National Registry of Emergency Medical Technicians (NREMT) Paramedic Cognitive Exam — Questions and Answers

Question 1: When using the NIMS framework, 'unified command' is used when:

Multiple agencies or jurisdictions share incident management responsibility (Correct answer)
The incident spans more than 24 hours and requires overnight operations
A single agency has jurisdiction over all aspects of the incident
Federal resources are deployed and assume control from local agencies

Correct answer: Multiple agencies or jurisdictions share incident management responsibility

Unified Command allows multiple agencies with overlapping jurisdiction or functional responsibility to coordinate through a shared command structure.

Question 2: You are assisting a home birth for a 32-year-old female in active labor. Upon examination, you discover a pulsating umbilical cord protruding from the vagina ahead of the presenting part. What is the most critical immediate action?

Place the patient in a knee-chest or exaggerated Sims' position and manually elevate the presenting fetal part off the cord. (Correct answer)
Attempt to gently push the prolapsed cord back into the vagina.
Administer high-flow oxygen via non-rebreather mask and prepare for rapid transport.
Encourage the mother to push forcefully with the next contraction to expedite delivery.

Correct answer: Place the patient in a knee-chest or exaggerated Sims' position and manually elevate the presenting fetal part off the cord.

Umbilical cord prolapse is a true obstetric emergency where the cord is compressed between the presenting part and the maternal pelvis, cutting off oxygen to the fetus. The immediate priority is to relieve this pressure. This is best accomplished by placing the mother in a gravity-dependent position (knee-chest or exaggerated Sims') and using a gloved hand to manually lift the presenting part off the cord. While oxygen and rapid transport are vital, they are secondary to relieving the cord compression.

Question 3: You are treating a 10-year-old in decompensated shock. After two 20 mL/kg fluid boluses of normal saline with no improvement, what is your next intervention?

Give 10 mL/kg packed red blood cells
Consider vasopressor support and reassess (Correct answer)
Administer a third 20 mL/kg bolus immediately
Switch to D5W bolus

Correct answer: Consider vasopressor support and reassess

If two fluid boluses fail to restore perfusion, consider vasopressor therapy (dopamine or epinephrine) and contact medical direction for further guidance.

Question 4: Which ECG finding is most associated with a hyperacute (very early) STEMI before ST elevation develops?

Pathologic Q waves in the affected leads
ST depression in the affected leads
PR interval prolongation
Peaked, tall T waves in the affected leads (Correct answer)

Correct answer: Peaked, tall T waves in the affected leads

Hyperacute T waves—tall, peaked, and asymmetric—are the earliest ECG sign of myocardial ischemia, appearing before ST elevation.

Question 5: Which finding differentiates placenta previa from placental abruption?

Amount of blood loss visible externally
Painless bright red vaginal bleeding vs. painful dark bleeding (Correct answer)
Maternal blood pressure level
Presence of fetal heart tones

Correct answer: Painless bright red vaginal bleeding vs. painful dark bleeding

Placenta previa typically causes painless bright red bleeding, while placental abruption presents with painful dark bleeding often with a rigid uterus.

Question 6: Which of the following is a contraindication to administering activated charcoal?

Tricyclic antidepressant overdose
Ingestion of a caustic acid or alkali (Correct answer)
Aspirin ingestion within 2 hours
Acetaminophen ingestion within 1 hour

Correct answer: Ingestion of a caustic acid or alkali

Activated charcoal does not bind caustic substances and can obscure endoscopic evaluation of mucosal injury, making it contraindicated with caustic ingestions.

Question 7: A CPAP device is being applied to a patient in acute pulmonary edema. Which pressure setting is MOST commonly used initially?

2-4 cm H2O
15-20 cm H2O
5-10 cm H2O (Correct answer)
20-25 cm H2O

Correct answer: 5-10 cm H2O

CPAP for pulmonary edema is typically initiated at 5-10 cm H2O, which recruits collapsed alveoli and reduces the work of breathing.

Question 8: A patient struck by a vehicle has anterior neck ecchymosis, hoarseness, and subcutaneous emphysema. What is the priority intervention?

Early definitive airway via RSI (Correct answer)
Nasopharyngeal airway insertion
High-flow oxygen via non-rebreather mask
Bag-valve-mask ventilation only

Correct answer: Early definitive airway via RSI

Laryngeal fracture can rapidly progress to complete airway obstruction; early RSI or surgical airway is indicated before edema eliminates the airway.

Question 9: In SALT triage, the first step in sorting patients is to:

Direct all who can walk to move to a designated area (Correct answer)
Assess respirations on all patients simultaneously
Identify and tag all obviously dead patients first
Check radial pulses on all supine patients

Correct answer: Direct all who can walk to move to a designated area

SALT triage begins with a global sort by asking ambulatory patients to walk to a designated area, quickly separating the least injured.

Question 10: Which federal law mandates that EMS agencies provide emergency care regardless of a patient's ability to pay?

EMTALA (Correct answer)
HIPAA
OSHA Act
Ryan White Act

Correct answer: EMTALA

The Emergency Medical Treatment and Labor Act (EMTALA) requires that any patient who comes to an emergency department receive a medical screening exam regardless of insurance or ability to pay.

