Elite Universal Test
Bank: New Hampshire
EMS Paramedic
Protocols (v9.3)
PART 0: THE NAVIGATOR
● Tier 1 (Questions 1–28) - Foundational Syntax & Application: Testing "Hard Deck"
definitions, core formulas, and primary protocol updates (v9.3) through realistic scenarios.
● Tier 2 (Questions 29–58) - Complex Application & Simulation: Situation-based
variables testing algorithmic deviations, contraindications, and real-time hemodynamic
management.
● Tier 3 (Questions 59–88) - Grandmaster Synthesis: High-stakes, multi-system
scenarios requiring the synthesis of competing protocols (e.g., TBI with hemorrhagic
shock, pregnant trauma).
PART I: THE PRIMER
Mastering the New Hampshire EMS Version 9.3 protocols transforms providers from algorithmic
technicians into elite clinical decision-makers capable of managing high-stakes, dynamically
degrading environments. This test bank forces the synthesis of strict regulatory parameters with
advanced physiological principles, ensuring unparalleled operational mastery in prehospital
medicine.
The "Critical Axioms" Cheat Sheet
Protocol Domain Critical Axiom Clinical Application
Obstetrics (2.16) Nifedipine must be immediate Escalate to 20 mg PO after 20
release (10 mg PO), with strict mins ONLY if SBP ≥ 160 or
escalation. DBP ≥ 110 mmHg.
Burns (4.0) The Parkland Formula yields Rate = (1–2 mL/kg x % TBSA) /
the hourly rate, not the 24-hour 8. Administer this exact volume
total. per hour.
TBI (4.9) Maximize venous drainage and Elevate head 30° immediately.
abandon legacy spinal Routine use of the long
immobilization. backboard is contraindicated.
Sepsis (Advanced) Push-dose epinephrine is the Administer 10–20 mcg (1–2 mL
bridge for refractory of 10 mcg/mL solution) every 2
hypotension. mins if fluids fail.
,Protocol Domain Critical Axiom Clinical Application
Restraints (6.5) Chemical restraint Utilize Ketamine OR a
pharmacology is strictly Benzodiazepine. Concurrent
mutually exclusive. administration is forbidden.
---
PART II: THE ELITE TEST BANK
Tier 1 - Foundational Syntax & Application
Q1: A 32-year-old female presents at 34 weeks gestation with a blood pressure of 172/114
mmHg. Following the administration of 10 mg PO Nifedipine, 20 minutes elapse. Her blood
pressure is now 164/112 mmHg. Based on the principles of NH EMS Protocols v9.3 (Obstetrical
Emergencies), which action is the MOST ACCURATE? A) Administer Nifedipine 10 mg PO
extended release. B) Administer Labetalol 20 mg IV push. C) Administer Nifedipine 20 mg PO
immediate release. D) Withhold further medication as the blood pressure is decreasing.
● The Answer: C (Administer Nifedipine 20 mg PO immediate release.)
● Distractor Analysis:
○ A is incorrect: Protocol strictly dictates immediate release formulations to ensure
prompt therapeutic effect.
○ B is incorrect: Labetalol is not the first-line oral antihypertensive authorized in this
specific NH protocol update.
○ D is incorrect: The threshold for the second dose is strictly SBP ≥ 160 or DBP ≥ 110
mmHg, which she still meets.
The Mentor's Analysis: Version 9.3 explicitly clarified nifedipine dosing to align with current
ACOG standards, requiring rapid intervention for severe preeclampsia. Professional/Academic
Intuition: Always utilize immediate-release nifedipine and strictly follow the 160/110 mmHg
threshold for the 20 mg secondary dose.
Q2: An EMS unit is operating under an emergency protocol modification authorized by the
Department of Safety Commissioner due to a severe national medication shortage. Based on
the principles of NH EMS Protocols v9.3 (Modifications), what is the MAXIMUM duration this
modification can remain in effect before requiring standard review? A) 30 days B) 90 days C)
180 days D) 365 days
● The Answer: C (180 days)
● Distractor Analysis:
○ A is incorrect: 30 days is an arbitrary administrative timeline.
