PM TEST 1

Test 1

1. You have elected to nasotracheally intubate a 66-year-old female in severe

congestive heart failure. As your partner assists the patient’s breathing with a bag-
mask and oxygen, you open the advanced airway kit to get the necessary
equipment. To perform nasotracheal intubation, what equipment and/or materials
would you obtain from the airway bag?

2. You have elected to nasotracheally intubate a 66-year-old female in severe

congestive heart failure. As your partner assists the patient’s breathing with a bag-
mask and oxygen, you open the advanced airway kit to get the necessary
equipment. You are inserting the tracheal tube when you begin to hear the sound of
the patient’s breathing. Your next action would be to:

End tidal CO

detector, tracheal tube, petroleum-based lubricant

Tracheal tube, stylet, 10 ml syringe

Tracheal tube, 10 ml syringe, lubricant
Curved laryngoscope blade, tracheal tube, end tidal CO

detector

Rationale

Placing a nasotracheal tube requires an endotracheal tube, 10-milliliter syringe, water-
soluble lubricant, stethoscope, securing device, and an end tidal CO

detector for ongoing

confirmation of placement. A bag-mask and supplemental oxygen is also required for
ventilation once the tracheal tube has been properly placed. Petroleum lubricant should
not be used since the body has a difficult time breaking it down, leaving a medium for
pathogenic growth and infection. A stylet is not used when placing a nasotracheal tube.
Since nasotracheal intubation is a “blind” technique, a laryngoscope is not required. If a
laryngoscope can be inserted into the pharynx, it is best to visually pass the tube via the
orotracheal route.

(Dot Objective 2-1.43)

wait for the patient to inhale and insert the tube further.

pull back on the tube and secure with tape.

inflate the distal cuff and secure the tube.
attach an end tidal CO

detector to confirm placement.

Rationale

When the sound of a patient’s breathing becomes noticeable, the distal tip of the tracheal
tube is near the glottic opening. The next action would be to insert the tracheal tube into
the larynx and trachea by inserting it slightly further when the patient inhales (vocal cords
are open). Inflation of the distal cuff and confirmation of placement via auscultation must
follow. Inflating the cuff and securing the tube before passing it into the larynx and
trachea would result in pharyngeal placement. The same result would occur by pulling the
tube back and securing it with tape. Since the tracheal tube is not yet in the trachea,

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3. You have elected to nasotracheally intubate a 66-year-old female in severe

congestive heart failure. As your partner assists the patient’s breathing with a bag-
mask and oxygen, you open the advanced airway kit to get the necessary
equipment. After performing the nasotracheal intubation, you note blood coming
from the nare in which the tracheal tube was passed. You would:

4. Which of the following patients has a relative contraindication to nasotracheal

intubation?

attaching an end tidal CO

detector to confirm placement is inappropriate. Additionally, an

end tidal CO

detector should not be used as a means to confirm initial placement of the

tracheal tube. Rather, the end tidal CO

detector is best suited to evaluate ongoing tube

placement.

(Dot Objective 2-1.43)

Remove 5 milliliters of air from the distal cuff.

Pull back on the tracheal tube.

Pinch the nostril around the tube.

Administer intranasal epinephrine.

Rationale

Since the nasopharynx and nares are very vascular, proper insertion of a nasotracheal
tube may cause some hemorrhage. To manage the bleeding, gently pinch the nostril
around the tracheal tube and suction blood from the oropharynx as needed. Although
epinephrine can constrict blood vessels and slow hemorrhage, intranasal administration is
not a field intervention. Partially deflating the distal cuff of the tracheal tube or pulling
back on the tube has nothing to do with hemorrhage originating within the nasal passage
or nasopharynx. The opportunity for hemorrhage can be minimized by using an
appropriately sized tracheal tube as well as the liberal use of water-soluble lubricant.

(Dot Objective 2-1.43)

62-year-old female in cardiogenic shock with a history of arthritis of the hip and who is
taking Naproxen.

48-year-old female in respiratory arrest secondary to a narcotic overdose involving
intravenous morphine sulfate.

37-year-old male in traumatic cardiac arrest and is fully immobilized to a backboard
with a cervical collar applied to his neck.

61-year-old male with a decreased level of consciousness in severe CHF with a history
of chronic atrial fibrillation and is currently taking Coumadin.

Rationale

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5. You have been dispatched to a residence for a male patient with an altered mental

status. On scene, you find the patient seated in a recliner and exhibiting snoring
respirations. Evaluation of his level of consciousness revels him to be responsive to
painful stimuli. Family members state that he is a diabetic and was complaining of
chest pain over the past few hours. They inform you that he took his insulin this
morning, but are unsure if he ate anything. Your immediate treatment for this
patient would be to:

6. A young female patient is suffering an exacerbation of asthma. She presents with

pursed lips, prolonged expirations, and wheezing on auscultation of the chest. Vital
signs are pulse 104 beats per minute, respirations 24 and labored, blood pressure
146/86 mmHg, and SpO

92% on room air. The peak expiratory flow meter

measures 200 liters per minute. Why would use of the peak expiratory flow meter
(PEFM) be useful for this patient?

Since the nasal passages and nasopharynx are extremely vascular regions of the body,
passage of a tracheal tube can result in moderate hemorrhage from these areas.
Therefore, a patient on Coumadin represents a relative contraindication to nasotracheal
intubation given the difficulty that may ensue in controlling subsequent bleeding. Apnea
associated with traumatic cardiopulmonary arrest or narcotic induced respiratory arrest
are absolute contraindications to nasotracheal intubation since there is no audible means
to determine if the distal end of the tube is near the glottic opening. While arthritis to the
cervical spine may make nasotracheal intubation more difficult, it is not a contraindication
to the procedure.

(Dot Objective 2-1.43)

perform a quick look with the cardiac monitor.

perform the head tilt chin lift.

administer high flow oxygen.

check a blood glucose level.

Rationale

Given the presence of snoring respirations, the paramedic must immediately open the
airway using the head tilt-chin lift. Airway management takes precedence over all other
medical issues, including cardiac dysrhythmia and potential blood sugar aberration. If the
airway is not open, supplemental oxygen cannot find its way into the lungs and alveolar
sacs. Since the patient is breathing and has some degree of cerebral function, cardiac
arrest is ruled out, and along with it the use of the paddles for a “quick look.” Checking
the blood glucose level is important given the patient’s presentation and history, however,
this would occur after the airway has been appropriately managed.

(Dot Objective 2-1.1)

It indicates the amount of carbon dioxide present in each exhalation.

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7. A young female patient is suffering an exacerbation of asthma. She presents with

pursed lips, prolonged expirations, and wheezing on auscultation of the chest. Vital
signs are pulse 104 beats per minute, respirations 24 and labored, blood pressure
146/86 mmHg, and SpO

92% on room air. The peak expiratory flow meter

measures 200 liters per minute. To get the patient to properly use the peak
expiratory flow meter, the paramedic would have instructed her to:

It provides a benchmark of ventilation capacity prior to treatment.

It determines the severity and degree of hypoxia present.

It assists in delivering medication deep into the lung tissue.

Rationale

Peak expiratory flow meters measure the amount of air the patient is able to forcibly
exhale over a very quick time period. In obstructive diseases like asthma and COPD, the
patient has a difficult time exhaling air from the lungs. The PEFM is used to measure the
amount of air the patient can exhale and provides a benchmark or severity prior to
treatment as well as objective signs of improvement or deterioration during and after
treatment. A normal expiratory flow rate for a young female is 400 to 500 liters per
minute. A reading of 200 liters per minute suggests moderate obstruction secondary to
bronchiole inflammation and mucous production along with bronchiole smooth muscle
constriction. The PEFM is a tool for the measurement of expired pulmonary volumes, not
medication delivery. Similarly, the PEFM does not measure the amount of carbon dioxide
exhaled or the degree of hypoxia caused by the obstructive lung disorder. A capnometer
and pulse oximeter are needed to quantify levels of carbon dioxide and oxygen
respectively.

(Dot Objective 2-1.11)

take a deep inspiration then forcibly exhale through the meter.

inhale forcibly through the meter to maximum lung inflation.

inhale slowly through the meter to maximum lung inflation.

inhale and exhale normally for 10 seconds through the meter.

Rationale

Proper use of the peak expiratory flow meter (PEFM) requires the patient to take as deep
a breath as possible, seal his or her lips around the device, and exhale as quickly and
forcibly as possible through the meter. The meter then registers a reading in liters per
minute and indicates the amount of air that the patient can exhale, making it useful in
measuring the degree of obstruction in pulmonary diseases like asthma or COPD (where
the fundamental difficulty is exhaling trapped air). Many authorities advocate doing this
exercise twice and using the highest reading. The PEFM is not designed to measure the
volume of air that can be inhaled, only that that is exhaled. Breathing normally in and out
of the meter for ten minutes is likewise inappropriate.

(Dot Objective 2-1.12)

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8. A young female patient is suffering an exacerbation of asthma. She presents with

pursed lips, prolonged expirations, and wheezing on auscultation of the chest. Vital
signs are pulse 104 beats per minute, respirations 24 and labored, blood pressure
146/86 mmHg, and SpO

92% on room air. The peak expiratory flow meter

measures 200 liters per minute. After two nebulized treatments of albuterol, which of
the following signs would directly indicate improvement in the patient’s overall
pulmonary function?

9. A patient with a tracheostomy tube is in respiratory distress and requires suctioning.

To appropriately suction the patient, which of the following pieces of equipment will
you need?

PEFM reading of 400 liters per minute
SpO

reading of 93%

Heart rate of 112 beats per minute

Absence of wheezing in the chest

Rationale

The PEFM reading of 400 liters per minute, when compared to the initial reading of 200
liters per minute, indicates tremendous improvement in the patient’s ability to exhale air
from the lower respiratory tract. An increasing heart rate does not indicate improvement
since the resolution of hypoxia should decrease the rate, not increase it. Although the
increased heart rate may be secondary to the stacked albuterol treatments, it is still not
suggestive of marked improvement. The pulse oximetry reading of 93% is a little better
than 92%, but not significant enough to indicate improvement, as might a reading of
97%. The absence of wheezing in the chest must be coupled with other signs like an
increasing PEFM reading or improving pulse oximeter readings before improvement can be
interpreted. Without supporting evidence of improvement, absence of any and all
wheezing indicates that the airflow through the lungs is so minimal it cannot produce any
wheezing. This is a major emergency and typically indicates the need for more aggressive
treatment, including tracheal intubation.

(Dot Objective 3-3.49)

Petroleum based lubricant

Sterile gloves

Uncuffed endotracheal tube

Rigid tip (Yankauer) suction catheter

Rationale

A tracheostomy permits access into the lower airway and you should use sterile
equipment, including sterile gloves, to prevent unnecessary infection. A soft tip catheter
(whistle tip catheter) is needed to access the trachea and mainstem bronchi, not a rigid
tip (Yankauer) suction catheter. Water-soluble lubricant, not petroleum based lubricant, is
used because it is readily broken down by the body should it remain in the trachea. This
decreases the chance for the colonization of pathogens within the lubricant resulting in

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10. You intubated a bradycardic patient who then went into ventricular fibrillation. After

defibrillating once, the patient went into a normal sinus rhythm at a rate of 88 beats
per minute and blood pressure of 136/90 mmHg. Within a few minutes, he regained
consciousness and now is fighting to remove the endotracheal tube. Medical
command has instructed you to extubate the patient. To remove the tube, you
would:

11. You, your partner, and several first responders are managing a 54-year-old female

with status asthmaticus. The patient is in extreme distress and has proven refractory
to all aerosolized treatments as well as subcutaneous epinephrine. She is profoundly
hypoxic and starting to exhibit episodic cardiac dysrhythmias on the cardiac monitor.
High flow oxygen is being administered through a nonrebreathing facemask and an
IV has been established. Given the status of the patient and a long transport time,
Medical command has instructed you to perform rapid sequence intubation using
midazalom (Versed) and succinylcholine (Anectine). As you prepare the medications
and equipment for rapid sequence intubation, it is critical to:

infection, as can occur with petroleum based gel. Endotracheal tubes are not needed
when suctioning through a tracheotomy, although they are required when performing
tracheobronchial suctioning via the upper airway.

(Dot Objective 2-1.31)

use the laryngoscope to remove the tracheal tube from the trachea.

deflate the cuff and remove the tube using the Magill forceps.

deflate the distal cuff and remove the tube as the patient exhales.

insert an oropharyngeal airway and then remove the tracheal tube.

Rationale

To remove the tracheal tube, the distal cuff must first be deflated then the tube pulled as
the patient exhales or coughs. This enables the tube to be removed with the greatest
amount of comfort and least risk for complication such as laryngeal trauma or involuntary
closure of the glottis. There is no need to directly visualize removal of the tube with the
laryngoscope. Use of the laryngoscope may also cause the patient to gag and vomit. The
same holds true for insertion of an oropharyngeal airway. Removal of the tracheal tube
can be done with the provider’s hands and does not necessitate the use of the Magill
forceps.

(Dot Objective 2-1.75)

determine the patient’s blood glucose level.

insert an oropharyngeal airway and hyperventilate.

administer a nebulized treatment of albuterol.

leave the nonrebreather in place for 3 to 5 minutes.

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12. You, your partner, and several first responders are managing a 54-year-old female

with status asthmaticus. The patient is in extreme distress and has proven refractory
to all aerosolized treatments as well as subcutaneous epinephrine. She is profoundly
hypoxic and starting to exhibit episodic cardiac dysrhythmias on the cardiac monitor.
High flow oxygen is being administered through a nonrebreathing facemask and an
IV has been established. Given the status of the patient and a long transport time,
Medical command has instructed you to perform rapid sequence intubation using
midazalom (Versed) and succinylcholine (Anectine). While performing rapid sequence
intubation, why would you have a first responder apply cricoid pressure?

Rationale

Preoxygenation with a nonrebreather facemask floods the lungs with pure oxygen. It is
important to remember that as the patient enters a state of paralysis, she will not be
actively breathing until the tracheal tube is correctly placed. Therefore, providing the
reservoir of oxygen in the lungs temporarily enables oxygen to continually diffuse into the
bloodstream and be transported to the cells and tissues. Three to five minutes of high
flow oxygen is acceptable and should be provided as you are assembling the necessary
materials for rapid sequence intubation. Since the patient is conscious, it must be
assumed that she has an intact gag reflex and will not accept the oropharyngeal airway. If
she would accept the airway, the use of sedative and paralytic agents may be
unnecessary. (If the patient has a poor minute volume, it may be best to assist
ventilations without the use of an oropharyngeal airway; however, this does dispose the
patient to gastric insufflation and increases the risk of aspiration.) A nebulizer does not
provide the degree of high flow oxygen that a nonrebreathing facemask does. (The same
holds true for a nebulizer built into a facemask.) The blood glucose level has no bearing
on the use of paralytics or the procedure of rapid sequence intubation. (The exception
being a combative hypoglycemic patient who should receive glucose, not rapid sequence
intubation!)

(Dot Objective 2-1.65)

to decrease the opportunity for aspiration.

to move the tongue forward and away from the glottis.

to move the epiglottis from over the top of the glottis opening.

to place the vocal cords in an open position.

Rationale

Generally, the patient encountered in the prehospital emergency setting is assumed to
have contents in their stomach, increasing the risk for aspiration. When paralyzing a
patient for rapid sequence intubation, this risk is further increased since the lower
esophageal sphincter tone is compromised and the presence of fasciculations promote the
movement of stomach contents up the esophagus into the pharynx. Therefore, when
performing rapid sequence intubation, it is critical that cricoid pressure be used to occlude
the upper portion of the esophagus. Cricoid pressure should not be removed until the
tracheal tube has been appropriately placed. Cricoid pressure does not move the tongue
away from the glottic opening nor does it cause the vocal cords to part and remain open.
Similarly, cricoid pressure does not move the epiglottis from over top the glottic opening.

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13. You, your partner, and several first responders are managing a 54-year-old female

with status asthmaticus. The patient is in extreme distress and has proven refractory
to all aerosolized treatments as well as subcutaneous epinephrine. She is profoundly
hypoxic and starting to exhibit episodic cardiac dysrhythmias on the cardiac monitor.
High flow oxygen is being administered through a nonrebreathing facemask and an
IV has been established. Given the status of the patient and a long transport time,
Medical command has instructed you to perform rapid sequence intubation using
midazalom (Versed) and succinylcholine (Anectine). The administration of
succinylcholine will aid in tracheal tube placement by:

14. You are performing rapid sequence intubation on a patient with a suspected

intracranial hemorrhage. Etomidate (Amidate) was administered for sedation and
you have just administered succinylcholine (Anectine) to induce paralysis. The
patient is staring forward with his eyes open. You note sporadic muscular
contractions (fasciculations) occurring to the extremities and fingers. Which of the
following signs indicate that the patient is paralyzed and ready for intubation?

(Dot Objective 2-1.65)

binding to the receptors of the muscle cells.

abolishing the patient’s gag reflex.

relaxing the central nervous system.

sedating the patient so that she cannot move.

Rationale

Succinylcholine is used for muscular paralysis and classified as a depolarizing agent. As
such, succinylcholine binds with receptors on the muscle cells, causing them to
depolarize. Since the succinylcholine is not released from the receptors for 3 to 5 minutes,
the muscles cannot move and paralysis is achieved. Paralysis facilitates tracheal tube
placement in the conscious patient. However, the diaphragm is also paralyzed, meaning
that the patient has lost their means to breathe on their own. As a muscular paralytic,
succinylcholine does not relax the central nervous system nor abolish the patient’s gag
reflex. Paralytic agents do not produce sedation. Rather, medications like midazalom
(Versed) are used for this purpose.

(Dot Objective 2-1.65)

Heart rate drops 10 to 20 beats per minute.

The patient’s eyes close.

Fasciculations are present in fingers only.

The chest wall ceases to rise and fall.

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15. You are performing rapid sequence intubation on a patient with a suspected

intracranial hemorrhage. Etomidate (Amidate) was administered for sedation and
you have just administered succinylcholine (Anectine) to induce paralysis. The
patient is staring forward with his eyes open. You note sporadic muscular
contractions (fasciculations) occurring to the extremities and fingers. After several
attempts, you are unable to place the tracheal tube into the trachea. Your immediate
action would be to:

16. You are managing a male patient with shortness of breath and a history of chronic

obstructive pulmonary disease (COPD). When reviewing the medications the patient
is taking, which of the following would be used to treat his condition of COPD?

Rationale

After administering succinylcholine, total paralysis is obtained within 60 to 90 seconds.
Signs that the succinylcholine has taken full effect include the absence of all
fasciculations, absence of chest wall movement, and relaxation of the jaw. At this point,
the patient is not breathing and rapid placement of the tracheal tube is paramount. Most
patients will not close their eyes, despite full paralysis. A drop in heart rate signifies a
serious underlying problem like hypoxia or cardiac dysrhythmia and warrants immediate
attention. As mentioned, total paralysis is evident by the cessation of all fasciculatory
activity.

(Dot Objective 2-1.65)

administer Romazicom.

perform a needle or surgical cricothyrotomy.

ventilate with the bag-valve-mask.

administer Narcan.

Rationale

Failure to place the tracheal tube in a paralyzed patient is a major emergency and
necessitates immediate action. The immediate treatment is to ventilate the patient until
the succinylcholine is broken down by the body and the patient is able to once again
breathe on his or her own. If the patient cannot be ventilated, then a backup airway such
as the Esophageal-Tracheal Combitube or Laryngeal Mask airway (LMA) should be used. If
these devices fail, the paramedic may have to resort to a needle or surgical
cricothyrotomy (but only as a last resort). Narcan will not reverse the effects of
succinylcholine. Romazicon may reverse the sedatory effects of the midazalom (Versed),
but will not affect the muscular paralysis caused by the succinylcholine. It would be best
to not administer the Romazicon but leave the patient sedated as you take measures to
ventilate and/or establish an airway in the failed intubation attempt.

(Dot Objective 2-1.65)

Aspirin

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17. Which of the following medication types would a physician prescribe to decrease the

inflammation associated with asthma?

18. Which of the following would be the most typical chief complaint of a person

suffering from otitis media?

Prednisone

Nitroglycerin

Lasix

Rationale

Steroids, including prednisone, are used to treat the inflammation associated with chronic
obstructive pulmonary disease, particularly chronic bronchitis and asthma. Steroids
stabilize cells and decrease the inflammatory process, resulting in clear and open airways
in the lower respiratory tract. However, because of detrimental side effects associated
with long-term use, steroids are prescribed for short durations in the COPD patient,
typically during periods of exacerbation. Recent studies have shown inhaled steroids to be
particularly effective and not exert the negative effects associated with long-term oral
use. Nitroglycerine, Lasix, and aspirin are medications used to treat conditions and
diseases originating with the cardiovascular system, not the respiratory system.

(Dot Objective 5-1.8)

Mucolytic
Beta

Bronchodilator

Steroid

Antibiotic

Rationale

Steroids decrease the inflammatory response in patients with diseases and conditions
involving inflammation, including asthma. Beta2 bronchodilators do not target
inflammation but facilitate bronchiole dilation by relaxing the smooth muscle around the
small airways. Mucolytics cause thick mucous to become thinner and help in its
expectoration from the body. Antibiotics are used to treat bacterial infections, not
inflammation.

(Dot Objective 5-1.8)

“My nose is running.”

“My jaw hurts.”

“My ear hurts.”

“It hurts when I swallow.”

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19. When treating a patient with an upper respiratory tract infection, it is important for

the paramedic to recognize that:

20. The mother of an 11-year-old tells you that her daughter cannot breathe.

Assessment reveals her to be complaining of a headache and malaise. Her mother
states that she has been sick for two days and does not seem to be getting any
better. Her vital signs are pulse 88 beats per minute, respirations 20 per minute,
blood pressure 102/70 mmHg, and SpO

99% on room air. Her temperature is 100.6

degrees Fahrenheit and she has a considerable amount of greenish-yellow mucous
discharging from her nose. Palpation to the sinuses under both cheekbones reveals
tenderness. What sinuses are tender when palpated?