Question 11: A 34-week pregnant patient develops generalized tonic-clonic seizures. After securing the airway, your next priority is:

Administer IV lorazepam for seizure control
Administer IV or IM magnesium sulfate (Correct answer)
Perform rapid delivery in the field
Administer IV dextrose to rule out hypoglycemia

Correct answer: Administer IV or IM magnesium sulfate

Magnesium sulfate is the first-line treatment for eclamptic seizures in pregnancy because it addresses the underlying pathophysiology.

Question 12: A 70-year-old patient is in asystole. After confirming the rhythm in two leads, what is the correct immediate action?

Administer atropine 3mg IV
Defibrillate at 200J
Perform transcutaneous pacing immediately
Begin high-quality CPR and administer epinephrine (Correct answer)

Correct answer: Begin high-quality CPR and administer epinephrine

Asystole is a non-shockable rhythm; treatment is high-quality CPR with epinephrine every 3–5 minutes and search for reversible causes.

Question 13: You are treating a seizing patient. After 5 minutes of continuous seizure activity with no IV access, which medication and route is most appropriate?

Midazolam 10 mg IM (Correct answer)
Phenytoin 20 mg/kg IV
Lorazepam 2 mg IV
Diazepam 5 mg PR (rectal)

Correct answer: Midazolam 10 mg IM

IM midazolam (typically 10 mg for adults) has been shown to be as effective as IV lorazepam and is the preferred route when IV access is unavailable for status epilepticus.

Question 14: Which of the following best describes the 'Unified Command' structure in ICS?

Medical control directs all operations
One agency controls all others on scene
Multiple agencies share command responsibilities (Correct answer)
Command transfers every 30 minutes

Correct answer: Multiple agencies share command responsibilities

Unified Command allows multiple agencies with jurisdiction to manage an incident cooperatively without losing individual authority.

Question 15: What does a colorimetric CO2 detector turning YELLOW indicate after endotracheal intubation?

Low EtCO2
Device malfunction
Tracheal intubation confirmed (Correct answer)
Esophageal intubation confirmed

Correct answer: Tracheal intubation confirmed

Yellow color on a colorimetric detector indicates the presence of CO2, confirming tracheal (not esophageal) placement.

Question 16: Which burn depth classification involves destruction of the epidermis, dermis, and underlying subcutaneous tissue?

Partial thickness deep
Partial thickness superficial
Full thickness (third-degree) (Correct answer)
Superficial (first-degree)

Correct answer: Full thickness (third-degree)

Full-thickness burns destroy all skin layers including subcutaneous tissue, appearing leathery and white/charred, with no pain sensation due to nerve destruction.

Question 17: The standard phonetic alphabet letter for 'M' is:

Metro
Mike (Correct answer)
Mary
Marco

Correct answer: Mike

In the NATO phonetic alphabet used in EMS communications, 'M' is represented by 'Mike.'

Question 18: A 35-year-old female ingested an entire bottle of acetaminophen 8 hours ago and now has nausea, vomiting, and right upper quadrant pain. What is the treatment of choice?

Flumazenil 0.2 mg IV
N-acetylcysteine (NAC) (Correct answer)
Naloxone 2 mg IV
Activated charcoal 1 g/kg orally

Correct answer: N-acetylcysteine (NAC)

N-acetylcysteine replenishes hepatic glutathione stores, preventing toxic metabolite accumulation and hepatotoxicity from acetaminophen overdose.

Question 19: A patient presents with symptomatic bradycardia at 38 bpm unresponsive to atropine. What is the next intervention?

Initiate transcutaneous pacing (Correct answer)
Administer a second dose of atropine 1 mg IV
Administer adenosine 6 mg IV
Synchronized cardioversion at 50 J

Correct answer: Initiate transcutaneous pacing

When atropine fails to treat symptomatic bradycardia, transcutaneous pacing is the next step while preparing for transvenous pacing.

Question 20: Which of the following is the preferred initial energy setting for defibrillation of ventricular fibrillation with a biphasic defibrillator?

120-200 J as recommended by the manufacturer (Correct answer)
200 J monophasic equivalent
360 J
50 J

Correct answer: 120-200 J as recommended by the manufacturer

Biphasic defibrillators should be used at the manufacturer-recommended dose (120-200 J); if unknown, use the maximum available.

Question 21: Which waveform on capnography indicates correct endotracheal tube placement?

Square waveform with EtCO2 35-45 mmHg (Correct answer)
Saw-tooth waveform
Spike-only waveform
Flat waveform at 0 mmHg

Correct answer: Square waveform with EtCO2 35-45 mmHg

A square capnography waveform with EtCO2 between 35-45 mmHg confirms tracheal placement with normal ventilation.

Question 22: Which finding best differentiates neurogenic shock from hypovolemic shock?

Narrow pulse pressure and cool, clammy skin
Altered level of consciousness
Bradycardia with warm, dry, flushed skin below the injury level (Correct answer)
Hypotension and tachycardia

Correct answer: Bradycardia with warm, dry, flushed skin below the injury level

Neurogenic shock characteristically presents with bradycardia and warm, dry, flushed skin below the spinal injury due to loss of sympathetic tone, distinguishing it from hypovolemic shock.

Question 23: Which of the following is NOT a fundamental skill that vertical rescue teams must possess?

