2026 BCEMP Exam Prep: Board Certified
Emergency Medicine Pharmacist Practice
Questions with Answer Explanations Acute Care
Pharmacology, Toxicology, Trauma & Critical
Care Exam Preparation Study Guide
DOMAIN I: EMERGENCY MEDICINE — OPERATIONS & MEDICAL
THERAPIES/DEVICES (55–60% — 55–60 Scored Questions)
Question 1
A 68-year-old male arrives in the emergency department in cardiac arrest with
pulseless ventricular tachycardia. After defibrillation, which medication should be
administered first?
A. Amiodarone 150 mg IV push
B. Epinephrine 1 mg IV every 3–5 minutes
C. Lidocaine 1–1.5 mg/kg IV push
D. Magnesium sulfate 2 g IV
Rationale: Epinephrine is the first-line vasopressor in ACLS for cardiac arrest,
administered at 1 mg IV every 3–5 minutes. Amiodarone and lidocaine are
antiarrhythmics given for refractory VF/pulseless VT after defibrillation and
epinephrine. Magnesium is used for torsades de pointes.
Question 2
A 45-year-old female with severe asthma exacerbation is not responding to
continuous albuterol and ipratropium. Which adjunctive IV medication is most
appropriate?
A. Magnesium sulfate 2 g IV over 20 minutes
B. Methylprednisolone 125 mg IV
C. Epinephrine 1 mg IV push
D. Ketamine 1 mg/kg IV
,Rationale: IV magnesium sulfate is an evidence-based adjunct in severe asthma
exacerbations not responding to inhaled bronchodilators and systemic
corticosteroids. Methylprednisolone is standard but already expected; magnesium
provides additional bronchodilation via smooth muscle relaxation.
Question 3
A 72-year-old male with a history of atrial fibrillation presents with acute
decompensated heart failure and a heart rate of 148 bpm. Which medication
is most appropriate for rate control?
A. Adenosine 6 mg IV push
B. Diltiazem 0.25 mg/kg IV bolus
C. Amiodarone 150 mg IV over 10 minutes
D. Digoxin 0.5 mg IV load
Rationale: IV diltiazem is first-line for acute rate control in atrial fibrillation with
rapid ventricular response in patients without severe heart failure decompensation
or hypotension. Adenosine is for supraventricular tachycardia. Amiodarone is for
refractory cases or when diltiazem is contraindicated. Digoxin has a slower onset.
Question 4
A 55-year-old male with a known seizure disorder presents in status epilepticus.
After two doses of IV lorazepam, seizures continue. Which medication is most
appropriate next?
A. Phenytoin 20 mg/kg IV
B. Levetiracetam 60 mg/kg IV
C. Propofol 2 mg/kg IV bolus
D. Midazolam 10 mg IM
Rationale: After benzodiazepines for status epilepticus, a second-line antiseizure
medication is indicated. Levetiracetam, fosphenytoin, or valproate are appropriate
options. Levetiracetam is increasingly preferred due to favorable safety and ease of
administration. Propofol is used for refractory status epilepticus requiring
intubation.
,Question 5
A 28-year-old female presents with a suspected opioid overdose. She has a
respiratory rate of 6 breaths/minute and pinpoint pupils. Which medication is first-
line?
A. Flumazenil 0.2 mg IV
B. Naloxone 0.4–2 mg IV/IM
C. Naltrexone 50 mg PO
D. Buprenorphine 2 mg SL
Rationale: Naloxone is the opioid antagonist of choice for acute opioid overdose
with respiratory depression. Flumazenil is for benzodiazepine reversal. Naltrexone
is for long-term maintenance. Buprenorphine is for opioid use disorder
maintenance, not acute reversal.
Question 6
A 42-year-old male presents with a tricyclic antidepressant overdose. He has a
QRS duration of 120 ms on ECG. Which medication is most appropriate?
