National Registry Paramedic Cognitive
Examination (NRP) — Advanced
Practice Question Bank v2.0 a well
detailed exam 2025/2026 graded A+
upgraded !!!
Exam Format: Computer-Adaptive Test (CAT) | 110–150 questions | 2.5-hour time limit |
Passing standard: scaled score of 950/1500
Content Domains: Airway, Respiration & Ventilation (8–12%) | Cardiology & Resuscitation (10–
14%) | Trauma (6–10%) | Medical/Obstetrics/Gynecology (24–28%) | EMS Operations (8–12%)
| Clinical Judgment (34–38%)
AIRWAY, RESPIRATION & VENTILATION (Questions 1–25)
1. A 55-year-old male with a history of COPD and obstructive sleep apnea is found
unresponsive by his spouse. He has shallow respirations at 6 breaths per minute, an SpO₂ of
78% on room air, and an ETCO₂ of 68 mmHg. Which of the following is the MOST appropriate
initial airway and ventilation strategy?
A. Bag-valve-mask ventilation at 15 breaths per minute with 100% oxygen
B. Non-invasive positive pressure ventilation with BiPAP at 10/5 cm H₂O
C. Endotracheal intubation with rapid sequence induction
D. High-flow nasal cannula at 60 L/min with 100% oxygen
Correct Answer: A
Rationale: This patient is in respiratory failure with hypercapnia (ETCO₂ 68) and severe
,hypoxemia (SpO₂ 78%). The most appropriate initial intervention is bag-valve-mask ventilation
to provide immediate ventilatory support while preparing for definitive airway management.
BiPAP may be considered but is less appropriate for an unresponsive patient. Intubation may be
required but BVM should be initiated first. High-flow nasal cannula does not provide ventilatory
support for hypercapnia.
2. A 7-year-old child with a history of asthma presents with severe respiratory distress,
inability to speak in full sentences, and a silent chest on auscultation. Which of the following
is the MOST appropriate immediate intervention?
A. Nebulized albuterol 2.5 mg and ipratropium 0.5 mg
B. Endotracheal intubation
C. Epinephrine 0.01 mg/kg IM
D. Continuous positive airway pressure (CPAP)
Correct Answer: B
Rationale: A silent chest in a child with asthma indicates severe bronchospasm with minimal air
movement and is a sign of impending respiratory failure. Endotracheal intubation is indicated to
secure the airway and provide mechanical ventilation. Nebulized medications may be ineffective
with poor air movement. Epinephrine IM is for anaphylaxis. CPAP may be used but is not
definitive for impending respiratory failure.
3. You are performing a surgical cricothyrotomy on a 45-year-old male with a "cannot
intubate, cannot ventilate" scenario. Which of the following anatomical landmarks is the
CORRECT site for the incision?
A. Between the thyroid cartilage and the cricoid cartilage
B. Between the cricoid cartilage and the first tracheal ring
C. Just above the sternal notch
D. Midline of the thyroid cartilage
Correct Answer: A
Rationale: The surgical cricothyrotomy incision is made through the cricothyroid membrane,
which is located between the thyroid cartilage (superiorly) and the cricoid cartilage (inferiorly).
This is the correct anatomical landmark for this procedure. The other options represent
incorrect anatomical locations.
,4. A 32-year-old female is being ventilated after a motor vehicle collision. She has a right-
sided pneumothorax that has been decompressed. Her ETCO₂ waveform shows a sudden drop
from 38 mmHg to 10 mmHg with a loss of the waveform plateau. Which of the following is
the MOST likely cause?
A. Displacement of the endotracheal tube into the esophagus
B. Disconnection from the ventilator circuit
C. Tension pneumothorax recurrence
D. Bronchospasm
Correct Answer: A
Rationale: A sudden drop in ETCO₂ with loss of waveform and plateau is most consistent with
esophageal intubation or disconnection. Since the patient is on a ventilator with a secured
airway, esophageal displacement is the most concerning cause. Tension pneumothorax would
cause a gradual decrease in ETCO₂, not a sudden drop. Bronchospasm would show a "shark fin"
appearance, not a sudden drop.
5. A 6-week-old infant presents with a history of paroxysmal coughing, wheezing, and
cyanotic episodes. The parents report the infant has been feeding poorly. Which of the
following is the MOST likely diagnosis and appropriate treatment?
A. Croup; nebulized racemic epinephrine
B. Bronchiolitis; supportive care with oxygen
C. Pertussis; supportive care and transport
D. Foreign body aspiration; Heimlich maneuver
Correct Answer: C
Rationale: Pertussis (whooping cough) presents with paroxysmal coughing, cyanotic episodes
(especially in infants), and poor feeding. The classic "whoop" may not be present in infants.