Proficiency in shore-based swimming (Correct answer)
Capability of packaging a patient
Adequate equipment to perform the job
Knot tying and anchoring skills

Correct answer: Proficiency in shore-based swimming

Vertical rescue teams specialize in high-angle or low-angle rope rescue scenarios, such as cliffs, buildings, or confined spaces with vertical access. While water rescue skills are important for some emergency services, proficiency in shore-based swimming is not a core fundamental skill specifically for *vertical* rescue operations. Their primary focus is on rope systems, patient packaging, and specialized equipment for vertical environments.

Question 24: You are setting up a ventilator for a 70 kg adult male patient diagnosed with Acute Respiratory Distress Syndrome (ARDS). According to the ARDSNet protocol, what should the initial tidal volume be set to?

12 mL/kg
10 mL/kg
6 mL/kg (Correct answer)
8 mL/kg

Correct answer: 6 mL/kg

The ARDSNet protocol recommends a lung-protective ventilation strategy that includes low tidal volumes to prevent ventilator-induced lung injury. The standard initial tidal volume is 6 mL/kg of predicted body weight. [10, 14, 21, 24]

Question 25: A patient with known CHF presents with severe pulmonary edema and a BP of 180/110 mmHg. Which medication is MOST appropriate as a first-line agent?

Nitroglycerin 0.4 mg SL (Correct answer)
Furosemide 40 mg IV
Dopamine infusion
Adenosine 6 mg rapid IV push

Correct answer: Nitroglycerin 0.4 mg SL

Nitroglycerin causes venodilation, rapidly reducing preload and afterload, making it first-line for hypertensive acute pulmonary edema.

Question 26: A nasopharyngeal airway (NPA) is contraindicated in which of the following situations?

Unconscious patient with intact gag reflex
Seizing patient with clenched jaw
Patient with suspected basilar skull fracture (Correct answer)
Patient who is semiconscious

Correct answer: Patient with suspected basilar skull fracture

An NPA is contraindicated with suspected basilar skull fracture due to risk of the device entering the cranial vault.

Question 27: What is the primary purpose of the Incident Action Plan (IAP) in ICS?

Document patient outcomes
Track responder overtime
Define objectives and tactics for the operational period (Correct answer)
Bill for services rendered

Correct answer: Define objectives and tactics for the operational period

The IAP documents the incident objectives, strategies, and tactics for a specific operational period, guiding all responders.

Question 28: During BVM ventilation, you notice gastric distension developing. What is the BEST corrective action?

Switch to a smaller mask
Increase bag squeeze volume
Increase ventilation rate
Apply cricoid pressure (Sellick maneuver) (Correct answer)

Correct answer: Apply cricoid pressure (Sellick maneuver)

Cricoid pressure compresses the esophagus against the vertebrae, reducing air entry into the stomach during BVM ventilation.

Question 29: A patient in cardiac arrest is rescued from a building fire. CPR is initiated but the patient remains pulseless after two rounds. The paramedic suspects tension pneumothorax secondary to blast injury. Which intervention is indicated?

Sodium bicarbonate 1 mEq/kg IV push
Increase CPR rate to 120 compressions per minute
Immediate defibrillation regardless of rhythm
Needle decompression of the affected chest (Correct answer)

Correct answer: Needle decompression of the affected chest

Tension pneumothorax is a reversible cause of cardiac arrest; needle decompression at the second intercostal space midclavicular line can restore circulation.

Question 30: Kussmaul respirations are characterized by:

Alternating periods of apnea and hyperpnea
Slow, shallow breathing with long pauses
Deep, rapid, labored breathing without pauses (Correct answer)
Irregular, gasping breaths

Correct answer: Deep, rapid, labored breathing without pauses

Kussmaul respirations are deep, rapid, and labored — a physiologic response to severe metabolic acidosis, classically seen in diabetic ketoacidosis.

Question 31: Which mechanism of injury MOST commonly causes aortic transection?

Fall from less than 10 feet
High-speed deceleration crash with anterior chest impact (Correct answer)
Direct lateral blow to the thorax
Penetrating abdominal trauma

Correct answer: High-speed deceleration crash with anterior chest impact

Aortic transection typically occurs at the ligamentum arteriosum due to shear forces in high-speed deceleration crashes, most often anterior chest impacts.

Question 32: A 66-year-old male with a history of angina reports an episode of crushing chest pain that resolved before your arrival. He is now pain-free. His 12-lead ECG shows deeply inverted T-waves in leads V2 and V3, with minimal ST elevation (<1mm) and no pathological Q waves. What is this ECG pattern most indicative of?

Posterior wall myocardial infarction
Benign early repolarization
Pericarditis
Wellens' Syndrome (Correct answer)

Correct answer: Wellens' Syndrome

Wellens' Syndrome is characterized by specific T-wave changes (deeply inverted or biphasic) in the precordial leads (V2-V3) in a patient who is currently pain-free but has a history of recent angina. It is highly specific for a critical stenosis of the proximal left anterior descending (LAD) coronary artery and indicates a high risk of extensive anterior wall MI.

Question 33: Which communication principle is MOST critical when transferring command at a complex rescue scene?

Verbal briefing only to save time
Written ICS 201 form faxed to the new commander
Radio handoff of the incident number to the incoming commander
A face-to-face briefing covering situation status, resources, hazards, and priorities (Correct answer)

Correct answer: A face-to-face briefing covering situation status, resources, hazards, and priorities

A face-to-face briefing ensures the incoming commander has accurate situational awareness of all critical factors before assuming command.