Rationale

Otitis media is a rather common infection that occurs in the middle ear. Consequently, the
patient with otitis media typically complains of ear pain. Other complaints may be that of
dizziness or headache and nausea. Rhinorrhea, or a runny nose, is commonly associated
with rhinitis or sinusitis and not an ear infection. Painful swallowing is suggestive of an
infection and inflammation in the pharynx, and can even indicate a life threatening
condition like epiglottitis or croup. Gastric pain is not a clinical manifestation of otitis
media.

(Dot Objective 5-1.1)

minimal EMS intervention is typically required.

infections will become life threatening if not treated.

IV therapy is the mainstay of prehospital treatment.

antibiotics are the most effective treatment.

Rationale

Upper respiratory tract infections (e.g., pharyngitis, sinusitis, and rhinitis) are rarely life
threatening and typically self-limiting. Care, including that provided by EMS, is minimal
and more supportive than interventional. Most often, care measures are geared towards
decreasing the discomfort associated with an upper respiratory tract infection, thus not an
immediate concern when encountered prehospitally. The majority of upper respiratory
tract infections are viral in origin, making antibiotics (used to treat bacterial infections)
ineffective. Oral hydration to thin and loosen mucous secretions is preferred to IV fluid
therapy for the same purpose.

(Dot Objective 5-1.1)

Ethmoidal

Frontal

Maxillary

Sphneoid

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21. The single largest cause of death for Americans is/are:

22. You have been called to the side of a 62-year-old male patient complaining of

weakness and dizziness. Assessment reveals the patient to be slightly confused, but
they have a patent airway with adequate breathing. The pulse is rapid and the skin is
cool and diaphoretic. Auscultation of the lungs reveals bilateral rales. The patient
states that the weakness and dizziness started 6 hours ago and is accompanied by a
notable discomfort in his chest. His past medical history includes angina and
hypertension for which he takes nitroglycerin and Captopril respectively. Vital signs
are pulse 168 beats per minute, respirations 18 per minute, blood pressure 82/60
mmHg, and SpO

92%. The cardiac monitor shows the following rhythm: Your

primary goal in treating this patient is to:

Rationale

The maxillary sinuses are located underneath the cheekbones and a common location for
a sinus infection, also known as sinusitis. Sinusitis describes the infection and
inflammation of the sinus cavities, and can be very painful and even require surgical
intervention for correction. The frontal sinuses are located above each eye in the frontal
bone of the skull. The ethmoidal sinuses are located on the bridge of the nose.

(Dot Objective 5-1.1)

cancer.

chronic obstructive airway disease.

traumatic injuries.

coronary heart disease.

Rationale

Coronary heart disease, also known as coronary artery disease (CAD), is the number one
threat to American health, killing an estimated 466,000 persons annually. While some
predisposition to coronary heart disease is non-modifiable, many of the risk factors are
behaviors that can be changed (e.g., obesity, sedentary lifestyle, and smoking). While
chronic obstructive pulmonary disease, cancer, and traumatic injuries represent major
health problems, they do not claim lives on the magnitude that does coronary heart
disease.

(Dot Objective 5-2.1)

increase cardiac contractility.

decrease the atrial rate.

decrease the ventricular rate.

restore a normal sinus rhythm.

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23. You have been called to the side of a 62-year-old male patient complaining of

92%. The cardiac monitor shows the following rhythm: In relation

to the ECG tracing, which of the following bests describes the activity of the atria?

24. You have been called to the side of a 62-year-old male patient complaining of

weakness and dizziness. Assessment reveals the patient to be slightly confused, but
have a patent airway with adequate breathing. The pulse is rapid and skin cool and
diaphoretic. Auscultation of the lungs reveals bilateral rales. The patient states that
the weakness and dizziness started 6 hours ago and is accompanied by a notable

Rationale

Prehospital care for rapid atrial fibrillation is geared towards decreasing the ventricular
rate. The slower rate (<100 beats per minute) will decrease the heart’s workload and
facilitate a better cardiac output by enabling a longer ventricular filling time. Rate control
can be accomplished with medications (e.g., adenosne or calcium channel blockers) and
synchronized cardioversion (for the unstable patient). Although restoration of a sinus
rhythm may occur, this is not a primary goal for field treatment since rhythm conversion
carries a significant risk for the release of blood clots that have formed in the atria
(especially if the atrial fibrillation has persisted for over 48 hours). Slowing the ventricular
rate does not slow the atrial rate, which can reach 250 to 350/minute. Rate control is the
initial focus, not contractility.

(Dot Objective 5-2.11)

Rapid contraction

Quivering

Slow

Absent

Rationale

In atrial fibrillation, multiple foci in the atria initiate electrical impulses that chaotically
depolarize the atrial tissue. The atrial rate is so fast (250 to 350/minute) that there is no
organized contraction (not even rapid), only a quivering motion, which is evidenced by
multitudes of “F” waves. In this sense, the atrial activity cannot be described as absent or
slow, only quivering.

(Dot Objective 5-2.31)

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discomfort in his chest. His past medical history includes angina and hypertension for
which he takes nitroglycerin and Captopril respectively. Vital signs are pulse 168
beats per minute, respirations 18 per minute, blood pressure 82/60 mmHg, and
SpO

92%. The cardiac monitor shows the following rhythm: What condition might

result from rhythm conversion?

25. Which of the following statements is true concerning the following ECG description?

Rhythm: Regular
Rate: 84 beats per minute
P wave: Upright
PR interval: 0.32 seconds
QRS: 0.10 seconds

Hyperkalemia

Stroke

Hypertension

Arterial hemorrhage

Rationale

The loss of an organized atrial contraction slows blood movement through the chambers.
Consequently, blood clots can form on the walls of the atria (typically seen after 48 hours
of atrial fibrillation). Slowing the rate with appropriate treatment can also spontaneously
convert the atrial fibrillation into a sinus rhythm. In a sinus rhythm, the organized
contraction of the atria can cause the blood clots to break free and become emboli,
leading to stroke, acute arterial occlusion, and/or pulmonary emboli. For this reason,
prehospital treatment is generally reserved for the hemodynamically unstable patient with
acute onset of atrial fib with a rapid ventricular response. Hyperkalemia, arterial
hemorrhage, and hypertension are not conditions resulting from the appropriate
treatment of atrial fibrillation.

(Dot Objective 5-2.11)

There is cardiac depolarization but no contraction.

A conduction disturbance exists in the intraventricular conduction system.

There is an abnormal conduction delay in the AV node.

The primary pacemaker is in the ventricles.

Rationale

The PR interval represents the delay of conduction between the atria and ventricles
(normally between 0.12 to 0.20 seconds). A conduction delay of 0.32 seconds exceeds
this range and represents an increased amount of time for the electrical impulse to pass
from the atria into the ventricles. A heart rate of 84 and QRS complexes of 0.10 seconds
indicate that the primary pacemaking site is atrial, not ventricular. Similarly, a conduction
time of 0.10 seconds through the ventricles does not indicate a disturbance in the intra-
ventricular tissue. Without feeling for a pulse, there is no way to determine the presence
or absence of cardiac contraction.

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26. You have been called to the parking lot of a restaurant for a confused 59-year-old

male who is profusely diaphoretic and vomiting. Bystanders state that the patient
pulled up in a car and got out before slumping to the ground. Your initial assessment
reveals him to have a patent airway but heavy breathing with scattered rales in both
lungs. His skin is pale and diaphoretic and radial pulse difficult to locate. Vital signs
are pulse 36, respirations 22, blood pressure 64/40 mmHg, and SpO

91%. You note

a diabetic alert bracelet on his left wrist. Application of the cardiac monitor shows the
rhythm below: Your initial intervention for this patient would be:

27. You have been called to the parking lot of a restaurant for a confused 59-year-old

91%. You note

a diabetic alert bracelet on his left wrist. Application of the cardiac monitor shows the
rhythm below: The ECG strip for this patient suggests ischemia or damage to what
part of the heart?

(Dot Objective 5-2.11)

glucose to correct a low blood glucose level.

dopamine infusion to increase the blood pressure.

furosemide (Lasix) to reduce fluid in the pulmonary tissue.

transcutaneous pacing to increase the cardiac output.

Rationale

The primary goal of treating symptomatic bradycardia in to increase the heart rate, which
in turn will increase the cardiac output (amount of blood pumped by the heart in one
minute). As such, transcutaneous pacing is a Class I indication for bradycardia regardless
of the underlying rhythm. Dopamine can increase the blood pressure, but should be used
after transcutaneous pacing has been attempted due to the time needed to establish an
IV and prepare the infusion. The pulmonary edema is most likely caused by the slow heart
rate and will probably resolve when the heart rate is increased. Additionally, it is
questionable whether a diuretic should be used given the hypotensive state of the patient.
There is no descriptive or clinical information that suggests that the patient is
hypoglycemic. Even if he were, the paramedic must address the cardiac problem prior to
the diabetic complication.

(Dot Objective 5-2.11)

Sinoatrial (SA) node

Ventricles

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28. You have arrived on the scene for a male diabetic patient who is not breathing. First

Responders on scene state that the patient arrested just moments before you walked
in so they initiated CPR until they could get their AED. You find the patient lying
supine in a hallway with CPR being performed. You place the paddles on his chest
and perform a “quick look.” The following rhythm is observed on the cardiac
monitor: (ECG-ventricular fibrillation) The priority of your treatment would be:

29. You have arrived on the scene for a male diabetic patient who is not breathing. First

Responders on scene state that the patient arrested just moments before you walked
in so they initiated CPR until they could get their AED. You find the patient lying
supine in a hallway with CPR being performed. You defibrillate once and then resume
CPR for 2 minutes. Your next action would be to:

Atria

Atrioventricular (AV) node

Rationale

A second-degree Type II AV heart block is characterized by intermittent conduction and
blocking of electrical impulses from the atria into the ventricles. This is evidenced by a
grater number of P waves than QRS complexes. Therefore, the paramedic can assume a
problem (ischemia, damage, or infarction) in the AV node. The presence of P waves
indicates that the sinoatrial node is functioning properly and that intra-atrial conduction is
normal. With no ectopic atrial beats and normal conduction through the ventricles (QRS of
<0.12 seconds), there isn't any indication of problems within the ventricles.

(Dot Objective 5-2.31)

endotracheal intubation.

medication administration.

electrical therapy.

chest compressions and ventilations.

Rationale

Rapid defibrillation (electrical therapy) is the definitive care for ventricular fibrillation if the
"down-time" is less than 4 minutes, as it is in this situation. Since successful conversion of
ventricular fibrillation is time dependent, any delay of defibrillation significantly decreases
the opportunity for conversion to a pulse producing rhythm. Although endotracheal
intubation, medication administration, and chest compressions and ventilations are
important interventions, they should be implemented only after the initial defibrillatory
shock has been given in the witnessed arrest.

(Dot Objective 5-2.11)

establish an IV.

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30. While transporting a 44-year-old male to the hospital, you note the rhythm below on

the cardiac monitor. The patient is conscious, alert, and oriented. Vital signs are
pulse 80, respirations 16, and blood pressure 138/82 mmHg. Your immediate action
would be to:

31. You are emergently transporting a patient with a severe GI bleed to the hospital.

During transport, the patient becomes unresponsive, apneic, and pulseless. The
cardiac monitor shows the rhythm below: Aside from endotracheal intubation and
medications, what other intervention will give this patient his best chance for
survival?

check the blood glucose level.

infuse lidocaine or amiodarone.

check the pulse.

Rationale

The paramedic must always assess for a pulse with any rhythm change. While
defibrillation may have been successful in restoring an organized electrical rhythm, this
rhythm may or may not be producing an effective myocardial contraction and effective
blood circulation throughout the body to the cells and tissues (pulseless electrical
activity). A maintenance infusion of lidocaine or amiodarone is appropriate, but only if the
patient has an adequate pulse and blood pressure. Establishing an IV, if not yet done, is
important, but should not delay checking the patient pulse. The same holds true for
checking the patient’s blood glucose level.

(Dot Objective 5-2.11)

start CPR.

defibrillate at 200 joules.

check the monitor.

place the patient supine with feet elevated.

Rationale

This ECG tracing is caused by an electrode that has pulled loose from the chest wall.
Therefore, the paramedic should check the cardiac monitor to determine what lead has
been affected. Since the patient is responsive and breathing, he is not in cardiac arrest.
Therefore, defibrillation and CPR are inappropriate. There are no indications (e.g.,
dizziness or syncope) to place the patient in a supine position with the feet elevated.

(Dot Objective 5-2.11)

Defibrillation

Pleural decompression

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32. You are dispatched to a residence for shortness of breath. As you approach the

patient, you note a 65-year-old female sitting upright on a chair in her living room.
She exhibits labored breathing but denies chest pain. Assessment reveals a patent
airway, tachypneic breathing, and rapid, weak, radial pulses accompanied by
cyanotic and diaphoretic skin that is cool to the touch. Findings from the focused
physical exam include rales to both lungs but no jugular venous distention. There is
no obvious ascites or pedal edema. Vital signs are pulse 136 beats per minute,
respirations 24 per minute, and blood pressure 148/90 mmHg. SpO

on room air is

89%. The cardiac monitor shows the following rhythm: Based on the above
information, you would recognize:

33. You are dispatched to a residence for shortness of breath. As you approach the

Volume infusion

Synchronized cardioversion

Rationale

To effectively reverse pulseless electrical activity (PEA), the underlying cause must be
identified and treated, all the while providing other aspects of advanced cardiac life
support (e.g. endotracheal intubation, oxygenation, and medication administration). Since
this patient has a history of blood loss, it should be assumed that he is hypovolemic and
requires fluid volume (although whole blood would be best). Defibrillation is an
intervention for ventricular fibrillation, not PEA. Synchronized cardioversion is appropriate
for unstable tachydysrhythmias with a pulse and not PEA. There is no information leading
the paramedic to believe that the patient has a tension pneumothorax, therefore
decompression of the pleural space is improper.

(Dot Objective 5-2.11)

right ventricular failure.

left ventricular failure.

right and left ventricular failure.

right and left atrial failure.

Rationale

The presence of rales indicates that the left ventricle is failing as a forward moving pump,
raising the hydrostatic pressure in the pulmonary circulatory system. In turn, fluid is
forced from the pulmonary blood vessels into the interstitial and alveolar compartments of
the lungs. If right ventricular failure were also present, the patient would display
additional signs like distention of the jugular veins and/or pedal edema or ascites.
Isolated atrial failure of either the left or right side of the heart would not cause blood to
back up in the lung tissue, as the outflow pumping of blood is a sole function of the larger
ventricles.

(Dot Objective 5-2.91)

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on room air is

89%. The cardiac monitor shows the following rhythm: The presence of rales
indicates:

34. You are dispatched to a residence for shortness of breath. As you approach the

on room air is

89%. The cardiac monitor shows the following rhythm: After giving the patient
nitroglycerin, she states that it is easier to breathe. You would relate this
improvement to:

failure of the left ventricle causing an increase in pressure in the pulmonary circulatory
system.

failure of the left ventricle that inhibits the entry of blood into the pulmonary circulatory
system.

failure of the right ventricle causing an increase in pressure in the pulmonary
circulatory system.

failure of the right ventricle causing a decrease of pressure in the pulmonary circulatory
system.

Rationale

Failure of the left ventricle as a forward moving pump will cause an increase in the
hydrostatic pressure in the pulmonary blood vessels, therein causing blood to escape
these vessels and collect in the interstitial and alveolar compartments of the lung. As the
air in the lung moves through this fluid, the breath sound typically described as rales
(crackles) is heard. If the right ventricle fails, a decreased movement of blood into the
pulmonary circulation would be realized resulting in a drop in hydrostatic pressure. This
would not cause fluid to escape into the interstitial and alveolar compartments of the lung
tissue. The left ventricle is responsible for pumping blood into the systemic circulation, not
the pulmonary circulation.

(Dot Objective 5-2.91)

constriction of the veins.

increase in cardiac contractility.

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35. You are dispatched to a local drug store for a patient with an elevated blood

pressure. On scene, the patient informs you that he was taking his blood pressure
using the automated blood pressure cuff and got a reading of 190/114 mmHg. He
retook it in his other arm and got a reading of 200/110 mmHg. He then became
worried and called 911. Assessment findings show the patient to be alert, oriented,
breathing easily, with a strong and bounding pulse. Vital signs are pulse 104 beats
per minute, respirations 18 per minute, and blood pressure 198/118 mmHg. He does
have a history of hypertension but has been non-compliant with his medications.
Based on this information, you would categorize his condition as:

36. You are dispatched to a local drug store for a patient with an elevated blood

pressure. On scene, the patient informs you that he was taking his blood pressure
using the automated blood pressure cuff and got a reading of 190/114 mmHg. He

dilation of the arterioles.

promotion of fluid loss through the kidneys.

Rationale

Nitroglycerin causes the arterioles and veins (to a lesser extent) to dilate. Dilation of the
arterioles decreases the pressure against which the left ventricle must pump blood. In
turn, it is easier for the left ventricle to move the blood that has backed up in the
pulmonary tissues to the systemic circulation. Removal of the fluid from the lung tissue
and alveoli results in the patient having an easier time breathing and oxygenating the
body cells and organs. Nitroglycerin does not possess inotropic qualities that increase the
force of cardiac contraction. Nitroglycerin does not cause venous constriction, but to some
extent will also dilate the veins. Diuretics, not nitroglycerin, cause the loss of fluid through
the kidneys.

(Dot Objective 5-2.91)

Hypertensive encephalopathy

Hypertensive crisis

Hypertensive emergency

Hypertensive urgency

Rationale

The elevated blood pressure, particularly the diastolic reading, is cause for concern.
However, since acute care is generally deferred until the diastolic pressure exceeds 130
mmHg, this patient is best classified as suffering a hypertensive urgency. As stated, a
hypertensive emergency occurs when the diastolic blood pressure exceeds 130 mmHg.
Hypertensive encephalopathy describes a state of extreme hypertension accompanied by
neurologic signs and symptoms like slurred speech, headache, or visual disturbances.

(Dot Objective 5-2.11)

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retook it in his other arm and got a reading of 200/110 mmHg. He then became
worried and called 911. Assessment findings show the patient to be alert, oriented,
breathing easily, with a strong and bounding pulse. Vital signs that you obtain
include a pulse of 104 beats per minute, respirations 18 per minute, and a blood
pressure 198/118 mmHg. He does have a history of hypertension but has been non-
compliant with his medications. Which of the following would be the best treatment
for this patient?

37. A 50-year-old male is responsive to painful stimuli and has a patent airway and

labored breathing. His radial pulse is difficult to locate and his skin is cool and
diaphoretic. Vital signs are pulse 240 beats per minute, respirations 18 per minute,
and blood pressure 72/50 mmHg. Breath sounds are clear and there is no sign of
edema to the ankles or feet. The cardiac monitor shows the rhythm below. No
medical history is available. Given this presentation, what is the primary problem
with the heart?

Supportive care

Sublingual nitroglycerin every 5 minutes

IV Labetalol (Beta blocker)

Transport in a supine position

Rationale

Since the patient is not experiencing signs and symptoms associated with the elevated
blood pressure, supportive care and monitoring are all that are needed for field treatment.
If the patient were experiencing hypertensive encephalopathy, treatment with
medications like beta-blockers or nitroglycerin may be indicated. There is no reason to
transport the patient supine, given that his blood pressure is more than adequate to
perfuse critical organs like the brain, heart, and kidneys.

(Dot Objective 5-2.11)

Poor myocardial contractility

Decreased stroke volume

Elevated afterload

Increased stroke volume

Rationale

In hemodynamically unstable supraventricular tachycardia, the heart is beating so fast
that the ventricles do not have adequate time to fill before pumping blood into the
peripheral circulatory system. This impairs the stroke volume leading to poor cardiac
output (the amount of blood pumped by the heart in one minute). The inadequate cardiac
output decreases perfusion of critical organs like the brain, resulting in altered mental
status. There is no indication of any condition (blood loss or dehydration) that would lead
to a decreased preload (blood returned to the heart for pumping). An elevated afterload
describes a higher arterial pressure that the left ventricle must overcome in order to
pump blood into the systemic circulation. This is commonly observed by an elevated blood

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38. A 50-year-old male is responsive to painful stimuli, has a patent airway, and labored

breathing. His radial pulse is difficult to locate and his skin is cool and diaphoretic.
Vital signs are pulse 240 beats per minute, respirations 18 per minute, and blood
pressure 72/50 mmHg. Breath sounds are clear and there is no sign of edema to the
ankles or feet. The cardiac monitor shows the rhythm below. No medical history is
available. Treatment of this patient would consist of:

39. A 50-year-old male is responsive to painful stimuli, has a patent airway, and labored

pressure, particularly the diastolic. Since the patient is hypotensive, an elevated afterload
is not present. There are no signs that suggest poor myocardial contractility (e.g.,
pulmonary edema, jugular venous distention, or peripheral edema).

(Dot Objective 5-2.7)

asynchronous cardioversion.

synchronized cardioversion.

transcutaneous pacing.

defibrillation.

Rationale

The most appropriate treatment for this patient would be synchronized cardioversion.
Synchronized cardioversion specifically places an electrical counter shock on the R wave in
an attempt to abolish the dysrhythmia. Following the shock, it is hoped that the heart will
resume a normal rhythm at a slower rate. Defibrillation is not indicated for
hemodynamically unstable supraventricular tachycardia (SVT). Asynchronous
cardioversion is another term for defibrillation and is likewise not indicated. Similarly,
transcutaneous pacing is not an indicated procedure for SVT.