Treatment is supportive care and transport. Croup presents with barking cough and stridor.
Bronchiolitis presents with wheezing and respiratory distress but not typically paroxysmal
coughing with cyanosis. Foreign body aspiration presents with sudden onset.
6. A 48-year-old patient with a history of myasthenia gravis is in respiratory failure. Which of
the following neuromuscular blockers should be AVOIDED during rapid sequence intubation in
this patient?
A. Rocuronium
B. Vecuronium
, C. Succinylcholine
D. Cisatracurium
Correct Answer: C
Rationale: Succinylcholine should be avoided in patients with myasthenia gravis due to the risk
of prolonged paralysis and hyperkalemia. Rocuronium and vecuronium are non-depolarizing
agents that can be used with careful monitoring. Cisatracurium is also a non-depolarizing agent.
The prolonged effect of succinylcholine in myasthenia gravis patients is a significant concern.
7. A patient with a tracheostomy tube is being ventilated. You note increased peak airway
pressures and a decrease in tidal volume. The patient is in respiratory distress. Which of the
following is the MOST likely cause and appropriate action?
A. Obstructed inner cannula; remove and replace
B. Cuff leak; inflate the cuff
C. Tube displacement; reposition the tube
D. Secretions in the stoma; suction the stoma
Correct Answer: A
Rationale: Increased peak airway pressures with decreased tidal volume in a tracheostomy
patient suggests obstruction of the inner cannula, likely from secretions. The most appropriate
action is to remove and replace the inner cannula. This is the fastest way to restore airway
patency. A cuff leak would cause decreased pressures, not increased. Tube displacement would
present with loss of breath sounds.
8. Which of the following is the CORRECT endotracheal tube size for a 3-year-old child using
the age-based formula?
A. 3.5 mm
B. 4.0 mm
C. 4.5 mm
D. 5.0 mm
Correct Answer: C
Rationale: The age-based formula for uncuffed endotracheal tube size in children aged 1–10
years is: (age in years + 16) / 4. For a 3-year-old: (3 + 16) / 4 = 19/4 = 4.75 mm, which rounds to
4.5 mm. Cuffed tube sizing would be (age/4) + 3. The correct answer is 4.5 mm (uncuffed) or 4.0
mm (cuffed), but since the question does not specify cuffed vs. uncuffed, the formula for
uncuffed is standard.
Examination (NRP) — Advanced
Practice Question Bank v2.0 a well
detailed exam 2025/2026 graded A+
upgraded !!!
Exam Format: Computer-Adaptive Test (CAT) | 110–150 questions | 2.5-hour time limit |
Passing standard: scaled score of 950/1500
Content Domains: Airway, Respiration & Ventilation (8–12%) | Cardiology & Resuscitation (10–
14%) | Trauma (6–10%) | Medical/Obstetrics/Gynecology (24–28%) | EMS Operations (8–12%)
| Clinical Judgment (34–38%)
AIRWAY, RESPIRATION & VENTILATION (Questions 1–25)
1. A 55-year-old male with a history of COPD and obstructive sleep apnea is found
unresponsive by his spouse. He has shallow respirations at 6 breaths per minute, an SpO₂ of
78% on room air, and an ETCO₂ of 68 mmHg. Which of the following is the MOST appropriate
initial airway and ventilation strategy?
A. Bag-valve-mask ventilation at 15 breaths per minute with 100% oxygen
B. Non-invasive positive pressure ventilation with BiPAP at 10/5 cm H₂O
C. Endotracheal intubation with rapid sequence induction
D. High-flow nasal cannula at 60 L/min with 100% oxygen
Correct Answer: A
Rationale: This patient is in respiratory failure with hypercapnia (ETCO₂ 68) and severe
,hypoxemia (SpO₂ 78%). The most appropriate initial intervention is bag-valve-mask ventilation
to provide immediate ventilatory support while preparing for definitive airway management.
BiPAP may be considered but is less appropriate for an unresponsive patient. Intubation may be
required but BVM should be initiated first. High-flow nasal cannula does not provide ventilatory
support for hypercapnia.
2. A 7-year-old child with a history of asthma presents with severe respiratory distress,
inability to speak in full sentences, and a silent chest on auscultation. Which of the following
is the MOST appropriate immediate intervention?
A. Nebulized albuterol 2.5 mg and ipratropium 0.5 mg
B. Endotracheal intubation
C. Epinephrine 0.01 mg/kg IM
D. Continuous positive airway pressure (CPAP)
Correct Answer: B
Rationale: A silent chest in a child with asthma indicates severe bronchospasm with minimal air
movement and is a sign of impending respiratory failure. Endotracheal intubation is indicated to
secure the airway and provide mechanical ventilation. Nebulized medications may be ineffective
with poor air movement. Epinephrine IM is for anaphylaxis. CPAP may be used but is not
definitive for impending respiratory failure.