A. Sodium bicarbonate 1–2 mEq/kg IV
B. Flumazenil 0.2 mg IV
C. Calcium chloride 1 g IV
D. Naloxone 2 mg IV
Rationale: Sodium bicarbonate is the antidote for TCA cardiotoxicity, widening
the QRS by providing sodium to overcome sodium channel blockade and
alkalinizing the serum to reduce drug binding. Flumazenil is for benzodiazepines.
Calcium is for calcium channel blocker toxicity.
Question 7
A 65-year-old female presents with a suspected acute ischemic stroke. Blood
pressure is 195/105 mmHg. She is a candidate for alteplase. What is
the maximum blood pressure threshold before thrombolysis can be administered?
A. 180/100 mmHg
B. 185/110 mmHg
, C. 200/120 mmHg
D. 220/130 mmHg
Rationale: According to AHA/ASA guidelines, blood pressure must be <185/110
mmHg before IV thrombolysis for acute ischemic stroke. If elevated, it should be
lowered with labetalol or nicardipine before treatment.
Question 8
A 58-year-old male with a massive pulmonary embolism presents with
hypotension and tachycardia. Which medication is most appropriate for
hemodynamic support?
A. Norepinephrine
B. Dobutamine
C. Dopamine
D. Phenylephrine
Rationale: Norepinephrine is the first-line vasopressor for hemodynamic support
in massive PE with hypotension, maintaining systemic vascular resistance and
coronary perfusion. Dobutamine may be added for right ventricular failure.
Phenylephrine is less preferred.
Question 9
A 3-year-old child presents with a suspected anaphylactic reaction after a bee sting.
Which medication is first-line?
A. Diphenhydramine 25 mg IV
B. Epinephrine 0.01 mg/kg IM (max 0.5 mg)
C. Methylprednisolone 1 mg/kg IV
D. Albuterol nebulized
Rationale: IM epinephrine is the first-line treatment for anaphylaxis in all age
groups. Antihistamines and corticosteroids are adjuncts, not primary treatment.
Albuterol is for bronchospasm only.
Question 10
Emergency Medicine Pharmacist Practice
Questions with Answer Explanations Acute Care
Pharmacology, Toxicology, Trauma & Critical
Care Exam Preparation Study Guide
DOMAIN I: EMERGENCY MEDICINE — OPERATIONS & MEDICAL
THERAPIES/DEVICES (55–60% — 55–60 Scored Questions)
Question 1
A 68-year-old male arrives in the emergency department in cardiac arrest with
pulseless ventricular tachycardia. After defibrillation, which medication should be
administered first?
A. Amiodarone 150 mg IV push
B. Epinephrine 1 mg IV every 3–5 minutes
C. Lidocaine 1–1.5 mg/kg IV push
D. Magnesium sulfate 2 g IV
Rationale: Epinephrine is the first-line vasopressor in ACLS for cardiac arrest,
administered at 1 mg IV every 3–5 minutes. Amiodarone and lidocaine are
antiarrhythmics given for refractory VF/pulseless VT after defibrillation and
epinephrine. Magnesium is used for torsades de pointes.
Question 2
A 45-year-old female with severe asthma exacerbation is not responding to
continuous albuterol and ipratropium. Which adjunctive IV medication is most
appropriate?
A. Magnesium sulfate 2 g IV over 20 minutes
B. Methylprednisolone 125 mg IV
C. Epinephrine 1 mg IV push
D. Ketamine 1 mg/kg IV
,Rationale: IV magnesium sulfate is an evidence-based adjunct in severe asthma
exacerbations not responding to inhaled bronchodilators and systemic
corticosteroids. Methylprednisolone is standard but already expected; magnesium
provides additional bronchodilation via smooth muscle relaxation.
Question 3
A 72-year-old male with a history of atrial fibrillation presents with acute
decompensated heart failure and a heart rate of 148 bpm. Which medication
is most appropriate for rate control?