Question 34: Which pediatric age group is at GREATEST risk for submersion injury due to their developmental stage?

School-age children (6–12 years)
Adolescents (13–17 years)
Toddlers (1–4 years) (Correct answer)
Newborns (0–1 month)

Correct answer: Toddlers (1–4 years)

Toddlers are at highest risk for drowning because they are mobile, curious, and lack the judgment to avoid water hazards.

Question 35: Which acid-base pattern is most characteristic of salicylate (aspirin) poisoning in adults?

Pure metabolic acidosis from the onset
Metabolic alkalosis followed by respiratory acidosis
Pure respiratory alkalosis throughout the course
Respiratory alkalosis followed by metabolic acidosis (Correct answer)

Correct answer: Respiratory alkalosis followed by metabolic acidosis

Salicylates directly stimulate the respiratory center causing initial respiratory alkalosis, then impair oxidative phosphorylation producing high anion gap metabolic acidosis.

Question 36: A paramedic is injured on the scene and cannot complete patient care. The best immediate action is to:

Refuse all further care and await an ambulance for yourself
Notify dispatch and request additional resources while ensuring scene safety (Correct answer)
Transport the patient immediately without documentation
Continue treating the patient until help arrives

Correct answer: Notify dispatch and request additional resources while ensuring scene safety

Notifying dispatch allows additional resources to be sent while ensuring the patient still receives necessary care.

Question 37: A patient presents with bradycardia at 38 bpm, hypotension, and diaphoresis. Atropine 0.5mg IV fails to improve the rate. What is the next most appropriate intervention?

Administer adenosine 6mg IV push
Initiate transcutaneous pacing (Correct answer)
Give epinephrine 1mg IV push
Repeat atropine 0.5mg up to a maximum of 1mg

Correct answer: Initiate transcutaneous pacing

When atropine fails for symptomatic bradycardia, transcutaneous pacing is the next indicated intervention per ACLS guidelines.

Question 38: During a confined space rescue, what is the MOST common cause of rescuer fatalities?

Exhaustion from physical exertion
Thermal burns from heat
Entering without proper equipment to save a victim (Correct answer)
Being struck by falling debris

Correct answer: Entering without proper equipment to save a victim

The majority of confined space rescuer deaths occur when would-be rescuers enter the space without proper equipment, becoming victims themselves.

Question 39: When inserting a nasopharyngeal airway in a pediatric patient, which measurement determines the correct size?

Distance from the corner of the mouth to the earlobe
Distance from the tip of the nose to the earlobe (Correct answer)
Distance from the mouth to the chin
The diameter of the patient's little finger

Correct answer: Distance from the tip of the nose to the earlobe

A nasopharyngeal airway is sized by measuring from the tip of the nose to the earlobe to ensure appropriate length.

Question 40: When approaching a scene where a patient is reported to have a weapon, paramedics should:

Stage at a safe distance until law enforcement secures the scene (Correct answer)
Attempt to disarm the patient
Call the patient by phone before approaching
Rush in quickly to prevent harm

Correct answer: Stage at a safe distance until law enforcement secures the scene

Paramedics must stage away from violent scenes and only enter after law enforcement declares the scene safe.

Question 41: Which of the following best describes the mechanism of action of amiodarone in ventricular arrhythmias?

Sodium channel opener that increases automaticity
Pure calcium channel blocker that decreases myocardial contractility
Multi-channel blocker that prolongs the action potential and refractory period (Correct answer)
Pure beta-1 receptor blocker that slows AV conduction only

Correct answer: Multi-channel blocker that prolongs the action potential and refractory period

Amiodarone blocks sodium, potassium, and calcium channels and also has beta-blocking properties, prolonging the action potential duration.

Question 42: A patient presents with palpitations. The 12-lead ECG shows a narrow-complex tachycardia at 280 bpm with a delta wave visible during brief slowing. This is most consistent with:

Atrial fibrillation with aberrant conduction
Wolff-Parkinson-White (WPW) syndrome (Correct answer)
Atrial flutter with 1:1 conduction
AV nodal reentrant tachycardia

Correct answer: Wolff-Parkinson-White (WPW) syndrome

A delta wave and tachycardia exceeding 250 bpm strongly suggest WPW syndrome with an accessory pathway.

Question 43: What does the acronym NIMS stand for in the context of emergency management?

National Incident Management System (Correct answer)
National Integrated Medical System
National Infrastructure Management Standard
Non-invasive Monitoring Standard

Correct answer: National Incident Management System

NIMS is the National Incident Management System, a comprehensive framework for incident management across all levels of government and the private sector.

Question 44: A patient presents with a wide-complex tachycardia at 180 bpm. The patient is hemodynamically unstable with a BP of 70/40 mmHg. What is the most appropriate immediate intervention?

Adenosine 6 mg rapid IV push
Administer amiodarone 150 mg IV
Synchronized cardioversion starting at 100 J (Correct answer)
Unsynchronized defibrillation at 200 J

Correct answer: Synchronized cardioversion starting at 100 J

Unstable wide-complex tachycardia requires immediate synchronized cardioversion; pharmacologic therapy is reserved for stable patients.