(Dot Objective 5-2.13)

Increased ventricular filling time

Relative bradycardia

Decreased cardiac output

Increased myocardial automaticity

Rationale

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40. A 72-year-old male patient complains of calf pain when exercising. After stopping the

exercise, the pain gradually resolves. Assessment of the calf reveals the extremity is
warm with normal color and a strong pedal pulse in the foot. There is no tenderness
noted on palpation. The patient has a history of atherosclerosis and hypertension.
Based on this information, the paramedic would recognize the presence of:

41. You have been summoned to the residence of a 62-year-old female patient with leg

pain. The patient states that her pain is in her left lower leg and has been occurring
over the past two days. Today, the leg became swollen and was difficult to walk on.
Assessment reveals the leg and foot to be moderately swollen and warm to the
touch. There is also tenderness to the calf region. A pedal pulse is noted. Vital signs
are pulse 80 beats per minute, respirations 14 per minute, blood pressure 142/78
mmHg, SpO

97% on room air, and temperature 97.9 degrees F. She has a history

of coronary artery disease, angina, and hypertension, for which she is prescribed
Lipitor, nitroglycerin, and Norvasc. Additionally, she takes Seroquel for depression

By administering synchronized cardioversion, the paramedic hopes to slow the rate, thus
allowing greater time for the ventricles to fill. In turn, more blood is pumped with every
heartbeat and an increased cardiac output enabled. Synchronized cardioversion will not
directly enhance myocardial contractility. As described, cardiac output will increase, not
decrease. Relative bradycardia is a dangerous rhythm in which the heart rate is above 60
beats per minute, but signs and symptoms of bradycardia are present (altered mental
status, pulmonary edema, hypotension, chest pain). The goal of providing synchronized
cardioversion is not to induce relative bradycardia.

(Dot Objective 5-2.7)

dissecting aneurysm.

phlebitis.

varicose veins.

claudication.

Rationale

Claudication describes severe pain in the calf muscle due to an inadequate supply of
oxygen-rich blood. Typically, claudication occurs when the calf muscle is being exerted
and demands more oxygenated blood than can be delivered (due to decreased vessel size
from atherosclerosis). Subsequently, the patient experiences ischemic pain until the
oxygen demand in the calf muscle is reduced and brought into line with the available
oxygen-rich blood (as occurs when the exercise or activity is stopped). Varicose veins are
dilated superficial veins that are visually apparent. There is no mention of varicose veins
in the scenario. Phlebitis describes the inflammation of a vein(s) and is evident by redness
along the course of the vein, increased temperature, and tenderness on palpation. None
of these signs or symptoms is present. Aneurysms typically affect larger vessels like the
aorta, and not smaller vessels located in the distal lower extremities.

(Dot Objective 5-2.14)

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and has no allergies. Which of the following pieces of information must the
paramedic recognize as critical to the identification of the patient’s underlying
condition?

42. You have been summoned to the residence of a 62-year-old female patient with leg

97% on room air, and temperature 97.9°F. She has a history of

Recent history of nausea, vomiting, and diarrhea

Presence of varicose veins in both legs

Abdominal scar from hysterectomy 10 years ago

Abrupt stopping of her Seroquel one month ago

Rationale

The presence of varicose veins is the most significant to the patient’s complaint of left leg
pain. Based on the assessment findings, the paramedic should recognize a probable deep
venous thrombosis (DVT). It has been demonstrated that 50% of persons with varicose
veins will develop a DVT, making it a significant risk factor for the condition. Although
abdominal surgery may cause a clot to embolize into the veins of the leg (or form a
pulmonary thromboembolism), ten years is a considerable time, making this item
unlikely. A recent history of nausea, vomiting, and diarrhea has little correlation to the leg
pain and DVT. Abruptly stopping Seroquel would most likely manifest itself with
psychiatric or behavioral complications, not complications to the vascular system.

(Dot Objective 5-2.14)

Application of cold packs to the leg

Elevation of the extremity

Massaging of the leg to alleviate cramping

Apply traction splint

Rationale

Elevating the extremity may assist draining venous blood, which can decrease pain and
discomfort. Application of cold packs will not result in significant benefit to the patient.
Massaging the leg to alleviate cramping is contraindicated since this may result in
embolization of the DVT to the lung. There is no indication for use of the traction splint
since there is no evidence of fracture and it is contraindicated for injuries of the lower
extremity.

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43. You have been summoned to the residence of a 62-year-old female patient with leg

97% on room air, and temperature 97.9°F. She has a history of

coronary artery disease, angina, and hypertension, for which she is prescribed
Lipitor, nitroglycerin, and Norvasc. Additionally, she takes Seroquel for depression
and has no allergies. You are ten minutes from the hospital and have just notified
medical command of your patient’s condition. Suddenly, the patient becomes short
of breath and complains of left-sided chest pain that worsens with inspiration. She is
also diaphoretic. The blood pressure is 132/76 mmHg. Which of the following signs
and symptoms must the paramedic recognize as most critical to the patient’s current
presentation?

44. You have been summoned to the residence of a 62-year-old female patient with leg

97% on room air, and temperature 97.9°F. She has a history of

(Dot Objective 5-2.15)

Presence of diaphoresis

Nausea with an accompanying headache

Blood pressure

Jugular venous distention

Rationale

A fundamental concern with deep venous thrombosis is embolization to the lungs and
subsequent pulmonary thromboembolism (PE). The sudden onset of shortness of breath
and pleuritic chest pain are hallmark indications that this has occurred. A pulmonary
embolism occludes the pulmonary artery(s). The presence of jugular venous distention
(JVD) is disturbing since this indicates massive occlusion with the subsequent backup of
blood through the right side of the heart and into the systemic circulation. The blood
pressure as listed is most likely elevated secondary to the sympathetic response of
hypoxia and stress associated with the PE. While important, it is as not as indicative of
the severity of the PE as is the presence of JVD. Nausea, headache, and diaphoresis are
not symptoms with direct correlation to the patient’s underlying condition of PE.

(Dot Objective 5-2.15)

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45. You are assessing an 86-year-old male complaining of generalized weakness. The

patient has a significant cardiovascular history including three previous heart attacks
and stenosis of the aortic valve. The appropriate location to auscultate the aortic
valve would be the:

provide a nebulized beta

bronchodilator.

administer low dose dopamine (2-5 mcg/kg/minute).

administer nitroglycerin and aspirin.

notify medical command.

Rationale

Treatment of this patient revolves around recognition, continued assessment, and rapid
transport to the most appropriate hospital. Since the patient is experiencing a life-
threatening event, medical command must be notified in order to give time to prepare the
ED resources for the critical patient. Given the patient’s blood pressure, dopamine is not
indicated. There is no information provided that suggests that a bronchodilator would be
beneficial. Although the patient has chest pain, its description does not appear in line with
pain of a cardiac origin, therefore nitroglycerin is most likely not indicated, although it
could be argued that aspirin might provide possible benefit through its anti-platelet
actions.

(Dot Objective 5-1.1)

over the epigastrium.

point of maximum impulse (PMI).

2nd intercostal space just right of the sternum.

4th intercostal space left of sternum.

Rationale

Considering the anatomy of the heart and its position in the chest, the paramedic would
place the diaphragm of the stethoscope in the 2nd intercostal space (ICS) just to the right
of the sternum. Auscultating the epigastrium will reveals sounds occurring in the stomach,
not the heart. Auscultating over the 5th ICS to the left of the sternum is best for sounds
produced by the tricuspid and/or mitral valve. The point of maximum impulse is located at
the 5th ICS just to the left of the sternum. As such, it would be the best location to
auscultate the tricuspid valve (as well as the mitral).

(Dot Objective 3-2.4)

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46. You are assessing an 86-year-old male complaining of generalized weakness. The

patient has a significant cardiovascular history including three previous heart attacks
and stenosis of the aortic valve. Auscultation of the patient’s heart sounds reveals
S1, S2, and S3 sounds. Based on these heart sounds, the paramedic would realize
that:

47. You are assessing an 86-year-old male complaining of generalized weakness. The

patient has a significant cardiovascular history including three previous heart attacks
and stenosis of the aortic valve. The presence of S2 indicates:

a cardiac abnormality is present.

the bell of the stethoscope must be used.

the patient has a decreased preload.

there is normal cardiac function.

Rationale

Heart sounds are related to closure of the different heart valves. S1 occurs as the bicuspid
and tricuspid valves (separating the atria and ventricles) close at the beginning of
ventricular systole. S2 represents the closing of the pulmonary and aortic valves at the
end of ventricular systole. While S1 and S2 heart tones are normal, the presence of extra
heart tones, such as an S3 are indicative of abnormal cardiac function. S3 heart sounds
can be caused by a variety of conditions including congestive heart failure. The diaphragm
of the stethoscope is generally best for auscultating heart sounds, not the bell. Decreased
preload describes the decreased return of blood to the heart and would not be evidenced
by an extra heart sound.

(Dot Objective 3-2.3)

Beginning of ventricular systole.

Pericardial friction rub.

Closing of the aortic and pulmonic valves.

Ventricular diastole.

Rationale

Heart sounds are related to closure of the different heart valves. S1 occurs as the bicuspid
and tricuspid valves (separating the atria and ventricles) close at the beginning of
ventricular systole. S2 represents the closing of the pulmonary and aortic valves at the
end of ventricular systole. Ventricular diastole would not produce any sounds since the
mitral valves are open and the pulmonic and aortic valves are closed. A pericardial friction
rub is a “grating” noise associated with inflammation or infection of the pericardial sac,
not closure of the pulmonic and aortic valves.

(Dot Objective 5-2.27)

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48. Your patient is confused, tachypneic, with a rapid and weak radial pulse that is

irregular. The patient does not exhibit any cyanosis but has skin that is warm-to-hot
in temperature. Vital signs are pulse 136, respirations 20 per minute, blood pressure
82/50 mmHg, and temperature of 102.3 degrees Fahrenheit. According to family,
the patient has a history of atrial fibrillation, multiple sclerosis, and anemia. Family
states that the patient has been experiencing vomiting and diarrhea over the past
week and has not been able to eat or drink anything. You have established an IV and
are administering oxygen. The cardiac monitor shows the following rhythm: What is
the most likely cause of the altered mental status?

49. Your patient is confused, tachypneic, with a rapid and weak radial pulse that is

irregular. The patient does not exhibit any cyanosis but has skin that is warm-to-hot
in temperature. Vital signs are pulse 136, respirations 20 per minute, blood pressure
82/50 mmHg, and temperature of 102.3 degrees Fahrenheit. According to family,
the patient has a history of atrial fibrillation, multiple sclerosis, and anemia. Family
states that the patient has been experiencing vomiting and diarrhea over the past
week and has not been able to eat or drink anything. You have established an IV and
are administering oxygen. The cardiac monitor shows the following rhythm: The
most appropriate treatment for this patient would be:

Increased afterload

Decreased stroke volume

Rapid heart rate

Elevated preload

Rationale

Given the history of illness with fluid loss (vomiting and diarrhea) along with the
assessment findings, the paramedic must recognize profound dehydration as a major
contributing factor to the patient’s altered mental status. Significant dehydration causes a
drop in the volume of circulating blood, therein reducing the amount of blood ejected with
each heart beat (stroke volume). As a result, the cardiac output will decline and along
with it, perfusion of the vital organs (like the brain) with oxygen rich blood. Since the
brain is not receiving an adequate amount of oxygen-rich blood, altered mental status
results. At 136 beats per minute (sinus tachycardia), the rate is not fast enough to
compromise cardiac output in and by itself. Dehydration leads to a decrease in preload
(blood returning to the heart), not an increase. Increased afterload describes a high blood
pressure (particularly the diastolic), that the left ventricle must overcome when ejecting
blood into the arterial system. The low blood pressure would indicate a decreased
afterload, not increased.

(Dot Objective 5-2.7)

fluid bolus.

ventricular antidysrhythmic.

adenosine.

transcutaneous pacing.

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50. Which of the following correctly describes the physiologic actions within the heart

during the QRS complex?

51. Upon assessment of a 32-year-old female who was involved in a motor vehicle

collision, you note that the patient is alert and oriented but appears to be very
anxious. Her skin is cool and moist. The patient’s vital signs are as follows: Pulse:
122, RR: 18, B/P: 100/76, SpO

: 94%. Which of the following conditions is she most

likely suffering from?

Rationale

Given that the patient is experiencing sinus tachycardia with PVCs secondary to
dehydration, the most appropriate treatment would be an IV fluid bolus to restore the
body’s circulating volume. This would improve the stroke volume and enable a better
cardiac output. In turn, the heart rate should slow and the altered mental status should
resolve as the brain experiences an increase in perfusion. Transcutaneous pacing is
indicated for hemodynamically significant bradycardia, not tachycardia. Since the rhythm
is too slow to be classified as supraventricular tachycardia and the problem lies with fluid
volume and not rate, adenosine is inappropriate. The occasional PVC does not
compromise cardiac output and should not be treated with a ventricular antidysrhythmic.
Again, the problem lies with the volume of blood, not a ventricular dysrhythmia.

(Dot Objective 5-2.37)

Ventricular repolarization

Movement of sodium into the cell

Atrial depolarization

Movement of potassium into the cell

Rationale

The QRS complex is indicative of ventricular depolarization. To depolarize, sodium rushes
into the cell while potassium leaves, causing the originally negatively charged inner cell
environment to become positive. Depolarization is followed by contraction of the
myocardial cells and is responsible for the physical pumping of blood into the circulatory
system. Ventricular repolarization describes the return of potassium to the inside of the
cells and removal of sodium to the outside of the cell. Ventricular repolarization is evident
on the ECG as the “T” wave and results in the inside of the cell regaining its negative
charge and the outside its positive charge. Atrial depolarization occurs during the “P”
wave of the ECG tracing. As stated, potassium leaves the cell during ventricular
depolarization and does not enter it.

(Dot Objective 5-2.17)

Hemorrhagic shock

Chest injuries with impaired gas exchange

Acute Respiratory Failure with impaired gas exchange

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52. You have responded to the scene for a car versus train accident. Prior to your arrival

on the scene, the BLS first responders radio you and advise you that there are 4
victims still trapped in the vehicle. You have a minimum transport time from the
scene of 35 minutes to the closest trauma center. Based on this new information,
what should you consider when determining the best care for the patients of this
collision?

53. You have responded to the scene for a car versus tree accident. As you are assessing

a 4-month-old injured in the accident, you determine that he is experiencing
respiratory difficulty. Which respiratory rate finding is most illustrative of significant
respiratory difficulty?

Pneumothorax with impaired gas exchange

Rationale

The patient is suffering from volume loss shock and as a result has a decreased amount of
red blood cells available for gas exchange. The patient’s vital signs are indicative of
volume loss shock but the pulse oximeter is still reading 94%. Pulse oximetry is a reliable
tool when utilized for trending patient progress but does have faults. In the case of this
scenario, the pulse oximeter reading is reflective of the amount of the hemoglobin that is
saturated, which is 94%, but it does not account for a lack of total functional hemoglobin.

(Dot Objective 2-1.12)

Get on scene and evaluate the patients before making any decisions

Immediate transport of all patients by the BLS squad

Dispatch of mutual aid BLS units

Dispatch of aeromedical units

Rationale

These patient’s have a significant mechanism of injury and as a result, they should be
treated as critical patients until an evaluation can be performed. The best course of action
in this scenario is to get the fastest, most well equipped transportation dispatched to the
scene at the earliest point in time. If the patients are critical, their best chance of survival
is based upon rapid transport to a trauma center for surgical intervention. The helicopter
is the best choice for rapid transport to a trauma center.

(Dot Objective 3-3.1)

Respiratory rate of 30

Respiratory rate of 54

Respiratory rate of 40

Respiratory rate of 24

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54. Which of the following patients would be most appropriate for triage to a non-trauma

center?

55. You have responded to a local residence of a 37-year-old male who had lacerated his

leg while using a chainsaw in the back of his house. Prior to your arrival, the
patient’s wife, who is a nurse, applied pressure to the wound and has the patient in
Trendelenburg position. Your assessment of the patient reveals him to be responsive
to painful stimuli with a weak carotid pulse and the blood pressure unobtainable.
There is a massive amount of blood surrounding the patient on the ground. The wife
tells you that the wound is arterial and the injury occurred about 10 to 15 minutes
ago. In addition to oxygen therapy, what are your treatment priorities for this
patient?

Rationale

In general, the first manifestation of respiratory distress in infants and young children is
tachypnea. Bradypnea would then indicate a pateint who's respiratory system is failing
and who is becoming critically hypoxic and acidotic. Normal respiratory rates for a 4-
month old infant range from 25-50 breaths per minute.

(Dot Objective 3-3.2)

19-year-old male involved in a single car MVC at a rate of 25 miles per hour

25-year-old female with a 1-inch laceration on her thigh

67-year-old female who was electrocuted by a 220 volt electrical outlet

14-year-old male who fell 11 feet out of a tree, landing on his back

Rationale

Of the 4 choices, the patient with a laceration on her thigh has an isolated injury and can
be effectively managed by a non-trauma center. The other 3 patients require a more
thorough assessment and therefore should be evaluated at a trauma center.

(Dot Objective 4-1.3)

Continue applying direct pressure to the wound and infuse IV crystalloids at 20cc/kg.

Apply an arterial tourniquet and infuse IV crystalloids wide open.

Apply an arterial tourniquet and infuse IV crystalloids at 20cc/kg.

Continue applying direct pressure to the wound and infuse IV crystalloids at TKO rate.

Rationale

Direct pressure and infusing crystalloids is this patient’s best chance for survival and
prevention of decompensated shock. Fluids should be infused at 20cc/kg to maintain a

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56. Which of the following patients is most likely experiencing an uncontrollable

hemorrhage?

57. You are managing a major trauma victim who appears to be in the “Irreversible”

stage of shock. What abnormalities in the red blood cells occur to promote vascular
occlusion at the capillary bed?

58. You have responded to a local park for a teenage male who has been shot in the

abdomen. Prior to your arrival on the scene, the police department states that they
have secured the scene and the shooter is in custody. Upon your assessment of the
patient, you find him to be unresponsive with a weak carotid pulse and the blood

blood pressure of at least 90-100mmHg. Too much crystalloid will promote increased
blood pressures and increased bleeding.

(Dot Objective 4-2)

45-year-old female with an amputated hand

25-year-old female with knife lodged in her cheek

14-year-old male with blunt abdominal trauma from a MVC

24-year-old male who fell 9 feet from scaffolding impaling a piece of rebar into his
thigh

Rationale

Bleeding into the abdominal compartment cannot be controlled by direct pressure or any
other non-surgical method and as a result should be considered to have an uncontrolled
bleed.

(Dot Objective 4-2.1)

Loss of ability to carry hemoglobin

Creation of rouleaux formations

Shrinkage of red blood cells

Destruction of cell membrane

Rationale

As the patient progresses through the phases of shock, lack of oxygen causes blood to
become acidotic. The acidotic blood then causes the red blood cells to stack-up into
misshaped chains. The result is a rouleaux formation. These formations will cause the red
cells to become inflexible and will promote vessel occlusion. When the post capillary
sphincters open during the final stage of the shock syndrome, the rouleaux formations
can cause microemboli to occur in various regions of the body.

(Dot Objective 4-2.2)

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pressure unobtainable. You determine that this patient is most likely in
decompensated shock. What pathophysiological changes would you expect to find in
this patient?

59. The PASG is currently used primarily as a splinting device. What type of injury would

most likely benefit from the utilization of the PASG as a splint?

60. You have responded for a 28-year-old male who was involved in a single car versus

tree MVC. There has been moderate damage to the vehicle. The patient is alert,
oriented, and appropriate, with his only complaint being pain to his lower
extremities, which are trapped under the dashboard of his vehicle. Assessment of
the extremities reveals local swelling and tenderness but no deformity or crepitus.
The tissue of the lower legs is intact but it does have some discoloration and is very
painful. Based on this information, what would you consider to be the most likely
cause of this patient’s signs and symptoms?

low catecholamine levels, cellular hypoxia, and intact capillary sphincters

elevated catecholamine levels, cellular hypoxia, and intact capillary sphincters

elevated catecholamine levels, cellular hypoxia, and failure of the precapillary
sphincters

low catecholamine levels, cellular hypoxia, and failure of the capillary sphincters

Rationale

The body’s ability to compensate by vasoconstriction, changes in heart rate, or contractile
force is essentially lost and as a result, the patient will become bradycardic, hypotensive,
and have alterations in mentation. Additionally, as perfusion is compromised, cellular
oxygenation will be as well. Finally, the precapillary sphincters, which promote flow
through capillary beds, begin to fail, resulting in pooling of blood

(Dot Objective 4-2.3)

Pelvic fracture

Femur fracture

Tibia/Fibula fracture

Lumbar spine fracture

Rationale

Splinting a pelvic fracture with the PASG is appropriate because it can provide
circumferential support to the pelvis and may actually assist in the closure of open pelvic
fractures.

(Dot Objective 4-2.4)

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61. Which of the following is an early, and the most prominent, finding in a crush injury?

62. You have responded to a structure fire. Upon your arrival to the scene, firefighters

advise you that they have pulled a patient out of the fire. Upon your assessment,
you find a 24-year-old female patient with second degree burns to approximately
20% of her BSA. The patient is tachycardic and hypotensive and she has an altered
mental status. What do you think the most likely cause of this patient’s hypotension
is?

Crush injury to the lower legs

Bilateral lower leg fractures

Uncontrollable internal hemorrhage

Hematomas to the lower legs

Rationale

This patient has most likely experienced soft tissue disruption and crush injuries to the
lower extremities. The presenting signs and symptoms do not correlate to any of the
other conditions listed.

