NREMT Paramedic Cognitive Exam Prep: High-Yield
Questions with Detailed Rationales
1. A 45-year-old male is in respiratory distress. He has a history of COPD and presents with a barrel chest, diminished breath sounds, and pursed-lip
breathing. His SpO2 is 88% on room air. What is the MOST appropriate initial intervention?
A. Assist ventilations with a BVM and 100% oxygen.
B. Administer oxygen via a non-rebreather mask at 15 L/min.
C. Initiate CPAP at 10 cm H2O.
D. Intubate immediately to secure the airway.
Answer: C
Rationale: This patient is in acute exacerbation of COPD with signs of air trapping. CPAP provides positive pressure to stent open the airways, improve
ventilation/perfusion mismatch, and reduce the work of breathing. While oxygen is needed, CPAP is the most appropriate initial therapy to prevent the need
for intubation. High-flow oxygen should be used cautiously in COPD patients to avoid suppressing hypoxic drive, but CPAP is the priority here.
,2. A 68-year-old female with a history of CHF is in severe respiratory distress. You auscultate coarse crackles in all lung fields. Her blood pressure is 160/90
mmHg and heart rate is 110. What is the BEST treatment choice?
A. Assist ventilations with a BVM and place an oropharyngeal airway.
B. Administer Nitroglycerin and Furosemide en route.
C. Apply CPAP and administer Nitroglycerin.
D. Perform rapid sequence intubation (RSI).
Answer: C
Rationale: This is cardiogenic pulmonary edema. CPAP helps push fluid out of the alveoli and improves oxygenation. Nitroglycerin reduces preload and
afterload, which decreases the workload on the heart and reduces pulmonary congestion. Furosemide (Lasix) is a secondary treatment; CPAP and Nitro are
the immediate life-saving interventions.
3. You are ventilating a 7-year-old child with a BVM. You notice that the chest is not rising adequately and you are meeting significant resistance. What is
the MOST likely cause?
A. Gastric distention.
B. Inadequate seal.
C. Inadequate airway positioning.
D. Bronchospasm.
Answer: A
Rationale: In children, the airway is more easily obstructed, and the epiglottis is more floppy. Overzealous ventilation often forces air into the stomach,
causing distention that pushes against the diaphragm and prevents lung expansion. If you meet resistance and the chest isn't rising, reposition the airway and
reattempt ventilation, but gastric distention is the classic cause of resistance in pediatric BVM use.
, 4. A 30-year-old male has a gunshot wound to the right chest. He is tachypneic and you hear absent breath sounds on the right. Which finding indicates that
needle decompression was SUCCESSFUL?
A. The patient states he feels better.
B. Breath sounds return on the right side.
C. A hissing sound is heard when the catheter is inserted.
D. The SpO2 increases from 88% to 94%.
Answer: B
Rationale: The definitive indicator of successful needle decompression for a tension pneumothorax is the return of breath sounds on the affected side and a
decrease in respiratory distress. A hissing sound (C) simply confirms placement into the pleural space but doesn't guarantee resolution. SpO2 increases (D)
are a secondary sign.
5. Which of the following is a CONTRAINDICATION to the use of a Nasopharyngeal Airway (NPA)?
A. Facial trauma.
B. Gag reflex present.
C. Suspected skull fracture.
D. Conscious patient.
Answer: C
Rationale: An NPA is contraindicated in suspected skull fractures or basilar skull fractures because the tube could enter the cranial vault through a fractured
cribriform plate. Facial trauma (A) is a contraindication for an OPA, not NPA. A gag reflex is a contraindication for an OPA but not NPA.
, 6. During RSI, you administer Etomidate. What is the primary advantage of this induction agent?
A. It provides profound analgesia.
B. It causes rapid muscle relaxation.
C. It is hemodynamically stable (minimal hypotension).
D. It has the shortest onset of action.
Answer: C
Rationale: Etomidate is often chosen in RSI because it provides sedation with minimal cardiovascular depression. It is very stable hemodynamically, making
it safe for patients with shock or cardiac compromise. Ketamine is also hemodynamically stable but can increase ICP. Succinylcholine (B) is the paralytic, not
the induction agent.
7. A patient has a tracheostomy tube that is dislodged and the stoma has closed. What is the primary airway management step?
A. Attempt to reinsert the tracheostomy tube.
B. Insert an endotracheal tube through the stoma.
C. Ventilate the patient's mouth and nose while occluding the stoma.
D. Perform a surgical cricothyrotomy.
Answer: B
Rationale: If the tracheostomy tube has been out for a significant time and the tract is closed, attempting to shove a tube through the tissue can create a false
passage. The safest approach is to insert a cuffed endotracheal tube (size 6.0 or 6.5) directly through the stoma into the trachea.