Question 45: You are treating a patient with a deep junctional wound in the groin that is not amenable to a tourniquet. Direct pressure is failing to control severe arterial bleeding. According to TCCC and modern trauma guidelines, what is the most appropriate next intervention?

Immediately clamp the visible bleeding vessel with a hemostat.
Pack the wound with a hemostatic gauze and hold firm pressure. (Correct answer)
Cover the wound with an occlusive dressing and transport rapidly.
Apply a second, wider tourniquet as high as possible.

Correct answer: Pack the wound with a hemostatic gauze and hold firm pressure.

For junctional hemorrhage (e.g., groin, axilla) that is not controllable by direct pressure alone, the standard of care is to pack the wound, preferably with a hemostatic gauze, and then apply and maintain firm, direct pressure over the packing.

Question 46: Which of the following does NOT justify giving oxygen to a hypoxic patient?

Increasing arterial oxygen levels
Increasing the percentage of expired oxygen (Correct answer)
Increasing the amount of oxygen delivered to the patient's cells
Increasing oxygen concentration at the alveolar level

Correct answer: Increasing the percentage of expired oxygen

The primary goal of giving oxygen to a hypoxic patient is to increase the oxygen concentration in the inspired air, thereby increasing arterial oxygen levels and the amount of oxygen delivered to the patient's cells and tissues. Increasing the percentage of expired oxygen is not a therapeutic goal; rather, it's a consequence of inefficient oxygen utilization or excessive delivery.

Question 47: A patient presents with third-degree (complete) heart block. Which of the following best describes this rhythm?

Regular P waves with no QRS complexes
P waves conduct to ventricles with progressively increasing PR intervals
Intermittent failure of P waves to conduct, with normal PR intervals when conduction occurs
Complete dissociation between atrial and ventricular activity with no relationship between P waves and QRS complexes (Correct answer)

Correct answer: Complete dissociation between atrial and ventricular activity with no relationship between P waves and QRS complexes

Third-degree heart block features complete AV dissociation where atria and ventricles beat independently with no relationship between P waves and QRS complexes.

Question 48: A patient has third-degree (complete) heart block with a ventricular rate of 30 bpm and hypotension. Which treatment is most appropriate?

Amiodarone 300mg IV
Transcutaneous pacing (Correct answer)
Adenosine 6mg IV push
Diltiazem 0.25 mg/kg IV

Correct answer: Transcutaneous pacing

Transcutaneous pacing is the definitive prehospital treatment for symptomatic third-degree heart block.

Question 49: A patient in respiratory arrest has dentures. What is the correct action before attempting BVM ventilation?

Remove upper denture only
Remove dentures to prevent airway obstruction
Leave well-fitting dentures in place to maintain facial seal (Correct answer)
Pack gauze around loose dentures

Correct answer: Leave well-fitting dentures in place to maintain facial seal

Well-fitting dentures should remain in place as they help maintain a better mask seal during BVM ventilation.

Question 50: Which of the following BEST describes the purpose of the rapid trauma assessment in a high-mechanism patient?

To detect life threats not found in the primary survey and prioritize transport (Correct answer)
To perform detailed neurological testing
To obtain a complete SAMPLE history
To identify and treat all injuries before transport

Correct answer: To detect life threats not found in the primary survey and prioritize transport

The rapid trauma assessment quickly identifies additional life threats after the primary survey while avoiding scene time delays that increase mortality.

Question 51: A transport supervisor at an MCI is responsible for:

Managing the decontamination corridor throughput
Performing primary triage on newly arriving patients
Requesting mutual aid from neighboring agencies
Coordinating ambulance assignments and patient destinations to hospitals (Correct answer)

Correct answer: Coordinating ambulance assignments and patient destinations to hospitals

The transport supervisor coordinates which patients go to which hospitals, tracks patient numbers, and manages the flow of ambulances in and out of the scene.

Question 52: A 22-year-old female is 32 weeks pregnant and presents with a BP of 165/110 mmHg, severe headache, and visual disturbances. What condition does this presentation suggest?

HELLP syndrome
Severe preeclampsia (Correct answer)
Placenta previa
Gestational hypertension

Correct answer: Severe preeclampsia

Hypertension above 160/110 mmHg with severe symptoms (headache, visual changes) after 20 weeks gestation defines severe preeclampsia, which requires urgent treatment.

Question 53: Which waveform on capnography indicates a patient is rebreathing CO2 due to an incompetent expiratory valve?

Prolonged plateau phase
Absent waveform
Elevated baseline above zero (Correct answer)
Shark fin waveform

Correct answer: Elevated baseline above zero

An elevated CO2 baseline above zero on capnography indicates rebreathing of CO2, often due to an incompetent expiratory valve or exhausted CO2 absorber.

Question 54: What does the 'T' wave on the ECG represent?

Ventricular depolarization
Atrial repolarization
Atrial depolarization
Ventricular repolarization (Correct answer)

Correct answer: Ventricular repolarization

The T wave represents ventricular repolarization, the electrical recovery phase of the ventricles.

Question 55: What type of brain injury DOES NOT frequently occur in a school-aged child?

Auto-pedestrian accidents
Bicycle accidents
Sporting events (Correct answer)
Falls from trees

Correct answer: Sporting events

Sporting events are a very frequent cause of brain injuries, particularly concussions, in school-aged children due to falls, collisions, and impacts. Therefore, stating that brain injuries from sporting events 'DOES NOT frequently occur' is generally incorrect. Auto-pedestrian accidents, falls from trees, and bicycle accidents are also common causes of brain injury in this age group, often leading to more severe traumatic brain injuries.