(Dot Objective 4-3.5)

Paralysis

Pulselessness

Paresthesia

Pain

Rationale

Pain is generally the most obvious sign of a crush injury and tends to present earliest out
of all of the other associated signs and symptoms.

(Dot Objective 4-3.12h)

Burn shock

Pain

Electrolyte imbalance

Hemorrhagic shock

Rationale

The patient is most likely suffering from hemorrhagic shock caused by an injury sustained
while she was trying to escape from the burning building. It is highly unlikely that the
patient has burn shock because of the rapid nature of the onset of hypotension.

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63. A high index of suspicion of a crush injury should be maintained in a patient who has

suffered which of the following scenarios?

64. Which of the following should be applied to a deep laceration to the neck?

65. A paramedic is caring for a patient who has a lacerated neck vein that is bleeding

profusely. How should she manage the bleeding in the patient’s neck?

(Dot Objective 4-3.15d)

Hand trapped in a press machine

A motor vehicle collision with a seat belt mark across the patient’s chest

An angulated fracture of her wrist after falling while rollerblading

An open femur fracture from a shotgun blast

Rationale

The patient with his hand in a press machine most likely has experienced soft tissue
disruption and significant pressure that has been applied to the extremity. While the other
scenarios definitely resulted in trauma, the mechanisms behind them were not crushing in
nature.

(Dot Objective 4-3.23)

Transparent bandage tightly secured

Pressure dressing to the wound

Loose bandaging with a 4x4 and Kerlix

Occlusive dressing taped on four sides

Rationale

An occlusive dressing is most appropriate in the management of this patient. In neck or
chest injury, a sucking wound may exist; an occlusive dressing should be applied to seal
the wound. If not, during active inspiration by the pateint, the negative pressure in the
chest can allow the entrainment of air into the damaged vessel causing an air embolism
to occur in the body.

(Dot Objective 4-3.35a3)

Apply pressure to both the internal and external carotid arteries.

Place direct pressure over the bleeding site.

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66. Your 26-year-old female patient has been pulled out of a house fire. Her chest and

arms have been burned. The area is charred and the patient states she has little pain
in the burned area. What is the most likely classification of this patient’s burns?

67. A patient complains of little pain despite obvious burns to the skin. Which of the

following burn classifications would you expect this patient to be diagnosed with?

Loosely pack the wound and cover it with a nonporous dressing.

Apply pressure distally and proximally to the point of bleeding.

Rationale

An occlusive dressing is most appropriate in the management of this patient. In neck or
chest injuries, a sucking wound may exist; an occlusive dressing should be applied to seal
the wound. To prevent occlusion of the vessels in the neck, direct pressure to the wound
should not be utilized unless all other mechanisms have failed to control the bleeding.

(Dot Objective 4-3.43a)

Full thickness

Superficial

Deep partial thickness burns

Superficial partial thicknes burns

Rationale

The patient is most likely experiencing a full thickness burn with disruption of the soft
tissue through the nerve root. They are typically painless, with the exception of the
penumbra, because of the lack of nerve stimulation.

(Dot Objective 4-4.5)

Partial- Full thickness

Superficial

Full thickness

Partial thickness

Rationale

The patient is most likely experiencing a full thickness burn with disruption of the soft
tissue, through the nerve root. Full thickness burns are typically painless with the
exception of the penumbra, because of the lack of nerve stimulation.

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68. You have responded to the scene for a patient who was reportedly electrocuted while

working on some power lines. On your arrival to the scene, you find a middle-aged
male seated upright complaining of numbness and tingling throughout his body.
Bystanders tell you that the patient was obviously shocked and fell from a standing
position into the basket of his cherry picker. The patient has no external signs of
burn injury. What potential complication of this event would you be most concerned
about in this patient?

69. You have responded for a 22-year-old male who was involved in a single car versus

telephone pole MVC. There has been significant damage to the vehicle. The patient is
alert, oriented, and complains of difficulty in speaking because of jaw pain and a
horrible headache. Assessment of the jaw reveals instability and tenderness. Based
on this information, what other serious injuries should you consider when managing
this patient?

(Dot Objective 4-4.15)

Cellular dehydration

Coagulopathy

Burns

Cardiac dysrhythmias

Rationale

The heart is an electrical system. When a surge of electricity is introduced into the body,
concern should be given to the potential for the development of cardiac dysrhythmias.

(Dot Objective 4-4.45)

Fractured orbital

Fractured clavicle

Fractured nose

Fractured cervical spine

Rationale

This patient should be assumed to have a cervical spine injury until proven otherwise. Any
injury above the level of the collarbone holds a significant mechanism for a cervical spine
injury. This especially holds true if the patient already has evidence of facial trauma.

(Dot Objective 4-5.4)

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70. You have responded for a 43-year-old male who was involved in an altercation. The

patient was reportedly beaten about the face and head with a baseball bat. The
patient is unresponsive. Evaluation of the patient’s face reveals instability from the
orbits to the mandible. Based on this information, how would you definitively
manage this patient’s airway?

71. Which type of intracranial hemorrhage may present with a very slow progression,

because it involves venous rupture and not arterial rupture?

72. You have responded to a local ED to transport a motor vehicle collision victim to the

regional trauma center. On your arrival, the nurse tells you that the patient was
having difficulty in clearing his airway. They tried to have the patient cough to bring
up the secretions in his airway and he reported that he was unable to cough
effectively. As a result of his inability to clear his airway, the physician opted to use
the RSI protocol to provide an airway for the patient. Given this history, what level
of cord injury would you expect this patient to be suffering from?

Orally intubate the patient and assist ventilations with a Bag-Valve-Mask.

Insert a nasal airway and assist ventilations with a Bag-Valve-Mask.

Insert an oral airway and assist ventilations with a Bag-Valve-Mask.

Immediately assist ventilations with a Bag-Valve-Mask.

Rationale

This patient has an unstable face and an unstable airway. Ultimately, this patient needs to
have his airway protected as quickly as possible with an endotracheal tube. With facial
instability, it is imperative that an adjunct be placed to ensure that the airway is not
occluded by the pressure on the jaw created with the application of the Bag-Valve-Mask.

(Dot Objective 4-5.9)

Intracerebral

Epidural

Subdural

Subarachnoid

Rationale

A subdural bleed is the only type of bleed listed that is always venous in nature. Hence it
will have a slower onset since the blood is under a lesser pressure as compared to the
arterial system.

(Dot Objective 4-5.39)

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73. Why does the patient with a significant head injury present with bradycardia in the

presence of the Cushing’s reflex response?

74. You have responded for a 22-year-old female who had fallen backwards 18 feet from

some bleachers. Prior to your arrival on the scene, an EMT is on scene and manually
stabilizing the spine. Upon your assessment of the patient, you find her to be
unresponsive with a weak carotid pulse at a rate of 56; the blood pressure is 80/60.
What pathophysiological changes would you expect to be causing the abnormal vital
signs in this patient?

Rationale

The nerves that exit the thoracic spine are primarily responsible for the intercostal
muscles that promote chest wall expansion. Disruption of the nerve pathways would likely
compromise the patient’s ability to breathe deeply and produce a forceful cough.

(Dot Objective 4-6.2b)

Decreased parasympathetic stimulation

Increased stimulation of the chemoreceptors

Decreased cardiac blood flow

Increased stimulation of the baroreceptors

Rationale

When the intracerebral pressures are elevated, the baroreceptors in the carotids and the
aorta are stimulated. Stimulation of the baroreceptors leads to activation of the
parasympathetic nervous system, resulting in a decrease in sympathetic stimulation and
ultimately, a decreased heart rate.

(Dot Objective 4-6.4)

Increased sympathetic tone because of a spinal injury

Increased parasympathetic tone because of a closed head injury

Increased sympathetic tone because of a closed head injury

Decreased sympathetic tone because of a spinal injury

Rationale

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75. While assessing a patient with a suspected spinal cord injury, you decide to evaluate

the corticospinal tracts. In your initial assessment, you ask the patient to flex and
extend his elbows. Which level of corticospinal tract are you evaluating?

76. While assessing a patient involved in a motor vehicle collision, you have determined

that the patient has a mechanism of injury suggestive of a significant spinal cord
injury. In addition to a significant mechanism of injury, you note that the patient also
has a decrease in mental status. Vital signs include a heart rate of 126, respirations
of 22, and a blood pressure of 88/palpation. What are your treatment priorities for
this patient?

The patient in spinal shock will typically have limited or no release or uptake of
catecholamines. The unopposed parasympathetic response includes systemic vasodilation
in combination with a normal or bradycardic rhythm. The result will be unopposed
hypotension coupled with alterations in mentation.

(Dot Objective 4-6.13a)

C6 and C7

C1 and C2

T4 and T5

S1 and S2

Rationale

In assessment of the spinal cord injured pativent, there are various spinal tracts that are
sensitive to pain, light touch sensation, and motor function. A simple squeeze test for grip
strength does not effectively evaluate the different nerve tracts or various levels of the
spinal cord. An effective and rapid assessment of the corticospinal tracts, which inolves
the flexion and extension of the elbows, would evaluate C6 and C7. Flexion of the elbows
tests C6 and extension of the elbows tests C7.

(Dot Objective 4-6.18)

Spinal immobilization, ABCs, blood glucose evaluation, dopamine infusion at 10-
20mcg/kg/min

Spinal immobilization, ABCs, blood glucose evaluation, dopamine infusion at 2-
10mcg/kg/min

Spinal immobilization, ABCs, blood glucose evaluation, crystalloid fluid infusion at
20cc/kg

Spinal immobilization, ABCs, blood glucose evaluation, crystalloid fluid infusion at wide
open rate

Rationale

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77. You have responded to a local ED to transport a patient involved in a motor vehicle

collision. While assessing her, you note that the patient is breathing shallow at a rate
of 14. The patient’s only complaint is pain to her left chest. Palpation of the chest
reveals a small amount of crepitus but no instability. The patient states that the pain
increases substantially on palpation and upon deep inspiration. Her vital signs
include a heart rate of 116, respirations of 14, and a blood pressure of 146/90
mmHg. The i-STAT reading of her ABG is a pH of 7.26, and a PaCO

of 52. What is

the most likely cause of this patient’s blood gas abnormalities?

78. You have responded to a local ED to transport a patient who was reportedly stabbed

in the left chest and suffered a ventricular injury. Given the anatomical position of
the heart within her thorax, which ventricle would most likely be injured?

Spinal cord tissue is nerve tissue and as a result, it is critical to ensure the patient has a
patent airway, adequate ventilatory status, and is being oxygenated effectively. Reversal
of hypotension by administering crystalloid fluids is paramount to conserve nerve tissue.
Hypoglycemia must also be identified and/or treated to ensure that the cells have
adequate energy and nutrients.

(Dot Objective 4-6.26)

Metabolic acidosis

Respiratory alkalosis

Metabolic alkalosis

Respiratory acidosis

Rationale

The patient’s history of a chest injury and pain on inspiration suggests that she is not
breathing deeply and therefore is not exchanging gases effectively. The pH is acidotic and
the etiology for her clinical presentation is respiratory.

(Dot Objective 4-7.9a)

Left Ventricle

Right and Left Ventricles

Neither ventricle is more prone to injury

Right Ventricle

Rationale

The right ventricle is more anterior and as a result is more commonly injured than the
left. Additionally, the right ventricle tends to bleed more than the left because there is
less pressure gradient created in the right chest, allowing more blood to leak out of the
heart. The left ventricle tends to be more self-sealing.

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79. While assessing a patient involved in a motor vehicle collision, you note that the

patient is dyspneic, has decreased lung sounds on the left side of his chest, and has
a scaphoid abdomen. The patient’s vital signs include a heart rate of 122,
respirations of 28, and a blood pressure of 114/palpation. What is your field
diagnosis of this patient?

80. Which of the following mechanisms of injury is most likely to cause traumatic

asphyxia?

81. You are attending to a 21-year-old male that has injured the right upper quadrant of

his abdomen after being involved in a motorcycle accident. The most likely organ in
this area that could cause life-threatening internal hemorrhage is the:

(Dot Objective 4-7.2)

Hemothorax

Tension pneumothorax

Pneumothorax

Diaphragmatic injury

Rationale

This patient should be diagnosed with a diaphragmatic injury because of the respiratory
impairment and, most importantly, the scaphoid abdomen. A scaphoid abdomen is
present when the contents of the abdomen have been displaced outside of the abdomen.

(Dot Objective 4-7.28)

Restraining of a patient face-down

Prolonged exposure to fumes in an enclosed space

Circumferential burns to a patient’s chest

Compression by a car on the patient’s chest

Rationale

Compression of a patient’s chest from a car is a potential cause for traumatic asphyxia.
Traumatic asphyxia results from violent compressive force on the chest, leading to
increased pressure on the ventricles that impede blood flow, and impairing normal thoacic
excursion, leading to hypoxemia.

(Dot Objective 4-7.38)

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82. Which of the following mechanisms would be considered to be an indirect injury?

83. A patient involved in a motor vehicle collision complains of pain to his left lower leg.

Evaluation of the extremity reveals an open fracture of the tibia. What is the
appropriate sequence to follow in immobilization of this patient’s injury?

Spleen

Small intestine

Large intestine

Liver

Rationale

The liver is the most prominent organ in the right upper abdomen and is the most likely
organ to cause bleeding and death if injured.

(Dot Objective 4-8.3)

A patient who fell off of his skate board and is complaining of pain to both of his wrists
after falling forward

A patient who jumped out of a window landing on his feet and is complaining of lower
back pain

A patient who has injured his knee while running and now states he cannot move his
knee

A patient with inhalation injuries that has recently begun to experience airway
compromise

Rationale

An indirect injury is one in which the injury occurs secondary to some other injury or
mechanism. In the case of the patient who jumped out of the window, the energy of the
impact on the patient’s heel was transmitted to the patient’s spine and the result was a
spinal injury.

(Dot Objective 4-9.3b)

Check distal pulse, motor and sensory, immobilize the extremity, recheck pulse, motor,
and sensory.

Check distal pulse, motor, and sensory then immobilize the extremity and transport.

First immobilize the extremity, then check distal pulse, motor, and sensory.

Immobilize the extremity and provide rapid transport.

Rationale

Assessing the pulse, motor, and sensory of an injured extremity before and after the
management process is important because it provides baseline information which can be

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84. You have responded for a 25-year-old male who has fallen while riding a bicycle.

Your assessment reveals an open and angulated left forearm. The patient’s vital
signs are stable. In splinting this extremity, which of the intervention steps listed
below would be most appropriate?

85. You have responded for a 25-year-old male who fell while riding a bicycle. Your

assessment reveals an open and angulated left forearm. The patient’s vital signs are
stable; however he appears very anxious and states he has a great deal of pain.
What pharmacological interventions would be appropriate for this patient?

86. You have been dispatched to a community golf course for a patient who has been

stung by a bee and is experiencing a severe allergic reaction. On scene, you find the

used to identify changes in the perfusion or neurovascular integrity of the limb.

(Dot Objective 4-9.1)

Do not get concerned with immobilization methods.

Push bone ends back beneath the skin.

Splint the extremity in the position found.

Splint the extremity in the position of function.

Rationale

The position of function is optimal in the management of fractures involving the hand or
wrist. This will ensure normal function is preserved during the ongoing immobilization and
healing of the bone.

(Dot Objective 4-9.2)

Demerol 100-200 mg IM

Morphine Sulfate 10-20 mg IM

Valium 5-10 mg IM

Ativan 5-10 mg IM

Rationale

Valium is an anxiolytic and skeletal muscle relaxant which makes it an ideal choice for
musculoskeletal injuries. Additionally, the dose listed for valium in this question is the
only correct drug dosage.

(Dot Objective 4-9.3)

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male patient lying under the shade of a tree with several other golfers standing
around him. He is responsive to painful stimuli and exhibiting stridorous respirations.
His face and hands are markedly swollen and his skin is flushed and covered with
hives. Cyanosis is noted to his fingers and toes. Auscultation of breath sounds
reveals bilateral wheezing and rhonchi. His vital signs are pulse 132 beats per
minute, respirations 28 per minute and labored, blood pressure 84/50 mmHg, and
SpO

88%. The cardiac monitor shows the rhythm below. Based on the presentation,

which of the following must be addressed first?

87. You have been dispatched to a community golf course for a patient who has been

stung by a bee and is experiencing a severe allergic reaction. On scene, you find the
male patient lying under the shade of a tree with several other golfers standing
around him. He is responsive to painful stimuli and exhibiting stridorous respirations.
His face and hands are markedly swollen and his skin is flushed and covered with
hives (urticaria). Cyanosis is noted to his fingers and toes. Auscultation of breath
sounds reveals bilateral wheezing and rhonchi. His vital signs are pulse 132 beats
per minute, respirations 28 per minute and labored, blood pressure 84/50 mmHg,
and SpO

88%. The cardiac monitor shows the rhythm below. Your immediate care

would be to:

Tachydysrhythmia

Hypoxia

Hypoglycemia

Hypotension

Rationale

Based on the patient’s presentation, the immediate threat to life is hypoxia secondary to
edema of the upper airway (stridor) and bronchoconstriction to the lower airway
(wheezing). If not addressed, the hypoxia will eventually cause cardiac arrest as the heart
becomes so damaged it loses its ability to effectively pump blood. The patient’s blood
pressure is a concern, but at 84/50 mmHg, the tissues are still receiving some degree of
perfusion. Accordingly, the paramedic would address the hypotension after the airway has
been secured. The tachycardic heart rate is a compensatory response to the hypoxia and
falling blood pressure. Managing the hypoxia and then the hypotension will most likely
correct the rapid heart rate. There is no mention of clinical indication that the patient is
hypoglycemic.

(Dot Objective 5-5.15)

Provide intramuscular Benadryl.

Place a tracheal tube.
Administer an inhaled beta

agonist.

Establish an IV and administer epinephrine.

Rationale

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88. You have been dispatched to a community golf course for a patient who has been

88%. The cardiac monitor shows the rhythm below. Which of the following

chemical mediators would account for the patient’s blood pressure?

89. You have been dispatched to a home for a “possible” suicide. On scene, you find an

alert and oriented 43-year-old woman who is extremely distressed over the bitter
breakup of a long-term relationship with her boyfriend. While obtaining a medical
history, she states that she is going to teach him a lesson by taking a “whole bunch
of her father’s heart medications and ending it all.” After ten minutes, the patient is
calmer and states that she really didn’t mean what she said and wants you to leave.

The stridorous respirations indicate that the patient is suffering from edema to the upper
airway and requires immediate placement of a tracheal tube. Since the airway is
progressively swelling, delaying placement of the tracheal tube to administer medication
like epinephrine or Benadryl will undoubtedly make future attempts at intubation more
difficult and most likely have a detrimental impact on patient outcome. Establishing an IV
is appropriate but should occur after the airway has been effectively secured. The
administration of epinephrine and isotonic fluids are the primary interventions used to
restore the patient’s circulating volume.

(Dot Objective 5-5.15)

Epinephrine

Histamine

Aldosterone

Glucagon

Rationale

The release of histamine from MAST cells causes the capillaries to dilate and become
“leaky.” The vasodilation and escape of fluid are the primary mechanisms underlying
hypotension in anaphylaxis. This is why Benadryl, an antihistamine, is an effective agent
in the treatment of a severe allergic reaction and/or anaphylactic shock. Glucagon is
released but causes the mobilization of additional glucose for energy, not vasodilation.
The release of endogenous epinephrine serves to constrict blood vessels, not dilate them.
Accordingly, the paramedic will administer epinephrine to help constrict the blood vessels
and increase blood pressure. Aldosterone is a hormone that increases blood pressure by
instructing the body to retain sodium.

(Dot Objective 5-5.5)

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How would you handle this situation?

90. You have been dispatched to a home for a “possible” suicide. On scene, you find an

Contact law enforcement.

Obtain a signed refusal.

Physically restrain her for transport.

Have her ex-boyfriend talk to her.

Rationale

Since the patient has made a remark indicating the possibility of suicide, the paramedic is
obligated to provide care and transport to an appropriate facility. If the paramedic does
not and the patient commits suicide, the paramedic could find him or herself in legal
trouble. The best course of action would be to involve law enforcement and use their
vested powers to order involuntary transport. Involving the ex-boyfriend is not advisable
in that this may escalate the situation. Physically restraining the patient for transport may
eventually be required, but should be done after other means of convincing the patient to
go to the hospital have failed. Additionally, physical restraints are best used in the
presence of and in conjunction with law enforcement personnel. Although the patient is
alert and oriented, the fact that she made mention of suicide, and has a preliminary plan
to do so, eliminates the possibility of obtaining a signed refusal.

(Dot Objective 5-12.5)

Suicidal ideation.

Unsuccessful suicide.

Suicide attempt.

Suicide.

Rationale

A suicide ideation is the thought (verbal or nonverbal) of suicide. As such, the patient’s
statement that she is going to take a “whole bunch of her father’s heart medications and
end it all” fits the description of a suicidal ideation. The term suicide is an after the fact
description of a successful suicide, which is not the case here. A suicide attempt and
unsuccessful suicide describe an unsuccessful effort at taking one’s own life.

(Dot Objective 5-12.5)

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91. When assessing a patient complaining of depression, which of the following would be

most suggestive that the patient is at risk for suicide?

92. You are assessing a 32-year-old male complaining of abdominal pain and weakness.

The patient informs you that he has Addison’s disease as a result of steroid use as a
teenager. No life-threatening conditions are noted to the airway, breathing, or
circulation. Vital signs are pulse 110 beats per minute, respirations 16 per minute,
blood pressure 110/72 mmHg, and SpO

98% on room air. Given the patient’s past

medical history, you would:

Hostility toward concerned family members

Recent diagnosis of hypertension

Previous attempt that was unsuccessful

Packing away of cherished possessions

Rationale

A previous attempt at suicide is highly suggestive of a patient’s risk for suicide. This is
compounded by the depression, which can exacerbate suicidal feelings and willingness to
carry out the act to finality. Persons contemplating suicide typically give possessions away
and do not store them. Hostility towards family members in and of itself is not an
indication of the potential for suicide. While a diagnosis of medical condition can
predispose one to consider suicide, these conditions are generally terminal (e.g., cancer,
HIV infection). Hypertension is generally treatable with lifestyle modification and
medications.