○ B is incorrect: 90 days was the legacy timeline from Version 9.0, explicitly updated
in 9.3.
○ D is incorrect: 365 days exceeds the authorized temporary window for emergency
rules.
The Mentor's Analysis: Administrative agility is critical during supply chain disruptions; the
extension to 180 days allows adequate time for formal review. Professional/Academic Intuition:
Emergency protocol modifications now carry a 180-day operational lifespan.
Q3: A 45-year-old male sustains deep partial-thickness burns to 30% of his body surface area.
He weighs 100 kg. Transport time will exceed one hour. Based on the principles of NH EMS
Protocols v9.3 (Burns), what is the MOST ACCURATE initial IV fluid administration rate? A)
3000 mL bolus over the first hour. B) 375 mL per hour. C) 500 mL bolus over 30 minutes. D)
,1500 mL per hour.
● The Answer: B (375 mL per hour.)
● Distractor Analysis:
○ A is incorrect: This calculates the entire 8-hour volume and administers it as a
bolus, risking deadly fluid overload.
○ C is incorrect: This is a standard trauma bolus, not the protocol-specific burn
calculation.
○ D is incorrect: This is a mathematical error using legacy formulas. Using 1 mL/kg: (1
x 100 x 30) / 8 = 375 mL/hr.
The Mentor's Analysis: Version 9.3 clarified that the formula (1–2 mL/kg x % TBSA) / 8
calculates the exact hourly rate for the first 8 hours. Professional/Academic Intuition: The
modified Parkland equation in NH yields an hourly infusion rate, not a massive initial
bolus.
Q4: A 22-year-old male is struck by a vehicle. He has a GCS of 7 and decerebrate posturing.
His airway is secured. Based on the principles of NH EMS Protocols v9.3 (Traumatic Brain
Injury), which action is the FIRST physical positioning priority? A) Secure the patient flat on a
rigid long backboard. B) Elevate the head of the stretcher to 45 degrees. C) Elevate the head of
the stretcher to a maximum of 30 degrees. D) Place the patient in the lateral recumbent
position.
● The Answer: C (Elevate the head of the stretcher to a maximum of 30 degrees.)
● Distractor Analysis:
○ A is incorrect: Version 9.3 explicitly removed the requirement for long backboards in
moderate/severe TBI.
○ B is incorrect: 45 degrees can compromise spinal alignment and cerebral perfusion
pressure.
○ D is incorrect: Lateral recumbent is for vomiting, not primary TBI ICP management.
The Mentor's Analysis: Elevating the head to 30 degrees optimizes venous drainage from the
cranial vault, directly reducing intracranial pressure without compromising cerebral perfusion.
Professional/Academic Intuition: For severe TBI, abandon the backboard and elevate the
head 30 degrees immediately.
Q5: A 60-year-old female presents with severe sepsis. She has received a 30 mL/kg normal
saline bolus but remains hypotensive with a MAP of 55 mmHg. Based on the principles of NH
EMS Protocols v9.3 (Advanced Sepsis), what is the MOST APPROPRIATE next
pharmacological intervention? A) Norepinephrine 0.1 mcg/kg/min infusion. B) Epinephrine 1 mg
(1:10,000) IV push. C) Push-dose Epinephrine 10–20 mcg every 2 minutes. D) Dopamine 5
mcg/kg/min infusion.
● The Answer: C (Push-dose Epinephrine 10–20 mcg every 2 minutes.)
● Distractor Analysis:
○ A is incorrect: While a standard ICU pressor, NH protocol specifically utilizes
push-dose epinephrine for immediate prehospital refractory hypotension.
○ B is incorrect: This is the cardiac arrest dose and will cause catastrophic
hypertension and tachycardia.
○ D is incorrect: Dopamine is a legacy pressor phased out of modern sepsis
protocols.