Question 56: What is the airway's superior-most portion?

Nasal cavity (Correct answer)
Oral cavity
Nasopharynx
Oropharynx

Correct answer: Nasal cavity

The nasal cavity is the superior-most portion of the airway, serving as the primary entry point for air into the respiratory system. It is responsible for filtering, warming, and humidifying inhaled air before it proceeds to the pharynx and lower airway. The oral cavity is an alternative entry point but not the superior-most.

Question 57: The treatment of choice for Torsades de Pointes (TdP) in a hemodynamically stable patient is:

Magnesium sulfate 1–2g IV over 5–20 minutes (Correct answer)
Synchronized cardioversion at 100J
Amiodarone 150mg IV over 10 minutes
Lidocaine 1.5 mg/kg IV bolus

Correct answer: Magnesium sulfate 1–2g IV over 5–20 minutes

Magnesium sulfate 1–2g IV is the first-line treatment for TdP as it suppresses the triggered activity causing the arrhythmia.

Question 58: A 22-year-old male presents with a single stab wound to the right side of his chest. He is anxious, tachycardic at 130 bpm, and hypotensive at 80/50 mmHg. You note absent breath sounds on the right, jugular vein distention, and tracheal deviation to the left. What is the most critical immediate intervention?

Apply an occlusive dressing to the chest wound.
Apply a high-flow oxygen mask.
Perform needle decompression of the right chest. (Correct answer)
Initiate a rapid fluid bolus with normal saline.

Correct answer: Perform needle decompression of the right chest.

The patient's signs and symptoms (hypotension, JVD, absent breath sounds, and tracheal deviation) are classic for a tension pneumothorax, which is an immediate life-threatening emergency. Needle decompression is the critical intervention to relieve the pressure in the pleural space, allowing the lung to re-expand and relieving pressure on the heart and great vessels.

Question 59: A 60-year-old dialysis patient presents with peaked T waves, a HR of 38 bpm, and a wide QRS complex. After calcium gluconate, what is the next appropriate intervention?

Furosemide 40 mg IV
Sodium bicarbonate 50 mEq IV (Correct answer)
Kayexalate (sodium polystyrene)
Albuterol nebulizer

Correct answer: Sodium bicarbonate 50 mEq IV

Sodium bicarbonate temporarily shifts potassium into cells by alkalizing the blood, providing a rapid but temporary reduction in serum potassium.

Question 60: What steps are involved in sending physiological data over a distance?

Cardio telemetry
Biotelemetry (Correct answer)
Electro telemetry
Tritelemetry

Correct answer: Biotelemetry

Biotelemetry is the process of remotely measuring and transmitting vital signs and other physiological data from a living organism. In EMS, this refers to the transmission of patient data, such as ECGs, blood pressure, and oxygen saturation, from the ambulance or scene to the receiving hospital over a distance.

Question 61: What should be done initially when managing an asthma attack in a child?

Establish an airway
Administer supplemental, humidified oxygen
Administer a steroid preparation
Administer an inhaled beta agonist (Correct answer)

Correct answer: Administer an inhaled beta agonist

The initial and most critical step in managing an acute asthma attack in a child is to administer a rapid-acting inhaled beta agonist, such as albuterol. These medications quickly relax the smooth muscles of the airways, relieving bronchospasm and improving airflow. While oxygen, steroids, and airway management are important, bronchodilator administration is the immediate priority for reversing the primary problem of bronchoconstriction.

Question 62: Which ETCO2 reading during CPR suggests good quality chest compressions and adequate perfusion?

20–40 mmHg (Correct answer)
10–20 mmHg
Less than 10 mmHg
Greater than 50 mmHg

Correct answer: 20–40 mmHg

ETCO2 of 20–40 mmHg during CPR correlates with adequate cardiac output and perfusion; values below 10 mmHg suggest poor compressions or futile resuscitation.

Question 63: A patient is experiencing an anaphylactic reaction with severe bronchospasm and stridor. After epinephrine, the NEXT airway intervention is:

Nasal cannula oxygen at 6 L/min
Waiting to see if epinephrine resolves the swelling
Applying a nonrebreather mask only
Oral intubation with RSI before swelling worsens (Correct answer)

Correct answer: Oral intubation with RSI before swelling worsens

Rapidly progressing anaphylaxis with stridor requires early definitive airway management (RSI/intubation) before further swelling makes intubation impossible.

Question 64: You are assessing a 68-year-old patient who presents with the sudden onset of a severe headache described as "the worst headache of my life." This was followed by nausea, vomiting, and nuchal rigidity. Which of the following conditions is most likely?

Hypertensive crisis
Ischemic stroke
Transient ischemic attack (TIA)
Subarachnoid hemorrhage (SAH) (Correct answer)

Correct answer: Subarachnoid hemorrhage (SAH)

The classic presentation of a subarachnoid hemorrhage (SAH) is a sudden, severe "thunderclap" headache, often described by patients as "the worst headache of my life." Associated symptoms like nausea, vomiting, and nuchal rigidity (stiff neck) are due to meningeal irritation from the blood in the subarachnoid space. Ischemic strokes and TIAs typically present with focal neurological deficits rather than a primary complaint of a sudden, maximal headache.