(Dot Objective 5-12.17)

check the blood glucose level.

administer calcium gluconate.

administer calcium chloride.

restrict IV fluids.

Rationale

Always check the blood glucose level of any patient with adrenal insufficiency. Adrenal
insufficiency is a disease in which the adrenal cortex does not secrete adequate levels of
mineral corticoids (aldosterone-promotes sodium regulation) and glucocorticoids (increase
blood glucose). Consequently, patient’s with adrenal insufficiency are prone to
hypoglycemia (decreased secretion of glucocorticoids). Since those with adrenal
insufficiency poorly secrete mineral corticoids associated with sodium retention, they are
prone to hypotension and could benefit from IV fluids. Similarly, adrenal insufficiency
often results in hypercalcemia, and would not benefit from the prehospital administration
of calcium in any form.

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93. You are by the side of a 44-year-old male construction worker who has been

performing laborious roadwork in 102 degrees Fahrenheit temperatures. The patient
is combative, confused, and verbally abusive. His airway is patent and breathing
rapid and shallow. He has a radial pulse that is moderate in strength, and skin that is
hot and dry to the touch. Vital signs are pulse 116 beats per minute, respirations 24
per minute, and blood pressure 80/60 mmHg. Coworkers state that he refused to
take any breaks today and has been working steadily for several hours. When they
noticed him acting “funny”, they carried him to the shade of a tree where you
currently find him. In his pocket you find a vial of Labetalol. Based on this
presentation, you would recognize:

94. You are by the side of a 44-year-old male construction worker who has been

(Dot Objective 5-44.72)

high fever

heat stroke

heat cramps

heat syncope

Rationale

Given the exertion in a hot environment and the patient’s noncompliance with taking
breaks, a heat emergency should be recognized. More specifically, the altered mental
status, hot skin, and hypotension are indicative of heat stroke, a life threatening
condition. Heat cramps describe cramping of muscles due to the loss of electrolytes and
water. Fever is differentiated from heat stroke by the fact that fever is caused by
pyrogens (fever producing agents) and is not the result of a hot environment with
subsequent heat gain. Heat syncope occurs when the afflicted individual has lost a
significant amount of body fluid and suddenly becomes dizzy or has a syncopal episode
when moving from a seated to upright position.

(Dot Objective 5-10.2)

administer salt pills to restore electrolyte abnormalities.

remove the patient’s clothing and move him to a cool environment.

restore lost volume with IV fluids.

administer Tylenol to lower the body temperature.

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95. You are by the side of a 44-year-old male construction worker who has been

96. A 57-year-old female informs you that she took a new antihypertensive medication

three hours ago as prescribed by her doctor. Soon after, she noticed the
development of hives on her legs and abdomen. She called her family physician who

Rationale

The initial priority in caring for this patient must be geared towards rapid cooling. To start,
all clothing must be removed and the patient must be moved to a cooler environment.
Additionally, he should be sprayed with water and fanned to promote heat loss through
evaporation. The use of Tylenol to lower body temperature is indicated when the
increased body temperature is caused by fever, not external heat gain. Restoring lost
volume with IV fluids is important, but would occur after measures to decrease body
temperature have been started. Given the patient’s level of consciousness, oral salt pills
are contraindicated. Additionally, salt pills are falling from grace given that they can be a
gastric irritant (increase the risk of vomiting and aspiration) and do not restore the lost
body fluid.

(Dot Objective 5-10.32)

Beta blockers promote heat gain by promoting vasoconstriction.

Beta blockers cause the hypothalamus to increase the body temperature.

Beta blockers promote heat gain by increasing the workload of the heart.

Beta blockers increase the loss of heat by increasing the heart rate.

Rationale

Beta blockers impact the body by slowing the heart rate and inhibiting vasodilation. Both
of these actions counteract the body s natural attempt to excrete heat though an
increased heart rate and vasodilation (which allows warm blood to offload heat at the
surface of the skin). Beta blockers do not increase the heart rate nor do they increase the
cardiac workload. Beta blockers do not target the hypothalamus or cause it to increase
the body temperature.

(Dot Objective 5-10.1)

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instructed her to call 911 immediately. Assessment reveals her to be alert and
oriented, although somewhat worried. Her airway is patent, breathing is adequate,
and she has a strong radial pulse with warm and dry skin. Breath sounds are clear
and equal. Her vital signs are pulse 88 beats per minute, respiration 14 per minute,
blood pressure 138/80 mmHg, and SpO

98% on room air. In addition to the history

of hypertension, she also has a history of angina and asthma for which she takes
nitroglycerin and albuterol respectively. Based on this presentation, the paramedic
would recognize a/an:

97. A 57-year-old female informs you that she took a new antihypertensive medication

three hours ago as prescribed by her doctor. Soon after, she noticed the
development of hives on her legs and abdomen. She called her family physician who
instructed her to call 911 immediately. Assessment reveals her to be alert and
oriented, although somewhat worried. Her airway is patent, breathing is adequate,
and she has a strong radial pulse with warm and dry skin. Breath sounds are clear
and equal. Her vital signs are pulse 88 beats per minute, respiration 14 per minute,
blood pressure 138/80 mmHg, and SpO

98% on room air. In addition to the history

of hypertension, she also has a history of angina and asthma for which she takes
nitroglycerin and albuterol respectively. The initial pharmacological management of
this patient would be:

hypersensitivity reaction.

asthma.

anaphylactic reaction.

allergic reaction

Rationale

The gradual development of urticaria (hives) and the absence of other serious signs, such
as airway edema, bronchiole wheezing, and hypotension, should lead the paramedic to
suspect an allergic reaction. If the onset was rapid and the patient exhibits additional
signs including airway edema, bronchoconstriction, respiratory distress, hypotension and
so forth, the paramedic must recognize anaphylaxis and act accordingly. There are no
clinical findings suggestive of exacerbated asthma, even though the patient suffers from
the disease. Allergic and anaphylactic reactions are often referred to as hypersensitivity
reactions, not hyposensitivity reactions.

(Dot Objective 5-5.51)

steroid and 1: 10,000 epinephrine administered intravenously.

0.5 mg of 1: 1000 epinephrine administered subcutaneously.

nebulized albuterol and Benadryl administered intravenously.

50 mg Benadryl administered intramuscularly.

Rationale

Given the mild presentation, the best pharmacologic treatment would consist of 25 to 50

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98. Which of the following substances is the most common cause of anaphylaxis?

99. You are planning a continuing education seminar with your service’s medical director.

After you both decide that behavioral emergencies need to be addressed, he asks
you to define normal behavior. You would reply:

mg of Benadryl administered intramuscularly or intravenously. Urticaria (hives) is caused
by the release of histamine, which generally responds to an antihistamine such as
Benadryl. Since the patient is not exhibiting respiratory distress and is hemodynamically
stable, the administration of epinephrine may not be indicated. The fact that the patient
has a cardiovascular history (angina) further warrants the withholding of epinephrine,
both subcutaneously and intravenously. The use of steroids in the prehospital treatment
of allergic reactions is controversial.

(Dot Objective 5-5.19)

Aspirin

Fungi and molds

Penicillin

Bee stings

Rationale

Penicillin and other antibiotics are the most common causal agents for anaphylaxis.
Authorities estimate penicillin to produce an allergic or anaphylactic reaction 1 out of
every 10,000 times it is used and cause an estimated 500 deaths per year. By contrast,
bee stings are responsible for less than 100 deaths annually. Anaphylactic reactions to
aspiring and fungi and molds are infrequent and therefore not common causal agents.

(Dot Objective 5-5.11)

Behavior that society views as acceptable

A person’s observable conduct or activity

Behavior that the person believes is normal

Behavior that does not hurt anyone

Rationale

Although a universal definition is difficult to establish, normal behavior is generally
defined as behavior that is readily accepted within a society. Behavior that a person
thinks is normal for him or herself may not be accepted by society and therefore is not
considered normal. An example would be a person who thinks that clothing is optional to
wear in a public setting. Just because a particular behavior does not hurt anyone does not
make it normal. Again, not wearing clothes in public does not hurt anyone, but is typically
frowned upon in modern society. A person s observable conduct or activity describes
behavior in a general sense and does not distinguish between normal and abnormal.

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100. You are called to a residence for a male patient with an unknown medical complaint.

On the scene, you find a 38-year-old male with a red area on his forehead. According
to his wife, they have been having marital problems and he came home intoxicated,
and threatened to kill her. In response, she hit him in the forehead with the coffee
maker. When it comes time to take the patient to the hospital, he refuses by saying,
“I know my rights and if I do not want to go, you cannot force me!” The wife states
that she is okay and offers to sign a refusal as a witness. Given this scenario, you
would:

101. You have been dispatched to a long-term care facility for a patient with a diabetic

history. On scene, you find a 72-year-old female who weakly moans when painful
stimuli is applied. Caregivers state that she is a non-insulin diabetic who has been in
a steady decline over the last few days. This morning her blood glucose registered
802 mg/dl on the glucometer. She also suffers from hypertension, arthritis, and
stroke with left-sided weakness. Assessment reveals her airway to be patent and
breathing easy. Her radial pulse is weak and rapid and skin warm and dry. Her pulse
is 132 beats per minute, respiration 18 and easy, and blood pressure 80/50 mmHg.
Your glucometer registers “HIGH” when testing the patient’s blood glucose level. She
has a Foley catheter in place. Oxygen is applied and an IV established. The cardiac
monitor shows the following rhythm: Based on the patient’s medical history and
presentation, which of the following statements would you most likely hear in
reference to the patient’s Foley catheter?

(Dot Objective 5-12.1)

restrain the patient and transport him to the hospital.

have the patient sign a refusal.

have the patient sign the refusal witnessed by his wife.

have dispatch send the police to your location.

Rationale

Given that a weapon and threat of physical violence to another person are involved, the
paramedic cannot have the patient sign a refusal and leave the scene, even if his wife
witnesses the refusal. If the paramedic did obtain a signed refusal and the man hurt or
killed his wife after EMS departure, the paramedic may be held liable in that the lack of
intervention may have contributed to her injury or death. Since the patient is intoxicated,
the paramedic cannot legally obtain an informed refusal given the patient’s mental status.
Therefore, the most prudent action would be to have the police respond and provide
assistance in removing the patient from the scene. Restraining the patient may be
required at some point, but only after the police have arrived (since he is not an
immediate threat).

(Dot Objective 5-12.13)

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102. You have been dispatched to a long-term care facility for a patient with a diabetic

history. On scene, you find a 72-year-old female who weakly moans when painful
stimuli is applied. Caregivers state that she is a non-insulin diabetic who has been in
a steady decline over the last few days. This morning her blood glucose registered
802 mg/dl on the glucometer. She also suffers from hypertension, arthritis, and
stroke with left-sided weakness. Assessment reveals her airway to be patent and
breathing easy. Her radial pulse is weak and rapid and skin warm and dry. Her pulse
is 132 beats per minute, respiration 18 and easy, and blood pressure 80/50 mmHg.
Your glucometer registers “HIGH” when testing the patient’s blood glucose level. She
has a Foley catheter in place. Oxygen is applied and an IV established. The cardiac
monitor shows the following rhythm: Which of the following would best explain the
etiology of the abnormality in the patient’s vital signs?

“Her urine is dark and cloudy.”

“There was noticeable blood in her urine.”

“Her urine has been very concentrated."

“We have been emptying her Foley bag frequently.”

Rationale

In hyperglycemic hyperosmolar nonketotic syndrome, the hyperglycemic state of the
blood causes water to be drawn from the cells into the bloodstream in an effort to dilute
the high glucose level. This expands the volume of the blood, which the hypothalamus
and kidneys perceive as a state of over hydration. As a result, the kidneys release the
excess blood plasma by producing and excreting voluminous quantities of urine. This
condition is called polyuria (much urine) and is evident by frequent emptying of the
patient s Foley catheter reservoir. Eventually, the body becomes fluid depleted and the
patient produces little urine (oliguria). Since the body is excreting large amounts of fluid,
the urine is typically light colored and dilute, not dark and concentrated. The presence of
blood in the urine (hematuria) indicates a separate issue not associated with the
hyperglycemia.

(Dot Objective 5-4.8)

Dehydration

High levels of insulin

Electrical conduction disturbance

Respiratory acidosis

Rationale

In hyperglycemic hyperosmolar nonketotic syndrome (HHNS), the hyperglycemic state of
the blood causes water to be drawn from the cells into the bloodstream in an effort to
dilute the high glucose level. This expands the volume of blood, which the hypothalamus
and kidneys perceive as a state of over hydration. As a result, the kidneys release the
excess blood plasma by producing and excreting voluminous quantities of urine. This
condition is called polyuria (much urine) and is evident by frequent emptying of the
patient’s Foley catheter reservoir. The end result is profound dehydration (in addition to
the hyperglycemia). To compensate for the hypovolemia, the body increases the heart

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103. You are assessing a 53-year-old female who neighbors discovered acting “funny.”

The patient appears to be fatigued and confused and exhibiting slurred speech. She
is breathing and has a pulse and skin that is cool and mottled. Vital signs are pulse
68 beats per minute, respirations 14 per minute, blood pressure 108/60 mmHg, and
temperature 92.7 degrees Fahrenheit. There are no signs of trauma to the patient.
Patient prescriptions of Verapamil, Digoxin, Synthroid, and nitroglycerin are found in
the bedroom. Allergies are unknown. The temperature in her apartment is 55
degrees Fahrenheit. Based on the assessment findings, which of the following
conditions is most likely a contributing factor to the patient’s condition?

104. You are assessing an alert and oriented 67-year-old male complaining of left lower

quadrant abdominal pain associated with bright red rectal bleeding. The patient’s
airway is patent and breathing adequate. His radial pulse is moderate and skin warm
to cool. Vital signs are pulse 120 beats per minute, respirations 18 per minute, blood
pressure 110/84 mmHg, and temperature 100.1 degrees Fahrenheit. He states a
past medical history of hypertension, insulin dependent diabetes mellitus, peptic
ulcers, cholecystitis, gastritis, and diverticulosis. His medications include insulin,
atenolol (beta blocker), and Protonix (acid pump inhibitor). He reports no allergies.
Oxygen has been applied and the cardiac monitor shows the following rhythm:

rate to circulate the remaining fluid and blood to the cells at a faster rate. In HHNS,
insulin levels are decreased, not elevated. The tachycardia is a response to the
dehydration and not a primary dysrhythmia produced by the cardiac conduction system.
Metabolic acidosis is typically not seen in HHNS like diabetic ketoacidosis. This most likely
occurs because there is enough insulin circulating to prevent the need to metabolize fats
(with resultant production of ketone bodies).

(Dot Objective 5-4.8)

Atrial fibrillation

Hypothyroidism

Seizure

Hypertension

Rationale

The paramedic must recognize that the patient is hypothermic, based on the body
temperature as well as the temperature in the apartment. Furthermore, the paramedic
must recognize that the patient suffers from hypothyroidism, as evidenced by her use of
Synthroid. Hypothyroidism describes a thyroid that is slow and can only generate minimal
cellular metabolism. Since heat generation is a product of cellular metabolism, the patient
s body temperature drops accordingly. Neither atrial fibrillation, hypertension, nor seizure
would cause the patient to become hypothermic.

(Dot Objective 5-10.36)

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105. You are assessing an alert and oriented 67-year-old male complaining of left lower

Hypoglycemia

Perforated ulcer

Diverticulitis

Gallstones

Rationale

Based on the patient’s past medical history, the abdominal pain and bright red rectal
bleeding can be attributed to diverticulitis. Diverticulitis describes the inflammation of out-
pouches within the intestines (diverticulosis), most commonly the descending and sigmoid
colon (located in the left lower abdominal quadrant). Since associated hemorrhage does
not have far to travel before exiting the rectum, it is typically bright red or wine colored
and may be mixed with feces. Hemorrhage associated with a peptic ulcer(s) is typically
dark colored since the blood is partially digested within the GI tract. Coffee ground-like
hematemesis and/or melena (dark-tarry stool) are frequently observed, not bright red
rectal bleeding. Hypoglycemia and gallstones do not cause rectal bleeding.

(Dot Objective 5-6.91)

Metabolic alkalosis

Peritonitis

Uremia

Hypertension

Rationale

Diverticulitis describes the inflammation of “out-pouches” within the intestines
(diverticulosis), most commonly the descending and sigmoid colon. As such, these areas
of out pouching are weak and prone to perforation. If the intestine perforates, bacteria
and waste products can spill into the abdominal cavity, resulting in bacterial peritonitis
(infection of the peritoneal cavity). In some cases, hemorrhage associated with
diverticulitis can be severe, resulting in hypotension, not hypertension. Similarly, heavy
blood loss and hypovolemic shock may result in metabolic acidosis, not metabolic
alkalosis. Uremia is a condition resulting from renal failure, of which the patient has no
past medical history.

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106. You are assessing an alert and oriented 67-year-old male complaining of left lower

107. Which of the following medications would you expect to find a patient who is being

treated for peptic ulcer disease to be taking?

(Dot Objective 5-6.41)

IV fluid bolus

25 grams of 50% dextrose

Analgesic therapy

Tylenol PO for fever

Rationale

Since the patient is symptomatic for blood loss (rectal bleeding and tachycardia in the
presence of beta blocker use), IV fluid therapy is warranted. There is no clinical evidence
that the patient is hypoglycemic and would benefit from the administration of 50%
dextrose. Analgesic therapy for abdominal pain is relatively contraindicated due to its
propensity to cause colonic spasm and mask signs of peritonitis (if present). Antipyretic
therapy is not a priority given the low-grade nature of the fever as well as the general
guideline that the patient suffering from diverticulitis should be given nothing by mouth
(in the event surgical intervention is necessary).

(Dot Objective 5-6.24)

Antibiotic

Non-steroidal anti-inflammatory

Aspirin

Calcium channel blocker

Rationale

It is estimated that about 80 percent of all cases of peptic ulcer disease are caused by the
presence of Helicobacter pylori (H pylori) bacteria. The bacteria damage the protective
mucosal lining of the stomach and/or duodenum, allowing it to be damaged by the strong
gastric acids used for digestion. Consequently, ulcerations in the mucosal lining and tissue
occur. Antibiotic therapy can control the population of H pylori and definitively treat the
ulcerative disease. Non-steroidal anti-inflammatory medications, including aspirin,
increase acid production and can worsen or exacerbate peptic ulcer disease. While calcium

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108. You have been called to an apartment in a low-income section of the city for a

pregnant female who is sick. On scene, you find a mother who has just come to the
United States, and her two daughters ages 10 and 6 years. The mother does not
speak English; however, the 10-year-old does and informs you that there was a mix
up while talking to the 911 operators. While the mother is two months pregnant, you
have actually been summoned for the 6-year-old who is sick. The girl continues by
stating that the 6-year-old has been sick and was taken to a local medical clinic
yesterday where she was told she had German measles (rubella). They could not
afford the medication for her and today the rash has spread from her face to the rest
of her body. Assessment of the girl reveals her to be alert and active and covered
with a fine pink rash. Her vital signs are pulse 100 beats per minute, respirations 25
per minute, blood pressure 106/70 mmHg, and temperature 100.2 degrees
Fahrenheit. On room air, her pulse oximeter reading is 99%. When asked, she states
that she has a sore throat but feels fine otherwise. No one in the family has received
the MMR (measles, mumps, and rubella) vaccination. Given the situation, which of
the following measures could the paramedic immediately take to minimize the
transmission of the measles to any and all parties on scene?

109. You have been called to an apartment in a low-income section of the city for a

channel blockers can be used in the treatment of gastro-esophageal reflux disease
(decrease spasm of the lower esophageal sphincter), they are not indicated in the
management of peptic ulcer disease.

(Dot Objective 5-6.51)

Wear a gown and goggles.

Avoid touching the rash.

Cover the patient with a gown.

Place a mask on the patient.

Rationale

Rubella is spread via airborne droplets emitted from the affected patient. Therefore,
placing a mask on the patient is the best means to minimize transmissions to others who
are susceptible (the mother and daughter who have not had the MMR vaccine). While the
rash may be visually disturbing, touching it will not spread the illness. Similarly, covering
the patient with a gown is not necessary. Donning a gown and goggles may prevent
exposure to the paramedic, but does not protect others on scene (the paramedic is most
likely immune due to receiving the MMR as a child).

(Dot Objective 5-11.34)

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have actually been summoned for the 6-year-old who is sick. The girl continues by
stating that the 6-year-old has been sick and was taken to a local medical clinic
yesterday where she was told she had German measles (rubella). They could not
afford the medication for her and today the rash has spread from her face to the rest
of her body. Assessment of the girl reveals her to be alert and active and covered
with a fine pink rash. Her vital signs are pulse 100 beats per minute, respirations 25
per minute, blood pressure 106/70 mmHg, and temperature 100.2 degrees
Fahrenheit. On room air, her pulse oximeter reading is 99%. When asked, she states
that she has a sore throat but feels fine otherwise. No one in the family has received
the MMR (measles, mumps, and rubella) vaccination. Given the patient’s diagnosis of
rubella and associated assessment findings, which of the following is most
appropriate concerning field treatment?

110. You have been called to an apartment in a low-income section of the city for a

IV access with a 20 ml/kg fluid bolus, oxygen.

Oxygen, IV access, cardiac monitor.

Epinephrine, Benadryl, rapid transport.