The Mentor's Analysis: When volume resuscitation fails to restore a MAP > 65 mmHg,
immediate vascular support is required via diluted, highly controlled catecholamine pushes.
Professional/Academic Intuition: Push-dose epinephrine (10-20 mcg) is the prehospital
bridge for refractory septic shock.
, Q6: You are preparing push-dose epinephrine for a septic patient. You have a 1 mg/10 mL (0.1
mg/mL) syringe of epinephrine. Based on the principles of NH EMS Protocols v9.3, which
preparation method is MOST ACCURATE? A) Push 1 mL of the 0.1 mg/mL solution directly into
the IV line. B) Add 1 mL of 0.1 mg/mL epinephrine to 9 mL of normal saline. C) Add 1 mg of
epinephrine to a 250 mL bag of normal saline. D) Add 0.3 mL of 1 mg/mL epinephrine to 10 mL
of normal saline.
● The Answer: B (Add 1 mL of 0.1 mg/mL epinephrine to 9 mL of normal saline.)
● Distractor Analysis:
○ A is incorrect: This delivers 100 mcg, which is 5 to 10 times the correct push dose.
○ C is incorrect: This creates a standard continuous infusion drip, not a push-dose
syringe.
○ D is incorrect: This utilizes the IM anaphylaxis concentration, risking massive
dosing errors.
The Mentor's Analysis: Creating a 10 mcg/mL solution requires precise dilution to prevent
iatrogenic myocardial injury or lethal arrhythmias. Professional/Academic Intuition: Dilute 1 mL
of cardiac epi in 9 mL of saline to yield the standard 10 mcg/mL push-dose
concentration.
Q7: A 28-year-old male is exhibiting severe excited delirium. Paramedics decide chemical
restraint is necessary. Based on the principles of NH EMS Protocols v9.3 (Restraints), which
pharmacological strategy is MOST ACCURATE? A) Administer Midazolam 5 mg IM followed
immediately by Ketamine 2 mg/kg IM. B) Administer Ketamine OR a Benzodiazepine, but not
both concurrently. C) Administer Haloperidol 5 mg IM combined with Lorazepam 2 mg IM. D)
Administer Ketamine 4 mg/kg IV push rapidly.
● The Answer: B (Administer Ketamine OR a Benzodiazepine, but not both concurrently.)
● Distractor Analysis:
○ A is incorrect: The protocol update explicitly added an "OR" to prevent stacked
respiratory depression.
○ C is incorrect: Haloperidol is generally reserved for targeted psychiatric protocols,
and the "B52" combo is not the primary NH behavioral restraint protocol.
○ D is incorrect: The IM dose for Ketamine in behavioral emergencies is higher; IV
pushes must be slow to prevent apnea.
The Mentor's Analysis: Stacking dissociative anesthetics with GABA-agonists exponentially
increases the risk of sudden respiratory arrest in the field. Professional/Academic Intuition:
Chemical restraints are mutually exclusive; choose Ketamine OR a Benzodiazepine.
Q8: A 4-year-old child presents with active status epilepticus. Intravenous access is unavailable.
Based on the principles of NH EMS Protocols v9.3 (Seizures), what is the FIRST line
pharmacological intervention? A) Diazepam 0.1 mg/kg IM. B) Lorazepam 0.1 mg/kg IN. C)
Midazolam 0.1 mg/kg IM or IN. D) Fentanyl 1 mcg/kg IN.
● The Answer: C (Midazolam 0.1 mg/kg IM or IN.)
● Distractor Analysis:
○ A is incorrect: Diazepam is erratically absorbed via the IM route and is
contraindicated here.
○ B is incorrect: Lorazepam requires refrigeration and is primarily utilized IV.
○ D is incorrect: Fentanyl is an opiate analgesic, not an anticonvulsant.
The Mentor's Analysis: Midazolam is highly lipophilic, making it the optimal agent for rapid
transmucosal or intramuscular absorption when vascular access is delayed.
Professional/Academic Intuition: When IV access is absent in status epilepticus, Midazolam
(IM/IN) is the absolute gold standard.