A. Adenosine 6 mg IV push
B. Diltiazem 0.25 mg/kg IV bolus
C. Amiodarone 150 mg IV over 10 minutes
D. Digoxin 0.5 mg IV load
Rationale: IV diltiazem is first-line for acute rate control in atrial fibrillation with
rapid ventricular response in patients without severe heart failure decompensation
or hypotension. Adenosine is for supraventricular tachycardia. Amiodarone is for
refractory cases or when diltiazem is contraindicated. Digoxin has a slower onset.
Question 4
A 55-year-old male with a known seizure disorder presents in status epilepticus.
After two doses of IV lorazepam, seizures continue. Which medication is most
appropriate next?
A. Phenytoin 20 mg/kg IV
B. Levetiracetam 60 mg/kg IV
C. Propofol 2 mg/kg IV bolus
D. Midazolam 10 mg IM
Rationale: After benzodiazepines for status epilepticus, a second-line antiseizure
medication is indicated. Levetiracetam, fosphenytoin, or valproate are appropriate
options. Levetiracetam is increasingly preferred due to favorable safety and ease of
administration. Propofol is used for refractory status epilepticus requiring
intubation.
,Question 5
A 28-year-old female presents with a suspected opioid overdose. She has a
respiratory rate of 6 breaths/minute and pinpoint pupils. Which medication is first-
line?
A. Flumazenil 0.2 mg IV
B. Naloxone 0.4–2 mg IV/IM
C. Naltrexone 50 mg PO
D. Buprenorphine 2 mg SL
Rationale: Naloxone is the opioid antagonist of choice for acute opioid overdose
with respiratory depression. Flumazenil is for benzodiazepine reversal. Naltrexone
is for long-term maintenance. Buprenorphine is for opioid use disorder
maintenance, not acute reversal.
Question 6
A 42-year-old male presents with a tricyclic antidepressant overdose. He has a
QRS duration of 120 ms on ECG. Which medication is most appropriate?
A. Sodium bicarbonate 1–2 mEq/kg IV
B. Flumazenil 0.2 mg IV
C. Calcium chloride 1 g IV
D. Naloxone 2 mg IV
Rationale: Sodium bicarbonate is the antidote for TCA cardiotoxicity, widening
the QRS by providing sodium to overcome sodium channel blockade and
alkalinizing the serum to reduce drug binding. Flumazenil is for benzodiazepines.
Calcium is for calcium channel blocker toxicity.
Question 7
A 65-year-old female presents with a suspected acute ischemic stroke. Blood
pressure is 195/105 mmHg. She is a candidate for alteplase. What is
the maximum blood pressure threshold before thrombolysis can be administered?
A. 180/100 mmHg
B. 185/110 mmHg
, C. 200/120 mmHg
D. 220/130 mmHg
Rationale: According to AHA/ASA guidelines, blood pressure must be <185/110
mmHg before IV thrombolysis for acute ischemic stroke. If elevated, it should be
lowered with labetalol or nicardipine before treatment.
Question 8
A 58-year-old male with a massive pulmonary embolism presents with
hypotension and tachycardia. Which medication is most appropriate for
hemodynamic support?
A. Norepinephrine
B. Dobutamine
C. Dopamine
D. Phenylephrine
Rationale: Norepinephrine is the first-line vasopressor for hemodynamic support
in massive PE with hypotension, maintaining systemic vascular resistance and
coronary perfusion. Dobutamine may be added for right ventricular failure.
Phenylephrine is less preferred.
Question 9
A 3-year-old child presents with a suspected anaphylactic reaction after a bee sting.
Which medication is first-line?
A. Diphenhydramine 25 mg IV
B. Epinephrine 0.01 mg/kg IM (max 0.5 mg)
C. Methylprednisolone 1 mg/kg IV
D. Albuterol nebulized
Rationale: IM epinephrine is the first-line treatment for anaphylaxis in all age
groups. Antihistamines and corticosteroids are adjuncts, not primary treatment.
Albuterol is for bronchospasm only.
Question 10