Oxygen, antipyretic, nonurgent transport.

Rationale

To the patient, rubella is often a self-limiting and benign disease. In its most severe
presentation, rubella can result in encephalitis outwardly evidenced by altered mental
status, which this patient does not show. Given the assessment findings coupled with
knowledge of viral illness, the paramedic should recognize the patient as stable.
Accordingly, the most appropriate treatment might involve oxygen and antipyretic for
fever (as needed) along with nonurgent transport to a medical facility. IV access and
cardiac monitoring are indicated due to the patient s stability. The patient s vital signs do
not indicate hypovolemia, eliminating the need for a 20-ml/kg bolus. Epinephrine,
Benadryl, and rapid transport would be indicated for the patient experiencing an allergic
reaction or anaphylaxis, not rubella. For such patients, it is important to differentiate rash
from urticaria (hives).

(Dot Objective 3-4.2)

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the MMR (measles, mumps, and rubella) vaccination. At the hospital, which of the
following pieces of information is critical to convey to the Emergency Physician?

111. You have been dispatched to a physician’s office for a patient with seizure activity. At

the office, you find a 46-year-old female patient on the floor being attended to by
the doctor, nurse, and medical assistant. The physician informs you that she has a
brain tumor and came to his office for increased weakness. While being examined,
the patient suddenly exhibited repetitive clonic movements of the left arm and leg
lasting for two minutes. She never lost consciousness nor became post ictal.
Assessment reveals her to be alert, oriented, and complaining of a headache and
nausea. Her pulse is 96 beats per minute, respiration 16 per minute, and blood
pressure 122/80 mmHg. At the present, she does not exhibit seizure activity. Given
the physician’s description of the seizure activity, what portion of the central nervous
system is the tumor located in?

It has been 25 years since your MMR vaccine.

The child also had chicken pox two years ago.

The young girl’s mother is pregnant.

Your partner is an insulin dependent diabetic.

Rationale

The transmission of rubella to the non-immunized pregnant female has a high probability
of causing congenital birth defects to the baby. Immunization typically offsets this risk,
but given that the mother has never been immunized, her baby is in danger. Therefore, it
is critical that the paramedic relays this information to the receiving physician. The fact
that the child had chicken pox two years prior is not necessarily pertinent to the present
case of rubella (however it should be documented or relayed at some point). The MMR
vaccine should convey lifetime immunity to the disease, enabling the paramedic to be
exposed without risk of contracting the disease. Diabetes does not place your partner at
greater risk of contracting rubella, assuming that he or she has received the MMR vaccine.

(Dot Objective 5-11.34)

Spinal cord

Meningeal layers

Right cerebrum

Left parietal region

Rationale

In the brain, the right hemisphere controls the left half of the body and the left
hemisphere controls the right. Since the patient experienced seizure activity to the left
extremities, the paramedic should recognize that the tumor lies within the right cerebral
hemisphere, not the left. Given the description of a brain tumor, the lesion would not lie
in the spinal cord. The meningeal layers that surround the brain (pia mater, arachnoid,
and dura mater) provide protection to the brain and do not partake in the transmission of
nervous impulses needed for sensation or movement.

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112. You have been dispatched to a physician’s office for a patient with seizure activity. At

the office, you find a 46-year-old female patient on the floor being attended to by
the doctor, nurse, and medical assistant. The physician informs you that she has a
brain tumor and came to his office for increased weakness. While being examined,
the patient suddenly exhibited repetitive clonic movements of the left arm and leg
lasting for two minutes. She never lost consciousness nor became post ictal.
Assessment reveals her to be alert, oriented, and complaining of a headache and
nausea. Her pulse is 96 beats per minute, respiration 16 per minute, and blood
pressure 122/80 mmHg. At the present, she does not exhibit seizure activity. Given
the description of the patient’s seizure activity, the paramedic would recognize what
type of seizure?

113. You have been dispatched to a physician’s office for a patient with seizure activity. At

the office, you find a 46-year-old female patient on the floor being attended to by
the doctor, nurse, and medical assistant. The physician informs you that she has a
brain tumor and came to his office for increased weakness. While being examined,
the patient suddenly exhibited repetitive clonic movements of the left arm and leg
lasting for two minutes. She never lost consciousness nor became post ictal.
Assessment reveals her to be alert, oriented, and complaining of a headache and
nausea. Her pulse is 96 beats per minute, respiration 16 per minute, and blood
pressure 122/80 mmHg. At the present, she does not exhibit seizure activity. In
addition to oxygen, the most appropriate treatment for this patient would also
include:

(Dot Objective 5-3.3)

Absence (petit mal)

Pseudo-seizure

Simple partial seizure

Generalized seizure (grand mal)

Rationale

A simple partial motor seizure results when the electrical discharge form one cerebral
hemisphere causes repetitive clonic movement to the opposite side of the body. A
generalized or grand mal seizure occurs when both cerebral hemispheres are involved and
results in clonic movements to the entire body, as well as a loss of consciousness and
post ictal phase. An absence (petit mal) seizure is caused by uncontrolled electrical
discharge from both hemispheres and is evidenced by a brief loss of consciousness. An
absence seizure is sometimes accompanied by fluttering of the eyelids and/or brief loss of
motor tone, but not global clonic movement. Pseudo-seizures are related to psychological
disorders and describe sharp bizarre movements of the body and can often be interrupted
by commands such as “stop it!”

(Dot Objective 5-3.3)

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114. You are interviewing a patient with multiple psychiatric disorders. The patient has

stated that she wishes to end her life. You reply by asking, “Why would you want to
do that?” This question is an example of a/an:

115. You have been dispatched to a long-term care facility to transport an 81-year-old

male patient to the emergency department for evaluation of acute renal failure.
While placing the patient onto the stretcher, the nurse informs you that the cause of

Transport in semi-fowler’s position and IV access.

Cardiac monitor and transport in supine position on cot with feet elevated.

IV Valium and cardiac monitor.

IV Valium and hyperventilation with bag-mask.

Rationale

An accompanying problem with brain tumors is vomiting, which can occlude the airway.
Transport in a semi-fowler s position gives the conscious patient more control of his or her
airway, as compared to the supine position. If the patient were altered in mentation, the
recovery position would be more appropriate. Establishing an IV is also useful should the
patient seize during transport and require an anticonvulsant (e.g., Valium). Application of
the cardiac monitor is also beneficial. Since the patient is not actively seizing, IV Valium is
not indicated. Additionally, hyperventilation is not provided unless the patient displays
signs of increased intracranial pressure in the presence of cerebral herniation through the
foramen magnum.

(Dot Objective 5-3.33)

confrontation.

reflection.

open-ended questioning.

closed-ended question.

Rationale

The question posed in the scenario is best described as an open-ended question. Open-
ended questions are questions that cannot be answered with a simple yes or no, but allow
the patient to answer in greater detail. In this case, the patient can begin to explain why
she wants to end her life, giving the paramedic greater insight into the patient’s
motivations, problems, and most appropriate management. Close-ended questions are
typically answered in one or two words like yes or no. Reflection is a listening technique in
which you repeat the patient’s words in an attempt to have the patient provide you with
more details or information. Confrontation is a technique used when there are
inconsistencies detected in information provided by the patient. For instance, “You say
that you have never done drugs, but there are needle marks on your arms.”

(Dot Objective 1-9.4)

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the failure is post renal. Assessment reveals the patient to have no obvious life
threat to the airway, breathing, or circulation. Vital signs are pulse 88 beats per
minute, respirations 18 per minute, blood pressure 138/70 mmHg, and SpO

94%

on room air. It is critical that the patient be placed on the cardiac monitor due to the
patient’s predisposition to:

116. You have been called to an apartment for an elderly female patient who has fallen.

As you enter the small four-bedroom apartment, you find the patient lying on a cold
tile floor in the living room. There are several family members sitting on the couch
and chairs watching television. The apartment is in deplorable condition and no one
seems concerned that the 83-year-old woman is on the floor. The patient states that
she lost her footing and fell four hours ago and no one would help her up, despite
her pleas. In reply, a family member laughingly states that she likes to be on the
floor. Assessment of the elderly patient reveals no obvious injuries, although she has
urinated and defecated on herself. She is legally blind and an insulin dependent
diabetic. Her blood sugar is 93 mg/dl by glucometer. Given the circumstances, you
are suspicious of abuse. Given the situation and assessment findings, what category
of abuse would be most applicable?

hyperkalemia.

metabolic acidosis.

hypertension.

hypoglycemia.

Rationale

Because the kidney is responsible for the regulation of electrolyte balances, acute renal
failure can result in electrolytic imbalances, the most dangerous being hyperkalemia.
Hyperkalemia can precipitate a variety of lethal cardiac dysrhythmias, up to and including
asystole. ECG characteristics indicative of hyperkalemia include flattened “P” waves,
widened QRS complexes, and heightened “T” waves. Treatment may involve the
administration of sodium bicarbonate, insulin, and/or calcium chloride. While hypertension
may accompany and/or cause renal failure, obtaining a blood pressure is the best means
to determine its presence or absence. A blood glucose reading is used to evaluate for
hypoglycemia. Metabolic acidosis typically accompanies renal failure, not metabolic
alkalosis.

(Dot Objective 5-2.47)

Physical

Neglect

Sexual

Financial

Rationale

Neglect describes the failure of a caregiver(s) to meet an individual’s basic needs. In this
case, assisting the patient up off of the floor. Sexual abuse is the nonconsensual contact

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117. You have been called to an apartment for an elderly female patient who has fallen.

As you enter the small four-bedroom apartment, you find the patient lying on a cold
tile floor in the living room. There are several family members sitting on the couch
and chairs watching television. The apartment is in deplorable condition and no one
seems concerned that the 83-year-old woman is on the floor. The patient states that
she lost her footing and fell four hours ago and no one would help her up, despite
her pleas. In reply, a family member laughingly states that she likes to be on the
floor. Assessment of the elderly patient reveals no obvious injuries, although she has
urinated and defecated on herself. She is legally blind and an insulin dependent
diabetic. Her blood sugar is 93 mg/dl by glucometer. Given the circumstances, you
are suspicious of abuse. Which of the following would be most appropriate at this
time?

118. A 36-year-old female has ingested a large quantity of Valium, Elavil, and Captopril.

The patient is supine on the floor and responds to painful stimuli with non-purposeful
movement. Additional assessment findings include: dried vomitus tinged with blood
around the patient’s mouth, bilateral rhonchi, and pupils that are 7 mm and slow to
react to light. Her skin is cool and cyanotic and her radial pulse rapid and weak. Vital

or similar doing related to sexual activity. Physical abuse is described as any act of
physical violence perpetrated by an individual on anther, resulting in pain and/or injury.
Since the patient fell on her own accord and family members did not push her down,
physical abuse does not properly describe this incident. Financial abuse describes the
misuse of exploitation of a person’s money of other financial assets for personal gain
(e.g., stealing checks or selling possessions).

(Dot Objective 6-3.5)

Determine why the family did not assist the patient.

Notify medical command of the situation.

Transfer the patient to the ambulance.

Contact social services to come council the family.

Rationale

Since the patient does not have any life threatening injuries, patient safety becomes the
priority. The most appropriate action would be to move the patient from the setting of
potential abuse to the safety of the ambulance. While contacting social services and
notifying medical command of the situation are appropriate, the paramedic would perform
these actions after the patient has been removed from the immediate scene. Determining
why the family did not help the patient may inflame an already tense situation,
jeopardizing the relatively calm scene as well as safety to all parties involved. Rather, the
paramedic should specifically document all scene findings and patient information and
notify the proper authorities.

(Dot Objective 6-4.4)

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signs are pulse 96 beats per minute, respirations 20 and deep, blood pressure
102/74 mmHg, and SpO

91% with high flow oxygen via a non-rebreathing

facemask. The cardiac monitor shows the following rhythm: Why does the patient
have a pulse oximeter reading of 91%?

119. A 36-year-old female has ingested a large quantity of Valium, Elavil, and Captopril.

91% with high flow oxygen via a non-rebreathing

facemask. The cardiac monitor shows the following rhythm: Your immediate action in
caring for this patient would be:

Aspiration

Pulmonary edema

Brain injury

Internal hemorrhage

Rationale

Given the presence of dried vomitus around the patient s mouth and bilateral rhonchi, the
paramedic must assume that aspiration of stomach contents is causing the patient
profound hypoxia (SpO2 91% despite high flow oxygen). Some blood in the vomitus is
common following a toxic ingestion, but in this case is not enough to cause the degree of
hypovolemia needed to impair oxygen delivery to the tissues. There is no clinical evidence
to indicate the presence of pulmonary edema (rales or crackles). Although the toxic level
of medications within the patient s blood may injure the brain, it has not impaired its
control over the respiratory drive as exhibited by the rate of 20 breaths per minute.
Therefore, brain injury is not the cause of the low SpO2 reading.

(Dot Objective 5-8.15)

sodium bicarbonate.

endotracheal intubation.

Narcan, 50% dextrose, and thiamine.

Narcan.

Rationale

Since the patient has a decreased level of consciousness and has aspirated stomach
contents, placement of an endotracheal tube to prevent additional aspiration and allow
the direct delivery of oxygen into the pulmonary system is the first issue that the
paramedic must address. If an orotracheal tube cannot be passed, the paramedic should
consider nasotracheal intubation or rapid sequence intubation if allowed by local medical
direction. There is no indication for Narcan given that the patient exhibits no signs of
narcotic ingestion (e.g., constricted pupils, respiratory depression). While the

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120. A 36-year-old female has ingested a large quantity of Valium, Elavil, and Captopril.

91% with high flow oxygen via a non-rebreathing

facemask. The cardiac monitor shows the following rhythm: Why would contacting
the poison control center (PCC) be advantageous?

121. What is the most effective way to approach a hostile situation?

administration of Narcan would not hurt the patient, it would delay more important and
potentially life saving measures like placement of a tracheal tube. Similarly, while sodium
bicarbonate may hold benefit given the tricyclic ingestion, the time required for
administration would most likely delay other more important interventions. Routine use of
the “coma cocktail” (Narcan, D50, and thiamine) is no longer advocated within the
emergency medical services.

(Dot Objective 5-8.16)

The PCC can walk the paramedic through the steps of performing a gastric lavage.

The PCC can advise the paramedic of specific complications that may arise secondary to
the medication(s) ingested.

The PCC can calculate the amount of medication taken based on the patient’s clinical
presentation.

The PCC can authorize specialized treatments that would otherwise require direct
medical command.

Rationale

Poison Control Centers (PCCs) are clearinghouses for information regarding poisoning
emergencies and when given the medication(s) taken, can provide information related to
anticipated complications and specialized treatment that may serve to benefit the patient.
PCCs do not calculate the exact amount(s) of medication taken by a patient based on
their signs and symptoms. It is not the responsibility of the PCC to assist the paramedic in
placing a nasogastric tube and subsequent lavage. The PCC does not have the authority
to authorize specialized treatments that require prior authorization by local medical
direction.

(Dot Objective 5-8.5)

Do not enter the situation until it is controlled by police.

Allow the hostile individuals to voice their concerns and agree with them.

Be aggressive and take immediate control of the situation.

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122. Your sympathetic nervous system is stimulated in response to a series of disturbing

emergency scenes over your last several EMS shifts. You have been experiencing
muscle tension, tremors, and difficulty in sleeping. These symptoms best describe
which stage of the stress response?

123. When preparing for the intubation of a patient who has vomited, what universal

precautions should you use that will provide the maximum level of personal
protection?

Call police and take immediate action on the situation.

Rationale

A hostile situation should be considered to be unsafe and as a result, you should not
entire a hostile situation or scene until control of the scene has been established by
police.

(Dot Objective 1-2.1)

Resistance stage

Acceptance stage

Exhaustion stage

Alarm stage

Rationale

During the exhaustion stage of stress, compensatory mechanisms of stress have failed
and an increase in physiologic and psychological stressors is seen.

(Dot Objective 1-2.2)

Gloves

Gloves and goggles

Gloves, goggles, and a mask

Gloves, goggles, mask, and a gown

Rationale

It should be expected that any patient who you will be intubating will vomit. Invasive
procedures, including airway management procedures, should suggest the maximum
protection for the paramedic.

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124. The National Safe Kids coalition is a program that advocates the use of child safety

devices and helps to educate the general public on appropriate child safety seat
utilization. The focus of the child safety seat program is to prevent injuries from ever
occurring. This is an example of:

125. If you notice that your partner is discussing a patient encounter on a recent call with

his wife, you would consider this misconduct as:

126. At the onset of tissue injury, which of the following chemical mediators is released

very quickly, has a short half-life, and is responsible for IgE mediated immune
response?

(Dot Objective 1-2.3)

tertiary prevention.

primary prevention.

secondary prevention.

quaternary prevention.

Rationale

The definition of primary prevention is a program that prevents an injury from ever
occurring.

(Dot Objective 1-3.6)

An ethical breach.

Both an ethical and legal breach.

A legal breach.

Neither an ethical nor a legal breach.

Rationale

It is expected that a professional will protect patient confidentiality at all times. It is both
unethical, as well as a possible legal issue if the paramedic discusses a patient with his
family members in a fashion that allows the family members to identify the person.

(Dot Objective 1-4.1)

Leukotrienes

Histamine

Thromboxane

Eosinophil chemotactic factor (ECF-A)

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127. Who was the scientist who accidentally discovered penicillin?

128. Why is it that many of the drugs that are currently used in the adult patient have not

been adopted for use in the pediatric patient?

129. You have responded to the scene for a patient with an angulated fracture of the left

wrist after falling off of his bike. The patient complains of significant pain and as a
result, you request an order for narcotic pain relief. The physician orders the
administration of 50mg of Demerol and 25mg of Phenergan IM. What is the term

Rationale

Histamine is a chemical released at the onset of an IgE reaction and begins to work very
rapidly to protect the body from the insult of an immune reaction. Histamine release will
produce coronary artery vasoconstriction, bronchial and smooth muscle constriction,
increased vascular permeability, increased nasal secretions, increased mucus production,
increased capillary permeability, and gastric acid secretion.

(Dot Objective 1-6.22)

Louis Pasteur

Edward Jenner

Robert Koch

Alexander Fleming

Rationale

In 1928, Alexander Fleming combined molds with bacteria and discovered that a certain
mold, penicillin, completely destroyed the bacterial cultures. This finding was the basis for
the penicillin vaccine that was used extensively in 1940.

(Dot Objective 1-7.1)

The drugs have negative effects on children.

There is insufficient research to support use in children.

The drugs are toxic when used in children.

The drugs cannot be metabolized by children.

Rationale

Research guidelines in the United States are very stringent, especially in children. They
generally prohibit the use of medications in children unless there is good research that
speaks to the efficacy and saftey in this population.

(Dot Objective 1-7.11)

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that refers to the actions of these two drugs combining to create a stronger effect
than either drug alone?

130. Morphine sulfate is supplied in a prefilled syringe with 10mg/2ml. What is the

concentration equivalent to?

131. What is the preferred method for the administration of epinephrine for the

anaphylactic patient who presents with a moderate reaction?

Cumulative action

Refractory

Antagonism

Synergism

Rationale

Synergism is the cumulative action of a drug to potentiate the effects of both drugs.

(Dot Objective 1-7.21)

5mg/2cc

5mg/cc

5ml/cc

5ml/2cc

Rationale

5mg/cc is exactly equal to 10mg/2cc or 10mg/ml. CC’s are the same thing as ml’s.

(Dot Objective 1-8.2)

Subcutaneous

Percutaneous

Transdermal

Intramuscular

Rationale

IM injections is the preferred injection method. The subcutaneous route provides slow
uptake, especially in the patient who has already begun to display poor peripheral
perfusion. If the peripheral perfusion is significantly diminished or absent, the drug should
be administered via the intravenous route for immediate absorption and distribution.

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132. If you were asked to listen to a patient’s lung sounds, what technique of assessment

would you be demonstrating?

133. You are completing an assessment of a medical patient and ask the patient to stick

his tongue out. What cranial nerve are you evaluating when you observe the
patient’s ability to move his tongue?

134. You have responded for a patient with obvious chest injuries from a single car motor

vehicle collision. You suspect that the patient has a hemothorax. What would you
expect to find on percussion of the patient’s chest that would verify your suspicion?

(Dot Objective 1-8.22)

Percussion

Auscultation

Inspection

Palpation

Rationale

Auscultation is listening. Inspection uses visual cues to tell you of the patient's underlying
condtion. Palpation is the assessment of the patient using touch and pressure. Percussion
is finding out the density of the tissues beneath the surface by striking the body sharply
above it and listening to the sound created.

(Dot Objective 3-2.1)

Facial nerve (Cranial nerve VII)

Olfactory nerve (Cranial nerve I)

Vagus nerve (Cranial nerve X)

Hypoglossal nerve (Cranial nerve XII)

Rationale

You are evaluating the hypoglossal cranial nerve, which is responsible for motor function
of the tongue. A deficiency that, if present, typically causes the tongue to deviate towards
one side if the patient is asked to stick their tongue out.

(Dot Objective 3-2.21)

Hyporesonance

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135. You are attending to a 17-year-old male that has injured the left upper quadrant of

his abdomen after being involved in a jet ski accident. The most likely organ in this
area that could cause life-threatening internal hemorrhage is the:

136. Which of the following may be considered the most reliable indicator of peripheral

vascular function at any point in time?

Hypertympany

Normoresonance

Hyperresonance

Rationale

A hemothorax is a thoracic cavity that contains fluid. Fluid in the thoracic cavity is
identified by dullness or hyporesonance to percussion.

(Dot Objective 3-2.31)

Spleen

Small intestine

Liver

Large intestine

Rationale

The spleen is the abdominal organ on the left side of the abdomen that has the potential
for the most significant injury. The liver is in the upper right quadrant. Although there are
small intestines in both the upper left and right quadrant, they typically do not bleed
significantly when injured.