Bank: New Hampshire
EMS Paramedic
Protocols (v9.3)
PART 0: THE NAVIGATOR
● Tier 1 (Questions 1–28) - Foundational Syntax & Application: Testing "Hard Deck"
definitions, core formulas, and primary protocol updates (v9.3) through realistic scenarios.
● Tier 2 (Questions 29–58) - Complex Application & Simulation: Situation-based
variables testing algorithmic deviations, contraindications, and real-time hemodynamic
management.
● Tier 3 (Questions 59–88) - Grandmaster Synthesis: High-stakes, multi-system
scenarios requiring the synthesis of competing protocols (e.g., TBI with hemorrhagic
shock, pregnant trauma).
PART I: THE PRIMER
Mastering the New Hampshire EMS Version 9.3 protocols transforms providers from algorithmic
technicians into elite clinical decision-makers capable of managing high-stakes, dynamically
degrading environments. This test bank forces the synthesis of strict regulatory parameters with
advanced physiological principles, ensuring unparalleled operational mastery in prehospital
medicine.
The "Critical Axioms" Cheat Sheet
Protocol Domain Critical Axiom Clinical Application
Obstetrics (2.16) Nifedipine must be immediate Escalate to 20 mg PO after 20
release (10 mg PO), with strict mins ONLY if SBP ≥ 160 or
escalation. DBP ≥ 110 mmHg.
Burns (4.0) The Parkland Formula yields Rate = (1–2 mL/kg x % TBSA) /
the hourly rate, not the 24-hour 8. Administer this exact volume
total. per hour.
TBI (4.9) Maximize venous drainage and Elevate head 30° immediately.
abandon legacy spinal Routine use of the long
immobilization. backboard is contraindicated.
Sepsis (Advanced) Push-dose epinephrine is the Administer 10–20 mcg (1–2 mL
bridge for refractory of 10 mcg/mL solution) every 2
hypotension. mins if fluids fail.
,Protocol Domain Critical Axiom Clinical Application
Restraints (6.5) Chemical restraint Utilize Ketamine OR a
pharmacology is strictly Benzodiazepine. Concurrent
mutually exclusive. administration is forbidden.
---
PART II: THE ELITE TEST BANK
Tier 1 - Foundational Syntax & Application
Q1: A 32-year-old female presents at 34 weeks gestation with a blood pressure of 172/114
mmHg. Following the administration of 10 mg PO Nifedipine, 20 minutes elapse. Her blood
pressure is now 164/112 mmHg. Based on the principles of NH EMS Protocols v9.3 (Obstetrical
Emergencies), which action is the MOST ACCURATE? A) Administer Nifedipine 10 mg PO
extended release. B) Administer Labetalol 20 mg IV push. C) Administer Nifedipine 20 mg PO
immediate release. D) Withhold further medication as the blood pressure is decreasing.
● The Answer: C (Administer Nifedipine 20 mg PO immediate release.)
● Distractor Analysis:
○ A is incorrect: Protocol strictly dictates immediate release formulations to ensure
prompt therapeutic effect.
○ B is incorrect: Labetalol is not the first-line oral antihypertensive authorized in this
specific NH protocol update.
○ D is incorrect: The threshold for the second dose is strictly SBP ≥ 160 or DBP ≥ 110
mmHg, which she still meets.
The Mentor's Analysis: Version 9.3 explicitly clarified nifedipine dosing to align with current
ACOG standards, requiring rapid intervention for severe preeclampsia. Professional/Academic
Intuition: Always utilize immediate-release nifedipine and strictly follow the 160/110 mmHg
threshold for the 20 mg secondary dose.
Q2: An EMS unit is operating under an emergency protocol modification authorized by the
Department of Safety Commissioner due to a severe national medication shortage. Based on
the principles of NH EMS Protocols v9.3 (Modifications), what is the MAXIMUM duration this
modification can remain in effect before requiring standard review? A) 30 days B) 90 days C)
180 days D) 365 days
● The Answer: C (180 days)
● Distractor Analysis:
○ A is incorrect: 30 days is an arbitrary administrative timeline.