Questions with Detailed Rationales
1. A 45-year-old male is in respiratory distress. He has a history of COPD and presents with a barrel chest, diminished breath sounds, and pursed-lip
breathing. His SpO2 is 88% on room air. What is the MOST appropriate initial intervention?
A. Assist ventilations with a BVM and 100% oxygen.
B. Administer oxygen via a non-rebreather mask at 15 L/min.
C. Initiate CPAP at 10 cm H2O.
D. Intubate immediately to secure the airway.
Answer: C
Rationale: This patient is in acute exacerbation of COPD with signs of air trapping. CPAP provides positive pressure to stent open the airways, improve
ventilation/perfusion mismatch, and reduce the work of breathing. While oxygen is needed, CPAP is the most appropriate initial therapy to prevent the need
for intubation. High-flow oxygen should be used cautiously in COPD patients to avoid suppressing hypoxic drive, but CPAP is the priority here.
,2. A 68-year-old female with a history of CHF is in severe respiratory distress. You auscultate coarse crackles in all lung fields. Her blood pressure is 160/90
mmHg and heart rate is 110. What is the BEST treatment choice?
A. Assist ventilations with a BVM and place an oropharyngeal airway.
B. Administer Nitroglycerin and Furosemide en route.
C. Apply CPAP and administer Nitroglycerin.
D. Perform rapid sequence intubation (RSI).
Answer: C
Rationale: This is cardiogenic pulmonary edema. CPAP helps push fluid out of the alveoli and improves oxygenation. Nitroglycerin reduces preload and
afterload, which decreases the workload on the heart and reduces pulmonary congestion. Furosemide (Lasix) is a secondary treatment; CPAP and Nitro are
the immediate life-saving interventions.
3. You are ventilating a 7-year-old child with a BVM. You notice that the chest is not rising adequately and you are meeting significant resistance. What is
the MOST likely cause?
A. Gastric distention.
B. Inadequate seal.
C. Inadequate airway positioning.
D. Bronchospasm.
Answer: A
Rationale: In children, the airway is more easily obstructed, and the epiglottis is more floppy. Overzealous ventilation often forces air into the stomach,
causing distention that pushes against the diaphragm and prevents lung expansion. If you meet resistance and the chest isn't rising, reposition the airway and
reattempt ventilation, but gastric distention is the classic cause of resistance in pediatric BVM use.
, 4. A 30-year-old male has a gunshot wound to the right chest. He is tachypneic and you hear absent breath sounds on the right. Which finding indicates that
needle decompression was SUCCESSFUL?
A. The patient states he feels better.
B. Breath sounds return on the right side.
C. A hissing sound is heard when the catheter is inserted.
D. The SpO2 increases from 88% to 94%.
Answer: B
Rationale: The definitive indicator of successful needle decompression for a tension pneumothorax is the return of breath sounds on the affected side and a
decrease in respiratory distress. A hissing sound (C) simply confirms placement into the pleural space but doesn't guarantee resolution. SpO2 increases (D)
are a secondary sign.
5. Which of the following is a CONTRAINDICATION to the use of a Nasopharyngeal Airway (NPA)?
A. Facial trauma.
B. Gag reflex present.
C. Suspected skull fracture.
D. Conscious patient.
Answer: C
Rationale: An NPA is contraindicated in suspected skull fractures or basilar skull fractures because the tube could enter the cranial vault through a fractured
cribriform plate. Facial trauma (A) is a contraindication for an OPA, not NPA. A gag reflex is a contraindication for an OPA but not NPA.
, 6. During RSI, you administer Etomidate. What is the primary advantage of this induction agent?
A. It provides profound analgesia.
B. It causes rapid muscle relaxation.
C. It is hemodynamically stable (minimal hypotension).
D. It has the shortest onset of action.
Answer: C
Rationale: Etomidate is often chosen in RSI because it provides sedation with minimal cardiovascular depression. It is very stable hemodynamically, making
it safe for patients with shock or cardiac compromise. Ketamine is also hemodynamically stable but can increase ICP. Succinylcholine (B) is the paralytic, not
the induction agent.
7. A patient has a tracheostomy tube that is dislodged and the stoma has closed. What is the primary airway management step?
A. Attempt to reinsert the tracheostomy tube.
B. Insert an endotracheal tube through the stoma.
C. Ventilate the patient's mouth and nose while occluding the stoma.
D. Perform a surgical cricothyrotomy.
Answer: B
Rationale: If the tracheostomy tube has been out for a significant time and the tract is closed, attempting to shove a tube through the tissue can create a false
passage. The safest approach is to insert a cuffed endotracheal tube (size 6.0 or 6.5) directly through the stoma into the trachea.