(Dot Objective 3-2.41)

Skin temperature

Respirations

Blood pressure

Capillary refill

Rationale

Peripheral vascular function is measured by blood pressure, most specifically the diastolic
blood pressure. Capillary refill is not reliable because it can be influenced by
environmental temperatures and the presence of peripheral vascular disease. Neither skin
temperature nor respirations are indicators of peripheral vascular function.

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137. You have responded for an unconscious, unknown medical patient. On your arrival,

you find a patient who responds to painful stimulation with decorticate posturing.
The patient has a heart rate of 48, respirations of 8, and a blood pressure of
246/124 mm Hg. What illness or injury do you suspect this patient is most likely
suffering from?

138. An intracerebral hemorrhage is most commonly associated with which of the

following scenarios?

139. What does a pulse oximetry reading actually tell you?

(Dot Objective 3-2.51)

Epilepsy

Concussion

Seizure disorder

Intracranial hemorrhage

Rationale

Persistent atherosclerotic disease causes damage to cerebral vessels and as a result, the
vessels become weak and brittle. Once exposed to higher than normal pressures, the
vessel cannot maintain its integrity and ruptures. The result is arterial bleeding into the
brain tissue that causes direct nervous tissue death and secondary swelling and ischemia.
This in turn results in cerebral dysfunction that presents with the common signs and
symptoms seen with nontraumatic head injuries.

(Dot Objective 4-5.49)

Fracture of the skull with vascular disruption

Hypertensive arterial rupture

Coup-contrecoup injuries

Spontaneous vessel rupture

Rationale

(Dot Objective 4-5.57c)

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140. You have responded for a 17 year-old male who has had a sudden onset of shortness

of breath. During your evaluation of the patient, he tells you that he has a history of
Marfan’s syndrome. The patient is dyspneic and has decreased lung sounds on the
left side of his chest. What do you think is the most likely cause of this patient’s
shortness of breath?

141. You have responded to a local school for a student that has experienced a rapid loss

of consciousness and motor coordination, violent muscle spasms, and uncontrolled
jerking. What would your field diagnosis of this patient be?

How much blood is dissolved in the plasma.

The amount of hemoglobin that can be saturated with oxygen

The amount of hemoglobin saturated with carbon dioxide

The amount of hemoglobin that is saturated with oxygen

Rationale

The pulse oximeter will give an indication of how much of the hemoglobin that is passing
through the capillary is saturated. The amount of light from the pulse oximeter that can
reach the other side of the pulse oximetry sensor dictates how much of the hemoglobin is
left unbound and the pulse oximetry reading will reflect that.

(Dot Objective 5-1.9)

Pneumonia

Spontaneous pneumothorax

Pulmonary embolis

Congenital lung disease

Rationale

A common complication seen in the patient with Marfan’s syndrome is a spontaneous
pneumothorax. Marfan's syndrome is a connective tissue disorder that results in weak
organ and tissue structure. Along with spontaneous pneumothoracies, they are also more
likely to develop aortic aneurysms.

(Dot Objective 5-1.10j)

Acute hypoglycemia

Simple partial seizure

Complex partial seizure

Tonic-clonic seizure

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142. You are with a young female who was raped by a hitchhiker after offering him a ride.

The woman is emotionally distraught and crying. After assuring no life-threatening
conditions on scene, she is placed in the back of the ambulance. Further assessment
reveals her to be bruised about her arms and neck and moderately bleeding from the
vaginal region. Proper treatment for the vaginal bleeding would include:

143. You are with a young female who was raped by a hitchhiker after offering him a ride.

The woman is emotionally distraught and crying. After assuring no life-threatening
conditions on scene, she is placed in the back of the ambulance. Further assessment
reveals her to be bruised about her arms and neck and moderately bleeding from the
vaginal region. Which of the following statements is most appropriate when talking
with the patient in the back of the ambulance?

Rationale

The clinical signs of a rapid loss of consciousness and motor coordination, coupled with
violent muscle spasms, and uncontrolled jerking is hallmark to a tonic-clonic seizure.
Following the seizure is commonly a postictal state when the patient remains
unresponsive.

(Dot Objective 5-3.14)

avoiding physical contact so as not to destroy evidence.

packing the vagina with sterile dressing.

applying a bulky dressing to the external genitalia.

administering Pitocin (Oxytocin).

Rationale

While the goal is not to disturb or destroy evidence, if the patient is bleeding, care must
be provided for this. Applying a bulky dressing to the external genitalia and holding it in
place with gentle pressure is the most appropriate means of controlling vaginal
hemorrhage. Additionally, the paramedic should never discard the dressing as they
become saturated since they may contain evidence of the crime. Rather, it is better to
bag the dressings and turn them over to the proper emergency department staff. Pitocin
is not indicated for the control of vaginal bleeding secondary to rape. The vaginal canal
should never be packed with dressing to control hemorrhage, no matter how severe.
Packing the vaginal canal eliminates the opportunity for the blood to exit the body and
may cause more difficulty as it backs up into the internal genitalia. While the paramedic
does not want to touch the patient unnecessarily, it would be improper to let the patient
actively bleed without some sort of hemorrhage control. As stated, all soaked dressing
should be saved for evidence as needed.

(Dot Objective 5-13.5)

“Can you describe the man who did this?”

“Why did you pick up someone that you did not know?”

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144. You are with a young female who was raped by a hitchhiker after offering him a ride.

The woman is emotionally distraught and crying. After assuring no life-threatening
conditions on scene, she is placed in the back of the ambulance. Further assessment
reveals her to be bruised about her arms and neck and moderately bleeding from the
vaginal region. Aside from treating the patient for physical injuries, it is critical that
the paramedic:

145. An anxious 26-year-old female who is 39 weeks pregnant informs you that a half an

“I see you are bleeding. Are you hurting anywhere else?”

“Everything will be okay, you are safe now.”

Rationale

When talking with a patient who has been raped or sexually assaulted, the paramedic
should gear all care towards immediate medical and emotional support. It is not the role
of the paramedic to inquire as to why the woman behaved as she did since this can create
more emotional difficulty by placing her on the defensive. Determining who is responsible
is the role of law enforcement, not EMS. While it is important to let the patient know that
they are safe in the back of the ambulance, the paramedic should never tell the patient
that everything is going to be okay. It is not fair to create a false sense of hope that can
be dashed if things do not turn out okay (e.g. STD transmission, permanent emotional
damage, pregnancy, or failure to apprehend the responsible party).

(Dot Objective 5-13.5)

perform an internal vaginal exam to look for internal injuries.

provide a safe and supportive environment for the patient.

attempt to determine if the attacker had any diseases or ejaculated inside her.

prepare the patient for the possibility she will need to be tested for HIV and STDs.

Rationale

Aside from treating physical injuries, the paramedic must provide emotional support and
convey to the patient that she is safe in the back of the ambulance. It is not the role of
the paramedic to prepare the patient that she may need to be tested for HIV and sexually
transmitted diseases. It is also inappropriate to conduct an internal vaginal exam in the
field setting. This can destroy precious evidence as well as be upsetting to the patient who
has just been raped or sexually assaulted. Likewise, the emergency physician and rape
councilor are better trained to perform the task of determining the possible transfer of
disease or pregnancy secondary to ejaculation inside of the patient.

(Dot Objective 5-13.5)

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have the urge to push nor move her bowels. Her obstetrical history is Gravida-1 and
Para-0. Based on these assessment findings, in what stage of labor is the patient?

146. An anxious 26-year-old female who is 39 weeks pregnant informs you that a half an

hour ago, her water broke and she began to experience contractions. Although the
contractions only last a few seconds, they are painful and occur regularly every 12
minutes. She last saw her obstetrician two days ago, and, at that time, was informed
that she was 4 centimeters dilated. When asked, the patient states that she does not
have the urge to push nor move her bowels. Her obstetrical history is Gravida-1 and
Para-0. Given the patient’s presentation, which of the following would be most
important to perform?

Stage three

Pre-labor stage

Placental stage

Stage one

Rationale

Stage one of labor begins with the onset of true labor contractions and ends with full
dilation (typically 10 centimeters) of the cervix. Contractions typically start mild and short
in duration, then increase in intensity and pain and occur more frequently. The patient’s
amniotic sac may or may not rupture at this time. Since the patient is now experiencing
painful contractions and her water has broken, the paramedic should recognize that the
patient is in the first stage of labor, also known as the “dilation” stage. The third stage of
labor, also known as the “placental” stage, begins immediately after the birth of the baby
and ends once the placental is delivered. Pre-labor stage is not an accepted description of
labor and is therefore incorrect.

(Dot Objective 5-14.4)

Internal vaginal exam to determine amount of dilation

Episiotomy to prevent tearing of the perineum

Fluid bolus for tocolytic therapy

Evaluation of the genitalia for umbilical cord protrusion

Rationale

Although the patient does not feel the need to “push,” it is critical that the paramedic
observe the genitalia to determine if any obvious complications exist, such as a prolapsed
umbilical cord. If the cord or other abnormality is observed, the paramedic can
immediately formulate a plan for management. Performing an internal vaginal exam for
degree of dilation is not a paramedic function and can cause complications like damage of
a low positioned placenta. Similarly, incising the perineal tissue (episiotomy) is not a
paramedic function. Since the patient is full term (greater than 38 weeks), there is no
indication for tocolytic therapy.

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147. An anxious 26-year-old female who is 39 weeks pregnant informs you that a half an

hour ago, her water broke and she began to experience contractions. Although the
contractions only last a few seconds, they are painful and occur regularly every 12
minutes. She last saw her obstetrician two days ago, and, at that time, was informed
that she was 4 centimeters dilated. When asked, the patient states that she does not
have the urge to push nor move her bowels. Her obstetrical history is Gravida-1 and
Para-0. How would you position this patient on the stretcher?

148. You have just delivered a baby. Which of the following assessment findings would

indicate the need for resuscitative activity?

(Dot Objective 5-14.4)

Prone

Trendelenburg

Left lateral

Knee-chest

Rationale

This position assists in keeping the weight of the uterus off of the vena cava (supine
hypotensive syndrome). The Trendelenburg (supine with feet elevated) would most likely
cause the patient to become short of breath as the abdominal contents push up against
the diaphragm and lungs. The knee-chest position is reserved for delivery involving
complications such as a breech birth that does not progress or limb presentation. The
prone position would be very uncomfortable for the pregnant patient and therefore is
avoided.

(Dot Objective 5-14.4)

Continuous crying

Cyanosis to the hands and feet

Heart rate of 90 beats per minute

50 respirations per minute

Rationale

A healthy newborn s heart rate is typically between 120 and 160 beats per minute.
Anytime that the heart rate falls below 100 beats per minute, he or she is distressed and
should receive ventilation and oxygen with the neonatal bag-mask. Continuous crying is a
healthy sign that the baby is breathing and responding to the extrauterine environment.
Newborns typically breathe between 30 and 60 breaths per minute, so a rate of fifty is
considered normal. Acrocyanosis, or cyanosis to the hands and feet, is normal in the first
few minutes following delivery. If the acrocyanosis does not resolve within a few minutes,
supplemental oxygen may be indicated.

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149. Which of the following signs indicate that the delivery of the placenta is imminent?

150. A pregnant female informs you that she has had three previous pregnancies and

currently has a 6-year-old girl and 2-year-old boy. Seven years ago, she contracted
an infection early in the pregnancy and had a miscarriage. Proper documentation of
her status would be:

(Dot Objective 5-14.14)

Increase in the baby’s heart rate

Sudden shortening of the umbilical cord

Gush of blood from the vaginal canal

Rupture of the amniotic membranes

Rationale

In the third stage of labor, the placenta will generally deliver within 5 to 20 minutes of the
baby. Signs that the placenta is about to be expelled from the uterus include a gush of
blood from the vaginal canal, as well as the mother feeling a need to push, and sudden
lengthening of the umbilical cord protruding from the vagina. Since the baby has already
been delivered (second stage of labor), the amniotic membranes have already ruptured.
Similarly, the baby has already been separated from the placenta (via cutting the cord) so
the baby s heart rate is independent of any placental activity.

(Dot Objective 5-14.4)

G-2; P-3; Ab-1

G-3; P-2; Ab-0

G-2; P-4; Ab-0

G-4; P-2; Ab-1

Rationale

Gravida refers to pregnancy. Since the patient has been pregnant three times previous
and is currently pregnant, she is referred to as Gravida-4 (G-4). Para describes the
number of viable children born to the female. Since she has delivered two living children
she is described as Para-2 (P-2). A miscarriage is referred to as a spontaneous abortion.
Given the death of the baby during the mother’s first pregnancy, she is assigned
Abortion-1 (Ab-1).

(Dot Objective 3-6.6)

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151. A child was sled riding and lost control of his sled and traveled onto a roadway into

the path of a pickup truck. The truck struck the child at a high rate of speed, sending
him 30 feet away from the point of impact. After being struck, his friends carried him
to his house, where his parents called 911 for help. Your assessment reveals a 9-
year-old child who responds to painful stimuli with a groan. He is breathing and has
a radial pulse that is moderate in strength. His skin is cool to cold and mottled in
appearance. He shows superficial bruising to the left chest and left flank as well as
deformity to his right lower leg and ankle. Vital signs are pulse 64 beats per minute,
respirations 10 per minute, blood pressure 156/98 mmHg, and SpO

97%. Based on

these assessment findings, what is the immediate threat to his life?

152. A child was sled riding and lost control of his sled and traveled onto a roadway into

97%. Which of

the following describes the most appropriate delivery of IV fluid therapy?

Ruptured spleen

Internal hemorrhage

Brain injury

Hypothermia

Rationale

The boy’s clinical presentation and vital signs indicate an internal head injury with an
accompanying increase in intracranial pressure. Pressure on the vagus nerve (10th cranial
nerve) causes the heart rate to drop while hypertension is a compensatory response by
the body to get oxygen-rich blood to the edematous brain tissue. The patient’s decreased
level of consciousness provides further evidence of a cerebral injury. Although the boy
may be somewhat hypothermic from exposure to the elements, this does not represent
the most immediate threat to his life (and may even provide some protection to the
brain). If the patient were suffering from internal hemorrhage, the paramedic would
expect to see a tachycardic heart rate as well as a decreasing blood pressure. A ruptured
spleen would result in significant blood loss and present as described for internal
hemorrhage.

(Dot Objective 6-2.7)

Up to three boluses of 0.9% normal saline or lactated ringers

Two large bore IVs of an isotonic crystalloid, run wide open

One time 20 ml/kg bolus of 0.9% normal saline

Lactated ringers or 0.9% normal saline at a KVO rate

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153. A child was sled riding and lost control of his sled and traveled onto a roadway into

the path of a pickup truck. The truck struck the child at a high rate of speed, sending
him 30 feet from the point of impact. After being struck, his friends carried him to
his house, where his parents called 911 for help. Your assessment reveals a 9-year-
old child who responds to painful stimuli with a groan. He is breathing and has a
radial pulse that is moderate in strength. His skin is cool to cold and mottled in
appearance. He shows superficial bruising to the left chest and left flank as well as
deformity to his right lower leg and ankle. Vital signs are pulse 64 beats per minute,
respirations 10 per minute, blood pressure 156/98 mmHg, and SpO

97%. First

responders are on the scene providing assistance. His parents are by his side with a
look of disbelief on their faces. His mother is crying and asking you if he is going to
be okay. In reference to the parents, it would be best to:

Rationale

Since the patient is not hypovolemic and presents as hypertensive, 0.9% normal saline or
lactated ringers delivered at a keep vein open (KVO) rate is most appropriate. There is no
indication for a 20 ml/kg bolus or fluids run wide open since blood loss is not the
underlying problem. Similarly, up to three consecutive boluses of 0.9% normal saline or
lactated ringers is also inappropriate.

(Dot Objective 6-2.5)

have a paramedic inform them of what is going on with the treatment.

have them leave for the hospital prior to your departure.

contact medical command and have the physician talk to the parents.

have a first responder escort the parents out of the room.

Rationale

Dealing with parents whose child is critically injured or sick can be exceptionally difficult.
The paramedic must remember that they are as much patients as is the child in need of
care. If the parents do not impede care, it is best and most humane to be honest and
provide information as to what you are doing for their child. If there is enough help,
assign a paramedic to stay with the parents and describe to them what is being done.
Studies have shown that parents who are present during critical treatment and
resuscitation gain better closure of the incident, especially if death or permanent injury
results. Since the parents in the scenario are not interfering with care, it would be
inappropriate to escort them out of the room as would having them speak with the
medical command physician, who is not on scene and cannot describe all that is
occurring. If possible, it may be best to have one parent ride in the ambulance during
transport to the hospital. Additionally, given their high state of emotion, it is advisable to
have someone else drive them to the hospital, if transporting one of the parents is not
possible.

(Dot Objective 6-2.11)

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154. You have responded to a local pool for a 9-year-old male who had just been pulled

out of the water and is reportedly not breathing. Your assessment of the child
reveals him to be unresponsive, apneic, and pulseless. In addition to cellular
hypoxia, what other pathophysiological changes would you expect to find in this
patient?

155. You have been dispatched to a residence for a 13-year-old female who has multiple

birth defects secondary to fetal alcohol syndrome. On scene, anxious family
members greet you and state that her ventilator does not seem to be working. Quick
assessment reveals the patient to have a tracheostomy and tube that is hooked to
the ventilator. The ventilator is beeping and appears to be delivering five to six
breaths per minute. The girl is cyanotic. You immediately disconnect the ventilator
from the tracheostomy tube and:

Intracellular hypernatremia and increased ATP production

Intracellular hyponatremia and decreased ATP production

Intracellular hyponatremia and increased ATP production

Intracellular hypernatremia and decreased ATP production

Rationale

The patient is not perfusing so cellular oxygenation is poor and as a result, cellular
hypoxia will develop. As hypoxia progresses, the patient will switch from aerobic to
anaerobic metabolism. The byproduct of anaerobic metabolism is lactic acid, which when
it reaches high enough levels will promote systemic acidosis. The acidotic environment of
the vasculature will eventually contribute to failure of the sodium/potassium pump and an
influx of sodium into the cell. Since water always follows sodium, there is also an influx of
water into the cell, which will cause cellular swelling. As the cells swell, so will the cellular
mitochondria. The swelling of the mitochondria will cause failure of energy production and
ATP production will decrease.

(Dot Objective 1-6.2)

administer high flow oxygen via oxygen tubing through the tracheostomy tube.

perform nasotracheal intubation and ventilate with high flow oxygen.

remove the tracheostomy tube and insert an endotracheal tube.

attach a bag-valve-mask that is connected to supplemental oxygen to the
tracheostomy tube and attempt to ventilate.

Rationale

When confronted with a ventilator that is malfunctioning, it is best to immediately
disconnect ventilator tubing from the tracheostomy tube and provide manual ventilations
with the bag mask (mask removed) and high flow oxygen. The 15/22 mm adapter on the
bag mask will attach directly to a tracheostomy tube, allowing a secure fitting and direct
route to provide ventilatory support. It is important to quickly determine whether or not
the pharynx is patent with the larynx and trachea. If it is, the paramedic will need to close
the mouth and pinch the nostrils closed so that each ventilation goes into the lungs and

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156. You have responded to the scene for a 6-month-old patient who had reportedly

ingested bleach. Upon your arrival, the parents of this infant tell you that they had
left the child unattended for just a few minutes and came back in to find the child
had obviously consumed what they guess to be about a cup of bleach. Your
assessment of the progression of this scenario is:

157. During the monthly menstrual cycle, what is the average amount of blood loss that

could be expected?

not out the mouth and nose (or occlude the tracheostomy tube and ventilate through the
mouth and nose). If there is no connection between the larynx and pharynx, ventilations
should be administered directly through the tracheostomy tube. With the presence of the
tracheostomy tube, there is no need for nasotracheal intubation. Since the tracheostomy
tube is in place and not dislodged, removal (and insertion of an endotracheal tube) is not
necessary. Given that the patient requires active ventilation through the ventilator, the
passive administration of oxygen directly to the tracheostomy tube (via oxygen tubing or
a tracheostomy mask) will not be drawn into her lungs.

(Dot Objective 6-6.16)

The bleach or household chemicals should not have been in reach of this child; it is
clearly neglect.

The parents should have been watching the child more closely so this would not have
occurred.

The scenario does not correlate with the story given by the parents, given the age of
the child.

It is common for a child of this age to ingest household products when not being
watched closely.

Rationale

A 6-month-old child does not have the fine motor skills or strength needed to open the
bleach container, let alone lift it to his or her mouth to drink it. The clinical picture does
not match the story because the child could not have ingested the chemical of his own
accord.

(Dot Objective 1-10.1)

100 cc

25 cc

75 cc

50 cc

Rationale

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158. You have responded to the residence of a 26-year-old female who states that she is

in labor. The patient tells you that she feels the urge to push and that her
contractions are about 45 seconds to 1 minute apart. As you perform a visual
assessment, you note the umbilical cord is protruding from the vaginal opening.
What would you do to manage this emergency?

159. In a field delivery, where should the umbilical cord be cut?

160. You have just delivered a full-term baby without difficulty. The proper sequence of

managing this neonate includes which of the following progressions?

The average woman bleeds out a total of approximately 50 cc during her monthly flow.

(Dot Objective 5-13.2)

Call for additional back-up and begin the immediate fundal massage.

Insert two gloved fingers into the vagina to raise the fetus off the cord.

Immediately prepare the mother for transport to the nearest OB center and begin
transport.

Immediately clamp and cut the cord while preparing to deliver the baby.

Rationale

With every contraction, the umbilical cord and the baby are being starved of oxygenated
blood flow. Placing a support (two gloved fingers) to raise the fetus off the cord will allow
blood circulation and prevent occlusion of cord blood.