Question 65: After needle decompression of a tension pneumothorax, the patient's condition does not improve. What is the next step?

Increase IV fluid rate
Perform needle decompression on the opposite side
Perform a finger thoracostomy (Correct answer)
Repeat needle decompression at the same site

Correct answer: Perform a finger thoracostomy

If needle decompression fails to relieve tension pneumothorax, a finger thoracostomy provides a definitive prehospital decompression by creating an open chest wall opening.

Question 66: What is the maximum depth at which chest compressions should be performed in an adult during CPR?

At least 2.5 inches (6.5 cm) with no maximum
As deep as possible to maximize output
At least 2 inches (5 cm) with a maximum of 2.4 inches (6 cm) (Correct answer)
Exactly 2 inches (5 cm)

Correct answer: At least 2 inches (5 cm) with a maximum of 2.4 inches (6 cm)

AHA guidelines specify compression depth of at least 2 inches but no more than 2.4 inches to optimize perfusion while avoiding injury.

Question 67: What is the most critical requirement that must be fulfilled for an EMT to assist a patient with angina who wants to take their nitroglycerin?

The nitroglycerin must be administered sublingually.
The patient's systolic blood pressure must be above 100 mm Hg.
The EMT must have medical control. (Correct answer)
The patient must be experiencing severe chest pain.

Correct answer: The EMT must have medical control.

While specific conditions like systolic blood pressure above 100 mm Hg and sublingual administration are important considerations for nitroglycerin, the overarching and most critical requirement for an EMT to administer or assist with any medication is to have medical control. This means receiving explicit permission or following standing orders from a physician or medical director. Without medical control, an EMT cannot legally or ethically administer medication.

Question 68: Which pediatric anatomical difference is MOST important to consider when managing a child's airway after blunt head trauma?

The occiput is proportionally larger, causing passive neck flexion when supine (Correct answer)
Children's airways are less susceptible to swelling
Children have smaller tonsils that rarely obstruct the airway
The trachea is longer and more rigid than in adults

Correct answer: The occiput is proportionally larger, causing passive neck flexion when supine

A child's large occiput causes the head to flex forward when supine, potentially obstructing the airway; a padding roll under the shoulders maintains a neutral position.

Question 69: In the management of a trauma patient with suspected internal, uncontrolled hemorrhage and signs of shock, which of the following fluid resuscitation strategies is most appropriate prior to definitive surgical control?

Withhold all IV fluids until arrival at the hospital to avoid hemodilution.
Administer two large-bore IVs with fluids wide open to rapidly normalize blood pressure to 120/80 mmHg.
Administer vasopressors as the first-line treatment to increase systemic vascular resistance.
Administer small fluid boluses with the goal of achieving a palpable radial pulse or a systolic blood pressure of 80-90 mmHg. (Correct answer)

Correct answer: Administer small fluid boluses with the goal of achieving a palpable radial pulse or a systolic blood pressure of 80-90 mmHg.

The concept of permissive hypotension, or hypotensive resuscitation, is the current standard for trauma patients with uncontrolled hemorrhage. The goal is to maintain just enough blood pressure to perfuse vital organs without raising the pressure so high that it disrupts existing clots ('popping the clot') and worsens the hemorrhage. Aggressive fluid resuscitation to normalize blood pressure can also lead to hemodilution and coagulopathy.

Question 70: Which of the following describes the correct technique when using a two-person BVM to ventilate an apneic adult?

One provider uses a C-E clamp with both hands to maintain mask seal; the second provider squeezes the bag (Correct answer)
One provider holds the mask while the second tilts the head and monitors SpO2
One provider squeezes the bag with two hands while the second provider manages the IV line
Both providers alternate squeezing the bag to reduce fatigue

Correct answer: One provider uses a C-E clamp with both hands to maintain mask seal; the second provider squeezes the bag

Two-person BVM technique has one provider dedicated to maintaining a two-handed C-E clamp mask seal while the second provider delivers breaths by squeezing the bag.

Question 71: A secondary triage reassessment at an MCI treatment sector is important because:

It allows reclassification of patients whose condition has changed while waiting (Correct answer)
It replaces the need for a dedicated triage officer at the scene perimeter
It allows green-tagged patients to be released without further evaluation
It reduces the total number of hospital notifications required

Correct answer: It allows reclassification of patients whose condition has changed while waiting

Patient conditions can deteriorate or improve while waiting in treatment sectors, making secondary reassessment critical to ensure correct prioritization.

Question 72: A 62-year-old male presents with substernal chest pain. A 12-lead EKG reveals ST-segment elevation of 3 mm in leads II, III, and aVF. Which coronary artery is most likely occluded, and what is a primary prehospital treatment goal?

Left Anterior Descending (LAD); Administration of furosemide.
Right Coronary Artery (RCA); Rapid transport to a PCI-capable facility. (Correct answer)
Circumflex Artery; Initiation of therapeutic hypothermia.
Posterior Descending Artery (PDA); Administration of sodium bicarbonate.

Correct answer: Right Coronary Artery (RCA); Rapid transport to a PCI-capable facility.