3. You are performing a surgical cricothyrotomy on a 45-year-old male with a "cannot
intubate, cannot ventilate" scenario. Which of the following anatomical landmarks is the
CORRECT site for the incision?
A. Between the thyroid cartilage and the cricoid cartilage
B. Between the cricoid cartilage and the first tracheal ring
C. Just above the sternal notch
D. Midline of the thyroid cartilage
Correct Answer: A
Rationale: The surgical cricothyrotomy incision is made through the cricothyroid membrane,
which is located between the thyroid cartilage (superiorly) and the cricoid cartilage (inferiorly).
This is the correct anatomical landmark for this procedure. The other options represent
incorrect anatomical locations.
,4. A 32-year-old female is being ventilated after a motor vehicle collision. She has a right-
sided pneumothorax that has been decompressed. Her ETCO₂ waveform shows a sudden drop
from 38 mmHg to 10 mmHg with a loss of the waveform plateau. Which of the following is
the MOST likely cause?
A. Displacement of the endotracheal tube into the esophagus
B. Disconnection from the ventilator circuit
C. Tension pneumothorax recurrence
D. Bronchospasm
Correct Answer: A
Rationale: A sudden drop in ETCO₂ with loss of waveform and plateau is most consistent with
esophageal intubation or disconnection. Since the patient is on a ventilator with a secured
airway, esophageal displacement is the most concerning cause. Tension pneumothorax would
cause a gradual decrease in ETCO₂, not a sudden drop. Bronchospasm would show a "shark fin"
appearance, not a sudden drop.
5. A 6-week-old infant presents with a history of paroxysmal coughing, wheezing, and
cyanotic episodes. The parents report the infant has been feeding poorly. Which of the
following is the MOST likely diagnosis and appropriate treatment?
A. Croup; nebulized racemic epinephrine
B. Bronchiolitis; supportive care with oxygen
C. Pertussis; supportive care and transport
D. Foreign body aspiration; Heimlich maneuver
Correct Answer: C
Rationale: Pertussis (whooping cough) presents with paroxysmal coughing, cyanotic episodes
(especially in infants), and poor feeding. The classic "whoop" may not be present in infants.
Treatment is supportive care and transport. Croup presents with barking cough and stridor.
Bronchiolitis presents with wheezing and respiratory distress but not typically paroxysmal
coughing with cyanosis. Foreign body aspiration presents with sudden onset.
6. A 48-year-old patient with a history of myasthenia gravis is in respiratory failure. Which of
the following neuromuscular blockers should be AVOIDED during rapid sequence intubation in
this patient?
A. Rocuronium
B. Vecuronium
, C. Succinylcholine
D. Cisatracurium
Correct Answer: C
Rationale: Succinylcholine should be avoided in patients with myasthenia gravis due to the risk
of prolonged paralysis and hyperkalemia. Rocuronium and vecuronium are non-depolarizing
agents that can be used with careful monitoring. Cisatracurium is also a non-depolarizing agent.
The prolonged effect of succinylcholine in myasthenia gravis patients is a significant concern.
7. A patient with a tracheostomy tube is being ventilated. You note increased peak airway
pressures and a decrease in tidal volume. The patient is in respiratory distress. Which of the
following is the MOST likely cause and appropriate action?
A. Obstructed inner cannula; remove and replace
B. Cuff leak; inflate the cuff
C. Tube displacement; reposition the tube
D. Secretions in the stoma; suction the stoma
Correct Answer: A
Rationale: Increased peak airway pressures with decreased tidal volume in a tracheostomy
patient suggests obstruction of the inner cannula, likely from secretions. The most appropriate
action is to remove and replace the inner cannula. This is the fastest way to restore airway
patency. A cuff leak would cause decreased pressures, not increased. Tube displacement would
present with loss of breath sounds.
8. Which of the following is the CORRECT endotracheal tube size for a 3-year-old child using
the age-based formula?
A. 3.5 mm
B. 4.0 mm
C. 4.5 mm
D. 5.0 mm
Correct Answer: C
Rationale: The age-based formula for uncuffed endotracheal tube size in children aged 1–10
years is: (age in years + 16) / 4. For a 3-year-old: (3 + 16) / 4 = 19/4 = 4.75 mm, which rounds to
4.5 mm. Cuffed tube sizing would be (age/4) + 3. The correct answer is 4.5 mm (uncuffed) or 4.0
mm (cuffed), but since the question does not specify cuffed vs. uncuffed, the formula for
uncuffed is standard.
