pain, difficulty breathing, tachycardia, and sometimes hypotension depending on the size and severity of the occlusion. Sudden chest pain with dyspnea in a postpartum patient should alert the paramedic to the possibility of a pulmonary embolus. 

The 23-year-old postpartum patient who delivered her newborn recently and presents with sudden-onset dyspnea and associated chest pain is much less likely to be experiencing angina pectoris (simply chest pain) because this pain is caused by low oxygen delivery to the myocardium (hypoxia). 

A true Myocardial Infarction (MI) is caused by a blockage in a coronary artery that causes the myocardial tissue past the blockage to become ischemic and often die. This blockage is most often caused by the breaking away of plaque on the vessel walls that travel to the myocardium and become lodged in a small coronary artery. It may occur from a circulating embolus; however, the blood clots associated with postpartum pulmonary embolus most often are larger and block the pulmonary circulation before reaching the small coronary arteries.

Septic Shock (SS) is unlikely because it is not often associated with sudden onset chest pain and dyspnea. Septic shock occurs as a complication of an infection where toxins can initiate a full-body inflammatory response.

Low-head dams are considered extremely dangerous and are known as drowning machines by water rescue teams. They have dangerous recirculating currents called boils. These currents trap victims, drag them underwater, and then a current called a backwash pulls them up to the surface and back into the boil. Strainers are floating objects and debris such as tree limbs that may be caught in the currents of a low-head dam.

Slow-moving water is not a concern, nor associated with low-head dams. The water in low-head dams is swift and very dangerous.

Visceral pain is described as burning, cramping, aching, and difficult to localize. It is associated with hollow organs. Examples of visceral pain include appendicitis, gallstones, diverticulitis, and pelvic pain.

Phlebitis is inflammation of a vein and commonly occurs after IV infiltration. It is not associated with visceral pain. Pelvic inflammation will cause somatic pain, which is described as sharp and localized. 

Croup is a viral infection of the upper airway. Epiglottitis is swelling of the epiglottis that results from an upper respiratory infection. RSV (respiratory syncytial virus) is a common respiratory viral infection. All these are likely to cause respiratory distress in pediatric patients. 

Asthma is a reactive airway disease and is not caused by an infection. It will also likely cause respiratory distress in pediatric patients. 

Correct answer: 2nd Degree Wenckebach Block

In a Wenckebach block, also known as a Mobitz Type I second-degree AV block, the AV node progressively delays the signal more with each heartbeat. This causes the PR interval to gradually lengthen until one atrial impulse (P wave) is not conducted, leading to a dropped QRS complex. This pattern then repeats.

A Mobitz Type II block occurs when some signals from the atria fail to conduct through the AV node to the ventricles. This block is characterized by dropped QRS complexes without the progressive lengthening of the PR interval, often resembling a sinus rhythm with intermittent missing QRS complexes and T waves.

Correct answer: Guillain-Barré syndrome 

Guillain-Barré syndrome is an autoimmune disorder that affects the body's peripheral nervous system. Initial symptoms include weakness or tingling sensations that often begin in the legs. The weakness/tingling often moves to the upper extremities as paralysis approaches. In late stages of the disease, the patient may not be able to effectively breathe due to the ensuing paralysis. The condition can be brought on by recent illness or gastrointestinal disorder.

Multiple Sclerosis (MS) is a progressive neurological disease that usually begins in childhood. It manifests when patches of myelin on the nerve cells are destroyed. This causes the patient to lose nervous control of certain parts of the body. It typically begins with numbness and tingling in affected regions of the body. MS does not usually affect breathing, and its onset is most often much earlier in life.

Patients with Huntington's Disease (HD) suffer from degeneration of neurons in the brain. This leads to uncontrollable movements, not weakness. Patients with HD often develop loss of intellectual faculties and emotional disturbances. In later stages, they often develop difficulty swallowing. They do not usually present with lower extremity weakness and paralysis.

Amyotrophic lateral sclerosis patients have a neurological disorder that causes degeneration of nerve tracts in the CNS. Patients most often develop weakness and tingling that begins in the hands and arms. In later stages of the disease, the patients experience lower extremity paralysis. They do not ordinarily present with lower extremity weakness and tingling that progresses to paralysis and/or shortness of breath as the paralysis spreads to the upper extremities as seen in Guillain-Barré syndrome.

Correct answer: IV heparin

The goal of treatment in atrial fibrillation that is greater than 48 hours old is to control the heart rate and to prevent the risk of blood clots. Treatment options include anticoagulant therapy, IV heparin, and an echocardiogram to rule out blood clots before cardioversion. Beta blockers and atropine are not indicated therapies. Defibrillation is a treatment for ventricular fibrillation and ventricular tachycardia.