ST elevation in leads II, III, and aVF indicates an inferior wall myocardial infarction, which is most commonly caused by an occlusion of the Right Coronary Artery (RCA). The primary goal for a STEMI patient is rapid reperfusion, making immediate transport to a hospital with percutaneous coronary intervention (PCI) capabilities essential to minimize cardiac muscle damage.

Question 73: What makes croup distinctive?

Occasional stridor
Drooling
Child prefers to sit up
Slow onset (Correct answer)

Correct answer: Slow onset

Croup (laryngotracheobronchitis) is typically characterized by a slow, gradual onset, often starting with cold-like symptoms that progress over a few days to the classic barking cough, inspiratory stridor, and hoarseness. This distinguishes it from conditions like epiglottitis, which has a rapid onset and is associated with drooling and a preference to sit up.

Question 74: What signs should you check to see if it's okay to enter a scene?

Hazardous substances or dangers like downed electrical lines, broken glass, etc.
Traffic from civilians, law enforcement or other rescue personnel.
All of the above. (Correct answer)
Environmental problems, such as unstable terrain, heat, or lack of light.

Correct answer: All of the above.

Before entering any scene, a paramedic must conduct a thorough scene size-up to ensure safety. This involves checking for all potential hazards, including environmental problems (unstable terrain, extreme weather), hazardous substances (spills, downed lines, broken glass), and human-related dangers (traffic, law enforcement, or other rescue personnel). Ensuring the safety of the rescuer, patient, and bystanders is paramount.

Question 75: A paramedic is caring for a 78-year-old patient who presents with altered mental status after a fall. The patient lives alone. Which additional agency should typically be notified?

Adult Protective Services (Correct answer)
The local fire department
The hospital billing department
The nearest pharmacy

Correct answer: Adult Protective Services

Adult Protective Services (APS) should be contacted when EMS identifies signs of elder neglect, abuse, or a vulnerable adult living in unsafe conditions.

Question 76: During water rescue, a non-swimming bystander is trying to reach a drowning victim. The paramedic should FIRST:

Direct the bystander to throw a rope or flotation device rather than enter the water (Correct answer)
Call for a boat before taking any other action
Have the bystander wade in waist-deep to extend reach
Allow the bystander to attempt rescue while preparing equipment

Correct answer: Direct the bystander to throw a rope or flotation device rather than enter the water

Reach-throw-row-go prioritization keeps rescuers safe; a panicking drowning victim can incapacitate an untrained swimmer.

Question 77: On arrival at an active shooter / MCI scene, EMS should stage at which zone?

On the perimeter visible to victims
Warm zone immediately behind officers
Cold zone at a pre-designated assembly point (Correct answer)
Hot zone alongside law enforcement

Correct answer: Cold zone at a pre-designated assembly point

EMS stages in the cold zone until law enforcement secures a warm or rescue task force zone, preventing additional casualties.

Question 78: A 58-year-old male presents with sudden onset tearing chest pain radiating to the back. BP is 190/110 in the right arm and 160/90 in the left arm. What is the most likely diagnosis?

Pulmonary embolism
Aortic dissection (Correct answer)
Acute MI
Esophageal rupture

Correct answer: Aortic dissection

Unequal blood pressures between arms combined with tearing back pain strongly suggests aortic dissection.

Question 79: A patient with a gunshot wound to the neck is speaking in a hoarse voice with subcutaneous emphysema palpable at the neck. The airway should be managed by:

Early definitive airway before swelling closes it (Correct answer)
Waiting and monitoring for deterioration
Nasopharyngeal airway insertion
High-flow oxygen by non-rebreather mask only

Correct answer: Early definitive airway before swelling closes it

Expanding hematoma and edema from zone II neck trauma can rapidly close the airway; early definitive airway management prevents a surgical emergency.

Question 80: After ROSC is achieved, targeted temperature management (TTM) is indicated. What is the recommended target temperature range?

36-38°C to prevent fever only
32-34°C for all post-cardiac arrest patients
32-36°C, selected and maintained for at least 24 hours (Correct answer)
Below 32°C for patients with VF arrest

Correct answer: 32-36°C, selected and maintained for at least 24 hours

Current guidelines recommend maintaining a target temperature between 32-36°C for at least 24 hours after ROSC to minimize neurologic injury.

Question 81: You are treating an 80-year-old male with a history of a previous MI who is complaining of dizziness and weakness. His heart rate is 38/min, BP is 82/54 mmHg, and an EKG shows a third-degree AV block. Atropine has been administered with no change in his condition. What is the most appropriate next step?

Administer an additional dose of Atropine.
Administer a fluid bolus of 500 mL normal saline.
Administer Amiodarone 150 mg IV.
Initiate transcutaneous pacing (TCP). (Correct answer)

Correct answer: Initiate transcutaneous pacing (TCP).

This patient has symptomatic bradycardia (dizziness, weakness, hypotension) caused by a third-degree AV block. Atropine is often ineffective for high-degree blocks (Mobitz II or third-degree) because the block is typically below the level of the AV node where atropine acts. The next indicated step in the ACLS algorithm for unstable bradycardia unresponsive to atropine is to initiate transcutaneous pacing.

National Registry of Emergency Medical Technicians (NREMT) Paramedic Cognitive Exam

The NREMT Paramedic Cognitive Exam assesses the knowledge and skills required to provide advanced prehospital emergency medical care as a Paramedic.

Questions

120 min

Time Limit

70%

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