(Dot Objective 5-14.5)

Approximately 10-15 inches from the baby

Approximately 10-15 cm from the baby

Approximately 10-15 inches from the placenta

Approximately 10-15 cm from the placenta

Rationale

The cord should be cut after the baby has been delivered and approximately 10-15 cm
from the umbilicus of the newborn.

(Dot Objective 5-14.15)

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161. You have just delivered a full-term baby without difficulty. On evaluation of the initial

APGAR score, you note that the baby’s body is blue, his heart rate is 60, he doesn’t
move to stimulation, no response to bulb syringe suctioning, and he has a
respiratory rate of 16. What is the baby’s APGAR score?

162. Why is it critical that the paramedic complete an equipment checklist at the

beginning of each shift?

Dry, position, warm, stimulate, suction

Position, dry, warm, suction, stimulate

Position, dry, warm, stimulate, suction

Dry, warm, position, suction, stimulate

Rationale

The proper sequence of events immediately following delivery, as advocated by the
American Academy of Pediatrics is to dry, warm, position, suction, and then stimulate the
infant.

(Dot Objective 6-1.1)

Rationale

The baby’s APGAR is 2. The only points this infant received were 1 for the presence of a
heart rate and 1 for the presence of respirations. An APGAR score this low correlates with
the need to provide aggressive care.

(Dot Objective 6-1.11)

Checklists are required by the Occupational Safety and Health Administration.

Completion reduces the risk of liability associated with providing prehospital medical
services.

Most medical insurance agencies require a copy of the checklist for ongoing liability
coverage

Completion is mandated by the US Department of Health and Human.

Rationale

Completion of an equipment/supply checklist enables the paramedic to determine the

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163. While on standby at a motor raceway, a spectator-filled bleacher collapses, falling 30

164. While on standby at a motor raceway, a spectator-filled bleacher collapses, falling 30

feet. The scene is chaotic with people trapped under the bleacher as well as lying
throughout the general area. Others are walking around screaming and crying. Your
only help is your partner who is an EMT B and three off-duty police officers who are
providing security for the event. After completing the above task, you begin to
specifically triage the patients using the START system. The first patient you
encounter is lying on the ground, conscious, confused, and breathing 40 times per

overall preparedness of the ambulance for patient care. Checklists allow the paramedic to
ascertain whether all necessary supplies and equipment are present and working as well
as the expiration dates on medications carried on the ambulance. This decreases liability
associated with providing prehospital emergency medical services by ensuring that
everything needed to properly care for a patient is present and in good working order.
Missing supplies, malfunctioning equipment, and expired drugs represent sources of
liability, especially if they result in improper patient care. The Occupational Safety and
Health Administration and US Department of Health and Human Services do not require
EMS services to complete an equipment/supply checklist. Finally, insurance agencies do
not require the submission of the equipment/supply checklists in order to provide ongoing
liability coverage for the service.

(Dot Objective 8-1.2)

quickly determine the number of living and dead patients.

move all of the walking patients to one area.

call for additional ambulances and rescue personnel.

instruct the off-duty police officers on the steps of basic triage.

Rationale

Your immediate action would be to call for additional ambulances and rescue personnel.
Although you do not know the specifics in terms of patient acuity and numbers, it is a
given that you and your partner cannot handle the incident by yourselves. Therefore, the
best course of action is to have additional resources heading to the incident, while you
then determine additional information (e.g., patient numbers, injuries, severity, etc.).
Moving all of the walking patients to a single area is appropriate, but should be done after
calling for additional resources. The same holds true for determining the number of dead
and living patients (done via triage). Instructing non-medical personnel in the specifics of
triage is time consuming and not a reliable means of triaging patients. Given the limited
resources at the present time, this will delay the overall efficiency with which the incident
must be handled.

(Dot Objective 8-2.4)

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minute. He states that he fell 10 feet and hurt the side of his chest. Your next action
would be to:

165. You have been dispatched to an industrial warehouse for an unknown medical

complaint. On arrival, you find a shirtless 30-year-old male patient covered from his
neck down with a white-gray powder. Apparently the man, who does not speak
English, was unloading a barrel of pesticide labeled Agritox when the top came off,
spilling its contents onto his body. He tried to brush off what he could, but became
very dizzy and nauseated and sat down on the warehouse floor. The Materials Safety
Data Sheet indicates that Agritox is an organophosphate pesticide. After brushing off
the majority of the pesticide, which of the following would be most appropriate given
the nature of the chemical?

apply a “Hold” (green) triage tag.

start oxygen therapy.

classify the patient as “Immediate” (red).

check the pulse rate.

Rationale

Using the START Triage system, a patient that is conscious and breathing over 30 times
per minute is classified as “Immediate.” An immediate (or red tag) patient is a priority
and is to be treated as quickly as possible, but not by the triage officer. It is the
responsibility of the triage officer to sort through and organize the patients so that
appropriate treatment by other EMS personnel can follow. If the triage officer becomes
involved in treatment, it is impossible to triage the remaining patients. Therefore,
applying oxygen must be left to other EMS personnel responsible for treatment. A
“Hold” (green) label describes a patient, who is walking, alert and oriented, and has a
respiratory rate and pulse within normal limits. These patients generally do not require
immediate care.

(Dot Objective 8-2.2)

Neutralize the pesticide with glycerin

Deactivate the chemical with alcohol

Apply copious amounts of water to the patient

Wrap the patient in a burn sheet and transport

Rationale

After brushing the majority of chemical off of the patient, the paramedic should apply
copious amounts of water to the patient’s body, so to dilute and remove the remainder of
the organophosphate. Since organophosphate is a dangerous chemical and readily
absorbed through the skin and mucous membranes, the application of water is a priority.
Glycerin and alcohol are not indicated in the decontamination of a patient exposed to an
organophosphate. Wrapping the exposed patient in a burn sheet without removing the
remaining pesticide allows continued absorption of the chemical into the man’s body,
placing him at great risk for systemic injury and death.

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166. You have been dispatched to an industrial warehouse for an unknown medical

complaint. On arrival, you find a shirtless 30-year-old male patient covered from his
neck down with a white-gray powder. Apparently the man, who does not speak
English, was unloading a barrel of pesticide labeled Agritox when the top came off,
spilling its contents onto his body. He tried to brush off what he could, but became
very dizzy and nauseated and sat down on the warehouse floor. The Materials Safety
Data Sheet indicates that Agritox is an organophosphate pesticide. Given the
classification of Agritox as an acetylcholinesterase inhibitor, which of the following
interventions should the paramedic be prepared to administer or perform?

167. You are by the side of a patient complaining of psychiatric problems. The man is

visibly upset and at times displays aggressive actions, both physical and verbal.
Given the situation, you and your partner elect to use the “contact and cover”
procedure for this patient, of which you will assume the “cover” role. As such, which
of the following actions is your responsibility?

(Dot Objective 8-4.1)

Rapid cooling of an increased body temperature

50% dextrose for hypoglycemia

Subcutaneous epinephrine for bradycardia

Suctioning of airway secretions

Rationale

As acetylcholinesterase inhibitors, organophosphates typically present with signs and
symptoms oriented to the parasympathetic nervous system. The term SLUDGE provides a
pneumonic to assist the paramedic in frequently encountered signs and symptoms
(salivation, lacrimation, urinary incontinence, diarrhea, GI distress, and emesis). The
production of salivary and pulmonary secretions can be tremendous, necessitating
removal via suction. As a matter of fact, upper and lower airway occlusion secondary to
secretions is a common cause of morbidity and mortality from organophosphate exposure.
Hypoglycemia and hyperthermia are not directly associated with organophosphate
poisoning. While bradycardia may present with exposure to an organophosphate, the
medication of choice is atropine, not epinephrine.

(Dot Objective 8-4.1)

Patient assessment

Observation of the scene for danger

Patient care only

Obtain information from bystanders

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168. As the head of the Quality Assurance Committee for your service, you review all

patient care reports prior to passing them on to the medical director. On one trip
sheet, you note the following narrative: “Patient states that he cannot move his
bowls and has had abdomenal pane for three weaks. Patient also states that he has
had a fever and took too Tylenol tablets this morming, but then became naseated.”
What advice would you give the paramedic regarding this report?

169. You are on the scene of a fire, in which 20 people have been injured, several

critically. Over the course of the next two hours, you treat and transport 4 of those
patients. After the incident, you realize that you failed to document the vital signs on
one of the critical patients. Thinking back you remember the blood pressure being
90/60 mmHg, but cannot remember the pulse or respiratory rate. Your best course

Rationale

The contact and cover method is a useful tool when dealing with a potentially violent
patient or scene. When using the contact and cover technique, one paramedic or EMT
“contacts” the patient while another stands 90 degrees to the side of the patient,
“covering” his or her partner. The paramedic or EMT providing contact is responsible for
all aspects of patient care (e.g., assessment, medical history, and treatment) while the
paramedic or EMT providing cover is charged with constant observation of the patient and
scene for any signs of danger. If signs of danger become evident, appropriate actions that
ensure safety must follow (e.g., restraint or retreat). This technique is used by police
officers when dealing with disruptive situations and has been shown to be successful.
Unfortunately, a limitation to the cover and contact technique is the critical patient for
whom multiple crewmembers must administer care.

(Dot Objective 8-5.6)

Get a dictionary and look up any questionable words when documenting.

Only document what you know how to spell.

Have the EMT-B do all of the documenting.

Make up abbreviations for any words he is unsure of how to spell.

Rationale

Proper spelling is critical to prehospital documentation. Documentation containing spelling
mistakes looks unprofessional and can cast doubt on the quality of care provided.
Therefore, it is best to advise the paramedic to use a dictionary and look up any and all
words that he is unsure of how to spell. Having the EMT-Basic document the advanced
level care is inappropriate. However, it would not be inappropriate to have the EMT read
over the documentation to point out spelling errors. Making up abbreviations for words
the paramedic is unsure of how to spell can create additional confusion and is not
considered good practice. Just documenting the aspects of patient care for which the
paramedic is comfortable with spelling creates incomplete documentation and is likewise
inappropriate.

(Dot Objective 3-5.1)

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of action would be to:

170. You and your partner, an EMT-B, are treating an unresponsive 63-year-old male

patient who, prior to EMS arrival, was complaining of “crushing” chest pain. Vital
signs are pulse 20 beats per minute, blood pressure 50/30 mmHg, and SpO

97%.

The heart monitor is showing a third degree heart block with a ventricular response.
The patient is intubated and being ventilated at a rate of 12 per minute. An IV has
been established as well as transcutaneous pacing. Presently, you are preparing a
dopamine infusion. Given the multiple tasks necessary to care for this patient, you
would have your partner:

place a note on the patient care report indicating the extenuating circumstances of the
incident.

estimate what you believe the heart and respiratory rate were when the patient was at
the scene.

contact the receiving hospital and obtain the patient’s heart and respiratory rate at the
time of arrival to the hospital.

document the blood pressure but leave the heart and respiratory rates off of the patient
care report.

Rationale

The needs of caring for multiple patients at a mass casualty incident present extenuating
circumstances regarding patient care documentation. It is best to take brief notes when
caring for multiple patients in order to accurately document later, but at times, this may
even be challenging. If vital information is forgotten, it is best to place a note or complete
an addendum explaining the extenuating circumstances of the incident as rationale for the
missing information. Obtaining and documenting the patient s vital signs on arrival at the
hospital does not reflect the patient s condition while in your care. Leaving the heart and
respiratory rate off of the patient care report is appropriate, but a note explaining why
this information is essential and reflects the best course of action. Estimating the patient s
heart and respiratory rate would be inaccurate and not indicative of the patient s true
condition while in your care.

(Dot Objective 3-6.16)

provide ventilations through the tracheal tube.

administer a 0.4 mg spray of nitroglycerin sublingually.

increase the milliamps (mA) on the transcutaneous pacer.

infuse the dopamine at 10 mcg/kg/minute.

Rationale

Since your partner is an EMT-Basic, the most appropriate task for delegation, based on
his level of training, is ventilation through the tracheal tube. Although some states allow
EMT-Basics to provide defibrillation either manually or with an AED, transcutaneous
pacing lies outside of their scope of practice. The same holds true for medications like
dopamine. Nitroglycerin is contraindicated given the hypotensive status of the patient.

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171. After administering nitroglycerin and aspirin to a patient with retrosternal chest pain,

the pain is not alleviated. Accordingly, you administer 3 mg of morphine sulfate.
Your ability to administer the morphine without contacting medical direction is best
described as:

172. A 5-year-old boy who was being watched by his grandmother called 911 after he

could not wake her up. You found her to be in cardiac arrest with on scene
resuscitation unsuccessful. After consulting with medical direction, resuscitation was
stopped and the coroner s office contacted. Since the grandmother was babysitting
the boy, there is no one else around and the family has yet to arrive. He is crying
and asks you if his grandmother will wake up in a little bit so that she can continue
to take care of him. You would reply:

(Dot Objective 1-1.6)

patient advocacy.

expanded scope.

off-line standing orders.

on-line medical direction.

Rationale

Off line standing orders are pre-authorized treatment procedures contained with
prehospital protocols that do not require consult with a medical command physician prior
to administration. On-line medical direction occurs when a pre-designated physician gives
direct orders to the paramedic via telephone or radio. Expanded scope describes the
incorporation or performance of activities and procedures not previously included in the
paramedic’s traditional scope of practice (e.g., health screening and immunizations).
Patient advocacy refers to doing what is in the best interest of the patient. While it could
be argued that administering an analgesic to halt to process of infarction is in the
patient’s best interest, the better answer is “off line standing orders.”

(Dot Objective 1-1.26)

“She will be asleep for a long time.”

“She has died and you did the right thing by calling 911.”

“Why don’t you wait outside for your parents.“

“Try not to cry because everything will be okay.”

Rationale

At the age of 5 years, many children believe that death is a temporary state and asks if
the person will return or wake up. Children may also feel responsible for the death or
think that they are being punished for something else. When dealing with children within

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173. You have assessed an 81-year-old female complaining of intractable pain secondary

to bone cancer. She is extremely frail and emaciated due to the effects of the cancer
and related treatment. Since she is in a second story bedroom, you elect to extricate
with a stair chair. When moving her on the stair chair, what is extremly important so
that you do not accidently drop her?

174. A paramedic has been accused of negligence after he inappropriately administered

adenosine to a patient who was in sinus tachycardia secondary to pneumonia and
fever. To prove the paramedic guilty of this charge, which item must be proven?

the 3 to 6 year age category, it is best to be honest, but frame that honesty within the 3
to 6 year old’s capacity of understanding. Given this, the best response would be “She has
died and you did the right thing by calling 911.” Telling the child that the grandmother will
be asleep for a long time provides false hope that she will return. Sending the child
outside does not address the issue at hand and is not a good idea due to lack of parental
supervision. It is okay for children (and adults) to cry and should even be encouraged.
Again, telling the boy that everything will be okay, when it may not be, is inappropriate.

(Dot Objective 1-2.29)

keep the stair chair and patient at least one foot from your body.

provide lifting power with your arms and back.

carry the patient down the stairs facing backward.

keep your palms up when gripping the stair chair.

Rationale

The paramedic can get the greatest strength, grip, and control of the stair chair (as well
as other devices used for patient movement) by holding the handles with palms in the
“up” position. All weight, no matter how seemingly insignificant, should be carried as close
to the body as possible, not at least one foot from the body. It is best to transport a
patient facing forward and feet first when using a stair chair. The stair chair is specifically
designed for this position and more evenly distributes the weight between the two
rescuers when used as such. Lifting should always come from the legs, not the arms and
back. It is critical that the paramedic employs these proper body mechanics when lifting
and moving patients to minimize the opportunity for injury(s).

(Dot Objective 1-2.9)

The dose of adenosine was too high.

The paramedic attached the cardiac monitor.

The patient suffered harm as a result of the paramedic's actions.

The medication was expired.

Rationale

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175. An off-duty paramedic runs into a grocery store to quickly pick up some items before

heading off to the airport for a flight to the West Coast. While in the checkout line,
he witnesses a man suffer a syncopal episode and fall to the ground. Given that any
delay may cause him to miss his flight, the paramedic is unsure of whether or not he
should render assistance. This would be an example of (a):

176. Assessment of a geriatric patient reveals him to have a decreased level of

consciousness, labored breathing, and rapid pulses that are difficult to locate. He
shows distention of the jugular veins and bilateral crackles and rales. Vital signs are
pulse 132 beats per minute, respirations 22 per minute, blood pressure 72/50
mmHg, and SpO

84% on room air. His skin is cool and diaphoretic and temperature

97.1 degrees Fahrenheit. Family reports a history of insulin dependent diabetes,
myocardial infarction, and hypertension. The cardiac monitor shows the following
rhythm strip: Based on this information, what would be your initial field diagnosis?

To be found guilty of negligence, the patient must suffer some sort of harm or damage,
either physically or emotionally. If harm does not occur, negligence cannot be proven.
Regardless of whether the dosage of the drug administered was incorrect or the
paramedic himself attached the cardiac monitor, the issue at hand is the administration of
a medication that was not indicated. In this case, the expiration date of the medication
has no bearing in determining whether or not the paramedic is negligent.

(Dot Objective 1-4.1)

moral dilemma.

abandonment.

breech of duty.

negligence.

Rationale

Healthcare ethics dictate that healthcare professionals help others and not do any harm.
Morals describe personal beliefs, and may not always be in accordance with the ethical
dictates of the profession to which an individual belongs. Since the paramedic is unsure of
whether or not to intervene, a moral dilemma exists (should he render care and miss his
flight or get his flight but not help another in need). There is no duty to act, given that the
paramedic is off duty, so breach of duty and negligence cannot be demonstrated. Since
the paramedic has not provided care, abandonment does not exist.

(Dot Objective 1-5.2)

Heart failure

Hypoglycemia

Viral infection

Cardiac dysrhythmia

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177. A promising new drug that is effective in limiting cardiac damage caused by

myocardial ischemia has been shown beneficial when administered in the prehospital
setting. Unfortunately, the medication is extremely susceptible to the phenomena of
first pass metabolism. Which of the following would help to overcome deactivation by
the liver prior to achieving its therapeutic level in the body?

178. In what way is a licensed paramedic different from a certified paramedic?

Rationale

Given the cardiovascular history (myocardial infarction and hypertension) along with the
signs and symptoms as presented, the paramedic should immediately recognize heart
failure and cardiogenic shock. Cardiogenic shock results when the heart is so weak that it
cannot generate an adequate cardiac output. The result is hypotension, pulmonary
edema, jugular venous distention (both caused by fluid backup behind the left ventricle),
and profound hypoxia as well as decreased perfusion of the vital organs including the
brain. While hypoglycemia may present with altered mental status and tachycardia, it is
not responsible for signs such as jugular venous distention or moist breath sounds. A viral
infection resulting in septic shock would most likely manifest itself with an elevation of
temperature. The sinus tachycardia (not supraventricular tachycardia) is not a
dysrhythmia in itself, but a compensatory means by which the body is trying to generate
more cardiac output.

(Dot Objective 1-6.11)

Administering the medication intravenously

Simultaneous administration with sodium bicarbonate

Taking the medication orally

Decreasing the dose

Rationale

First pass metabolism refers to the deactivation of a medication as it passes through the
liver. Any medication taken orally is absorbed through the small intestine and transported
via the portal circulatory system to the liver. Therefore, taking this medication by mouth
will result in poor achievement of therapeutic levels. Medications administered through an
IV bypass the liver (at least initially) giving them direct access to their target site of
action. For drugs that face high metabolism by the liver, the drug dose is typically
increased, not decreased. The simultaneous administration of sodium bicarbonate
sometimes aids is excretion of acidic drugs but does not impact the liver or its ability to
metabolize medications.

(Dot Objective 1-8.1)

A licensed paramedic has authority to act on his own without medical control
authorization and a certified paramedic must act under direct orders from medical
control.

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179. A paramedic takes responsibility for his or her actions and demonstrates

professionalism in many ways. Which of the following behaviors is NOT suggestive of
a healthcare professional?

180. Paramedics function directly under the license of the physician medical director to

care for patients outside of the hospital. It is becoming more acceptable for the
paramedic to provide care for these patients without providing transportation to the
hospital. What role does the paramedic fill when treating and not transporting
patients to the hospital?

A certified paramedic has authority to act on his own without medical control
authorization and a licensed paramedic must act under direct orders from medical
control.

A licensed paramedic has proven competence, as recognized by a governmental
agency, and has attained may engage in his chosen profession and a certified
paramedic has met the qualifications of an agency or association.

A certified paramedic has proven competence and has authority to function under
medical direction and a licensed paramedic has met the qualifications to function under
medical direction.

Rationale

Licensure is the process by which a governmental agency grants permission to engage in
a given occupation to an applicant who has attained the degree of competency required to
ensure the public’s safety. Certification is the process by which an agency or association
grants recognition to an individual who has met it’s qualifications.

(Dot Objective 1-1.7)

Receiving monetary compensation for job performance

Subscribing to and reading EMS journals

Obtaining the minimum number of hours necessary for recertification

Belonging to professional organizations

Rationale

It is expected that an individual will take payment for services rendered but that is not an
aspect of professionalism. Being paid for working as an EMS provider is not the sole
determinant of being a professional. Doing things like always representing your service
and youself the best you can to the patient and the public, subscribing to professional
journals, joining professional EMS organizations, and attending EMS conferences helps to
illustrate one's professionalism.

(Dot Objective 1-1.17)

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Home care provider

Physician extender

Physician assistant

Emergency care practitioner

Rationale

In certain areas of the country, paramedics work as physician extenders. In this role, the
Paramedic continues to function under the licensure of the medical director. In addition,
all patient related decisions are under the direction of the physician.

(Dot Objective 1-1.27)

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