○ B is incorrect: 90 days was the legacy timeline from Version 9.0, explicitly updated
in 9.3.
○ D is incorrect: 365 days exceeds the authorized temporary window for emergency
rules.
The Mentor's Analysis: Administrative agility is critical during supply chain disruptions; the
extension to 180 days allows adequate time for formal review. Professional/Academic Intuition:
Emergency protocol modifications now carry a 180-day operational lifespan.
Q3: A 45-year-old male sustains deep partial-thickness burns to 30% of his body surface area.
He weighs 100 kg. Transport time will exceed one hour. Based on the principles of NH EMS
Protocols v9.3 (Burns), what is the MOST ACCURATE initial IV fluid administration rate? A)
3000 mL bolus over the first hour. B) 375 mL per hour. C) 500 mL bolus over 30 minutes. D)
,1500 mL per hour.
● The Answer: B (375 mL per hour.)
● Distractor Analysis:
○ A is incorrect: This calculates the entire 8-hour volume and administers it as a
bolus, risking deadly fluid overload.
○ C is incorrect: This is a standard trauma bolus, not the protocol-specific burn
calculation.
○ D is incorrect: This is a mathematical error using legacy formulas. Using 1 mL/kg: (1
x 100 x 30) / 8 = 375 mL/hr.
The Mentor's Analysis: Version 9.3 clarified that the formula (1–2 mL/kg x % TBSA) / 8
calculates the exact hourly rate for the first 8 hours. Professional/Academic Intuition: The
modified Parkland equation in NH yields an hourly infusion rate, not a massive initial
bolus.
Q4: A 22-year-old male is struck by a vehicle. He has a GCS of 7 and decerebrate posturing.
His airway is secured. Based on the principles of NH EMS Protocols v9.3 (Traumatic Brain
Injury), which action is the FIRST physical positioning priority? A) Secure the patient flat on a
rigid long backboard. B) Elevate the head of the stretcher to 45 degrees. C) Elevate the head of
the stretcher to a maximum of 30 degrees. D) Place the patient in the lateral recumbent
position.
● The Answer: C (Elevate the head of the stretcher to a maximum of 30 degrees.)
● Distractor Analysis:
○ A is incorrect: Version 9.3 explicitly removed the requirement for long backboards in
moderate/severe TBI.
○ B is incorrect: 45 degrees can compromise spinal alignment and cerebral perfusion
pressure.
○ D is incorrect: Lateral recumbent is for vomiting, not primary TBI ICP management.
The Mentor's Analysis: Elevating the head to 30 degrees optimizes venous drainage from the
cranial vault, directly reducing intracranial pressure without compromising cerebral perfusion.
Professional/Academic Intuition: For severe TBI, abandon the backboard and elevate the
head 30 degrees immediately.
Q5: A 60-year-old female presents with severe sepsis. She has received a 30 mL/kg normal
saline bolus but remains hypotensive with a MAP of 55 mmHg. Based on the principles of NH
EMS Protocols v9.3 (Advanced Sepsis), what is the MOST APPROPRIATE next
pharmacological intervention? A) Norepinephrine 0.1 mcg/kg/min infusion. B) Epinephrine 1 mg
(1:10,000) IV push. C) Push-dose Epinephrine 10–20 mcg every 2 minutes. D) Dopamine 5
mcg/kg/min infusion.
● The Answer: C (Push-dose Epinephrine 10–20 mcg every 2 minutes.)
● Distractor Analysis:
○ A is incorrect: While a standard ICU pressor, NH protocol specifically utilizes
push-dose epinephrine for immediate prehospital refractory hypotension.
○ B is incorrect: This is the cardiac arrest dose and will cause catastrophic
hypertension and tachycardia.
○ D is incorrect: Dopamine is a legacy pressor phased out of modern sepsis
protocols.
The Mentor's Analysis: When volume resuscitation fails to restore a MAP > 65 mmHg,
immediate vascular support is required via diluted, highly controlled catecholamine pushes.
Professional/Academic Intuition: Push-dose epinephrine (10-20 mcg) is the prehospital
bridge for refractory septic shock.
, Q6: You are preparing push-dose epinephrine for a septic patient. You have a 1 mg/10 mL (0.1
mg/mL) syringe of epinephrine. Based on the principles of NH EMS Protocols v9.3, which
preparation method is MOST ACCURATE? A) Push 1 mL of the 0.1 mg/mL solution directly into
the IV line. B) Add 1 mL of 0.1 mg/mL epinephrine to 9 mL of normal saline. C) Add 1 mg of
epinephrine to a 250 mL bag of normal saline. D) Add 0.3 mL of 1 mg/mL epinephrine to 10 mL
of normal saline.
● The Answer: B (Add 1 mL of 0.1 mg/mL epinephrine to 9 mL of normal saline.)
● Distractor Analysis:
○ A is incorrect: This delivers 100 mcg, which is 5 to 10 times the correct push dose.
○ C is incorrect: This creates a standard continuous infusion drip, not a push-dose
syringe.
○ D is incorrect: This utilizes the IM anaphylaxis concentration, risking massive
dosing errors.
The Mentor's Analysis: Creating a 10 mcg/mL solution requires precise dilution to prevent
iatrogenic myocardial injury or lethal arrhythmias. Professional/Academic Intuition: Dilute 1 mL
of cardiac epi in 9 mL of saline to yield the standard 10 mcg/mL push-dose
concentration.
Q7: A 28-year-old male is exhibiting severe excited delirium. Paramedics decide chemical
restraint is necessary. Based on the principles of NH EMS Protocols v9.3 (Restraints), which
pharmacological strategy is MOST ACCURATE? A) Administer Midazolam 5 mg IM followed
immediately by Ketamine 2 mg/kg IM. B) Administer Ketamine OR a Benzodiazepine, but not
both concurrently. C) Administer Haloperidol 5 mg IM combined with Lorazepam 2 mg IM. D)
Administer Ketamine 4 mg/kg IV push rapidly.
● The Answer: B (Administer Ketamine OR a Benzodiazepine, but not both concurrently.)
● Distractor Analysis:
○ A is incorrect: The protocol update explicitly added an "OR" to prevent stacked
respiratory depression.
○ C is incorrect: Haloperidol is generally reserved for targeted psychiatric protocols,
and the "B52" combo is not the primary NH behavioral restraint protocol.
○ D is incorrect: The IM dose for Ketamine in behavioral emergencies is higher; IV
pushes must be slow to prevent apnea.
The Mentor's Analysis: Stacking dissociative anesthetics with GABA-agonists exponentially
increases the risk of sudden respiratory arrest in the field. Professional/Academic Intuition:
Chemical restraints are mutually exclusive; choose Ketamine OR a Benzodiazepine.
Q8: A 4-year-old child presents with active status epilepticus. Intravenous access is unavailable.
Based on the principles of NH EMS Protocols v9.3 (Seizures), what is the FIRST line
pharmacological intervention? A) Diazepam 0.1 mg/kg IM. B) Lorazepam 0.1 mg/kg IN. C)
Midazolam 0.1 mg/kg IM or IN. D) Fentanyl 1 mcg/kg IN.
● The Answer: C (Midazolam 0.1 mg/kg IM or IN.)
● Distractor Analysis:
○ A is incorrect: Diazepam is erratically absorbed via the IM route and is
contraindicated here.
○ B is incorrect: Lorazepam requires refrigeration and is primarily utilized IV.
○ D is incorrect: Fentanyl is an opiate analgesic, not an anticonvulsant.
The Mentor's Analysis: Midazolam is highly lipophilic, making it the optimal agent for rapid
transmucosal or intramuscular absorption when vascular access is delayed.
Professional/Academic Intuition: When IV access is absent in status epilepticus, Midazolam
(IM/IN) is the absolute gold standard.
