SAEM FINAL PRACTICE EXAM
National Emergency Medicine Clerkship / In-Training
Curriculum
2026–2027 Academic Year
SECTION I: AIRWAY, RESPIRATORY & THORACIC
1. A 45-year-old with a history of COPD presents with acute respiratory distress.
He is tripoding, using accessory muscles, and has diminished breath sounds on
the right with hyperresonance to percussion. HR 130, BP 100/70, RR 36, SpO2
88% on 4L NC. Which of the following is the immediate next step?
A) Stat portable chest X-ray
B) Needle decompression of the right chest
C) Intubation with rapid sequence induction
D) Bilevel positive airway pressure (BiPAP)
Correct Answer: B – This is a tension pneumothorax (hyperresonance, absent
breath sounds, hypotension, tachycardia, hypoxia). Needle decompression
(second intercostal space, midclavicular line) is the immediate life-saving
intervention before CXR. BiPAP can worsen tension physiology; intubation is not
the first step if decompression can stabilize him.
Rationale: Tension pneumothorax compresses the vena cava, reducing
preload and causing obstructive shock. Immediate decompression is mandatory.
Do not wait for imaging.
2. A 22-year-old intubated motor vehicle crash victim has a post-intubation
SpO2 of 82% despite being placed on 100% FiO2. Breath sounds are absent on
the left with a deviated trachea to the right. BP 80/50. What is the definitive
management?
A) Left-sided chest tube thoracostomy
B) Needle decompression of the left chest
C) Emergency pericardiocentesis
D) Endotracheal tube repositioning
, Correct Answer: A – This is a tension pneumothorax in a ventilated patient. In
an intubated patient, needle decompression is a temporizing measure; definitive
management is a tube thoracostomy (chest tube) because positive pressure
ventilation causes rapid reaccumulation.
Rationale: Intubated patients with a tension pneumothorax require chest
tube placement after initial needle decompression (if performed). The tracheal
deviation indicates severe mediastinal shift.
3. Which of the following is the most reliable sign of proper endotracheal tube
placement in a cardiac arrest patient?
A) Bilateral breath sounds
B) Mist in the endotracheal tube
C) End-tidal CO2 (ETCO2) ≥ 10 mmHg
D) Chest X-ray showing the tip above the carina
Correct Answer: C – In cardiac arrest, ETCO2 (capnography) is the most
reliable confirmation of tube placement. A waveform capnography showing a
sustained reading confirms placement in the trachea. Breath sounds can be
misleading; chest X-ray takes time.
Rationale: During CPR, ETCO2 levels reflect pulmonary blood flow. Even a low
but detectable ETCO2 (≥10) confirms tracheal placement. Esophageal intubation
yields zero ETCO2.
4. A 55-year-old with asthma presents in status asthmaticus. He is speaking only
2-word sentences. Which of the following is a contraindication to Non-Invasive
Positive Pressure Ventilation (NIPPV) in this patient?
A) Hypercarbia (PaCO2 50 mmHg)
B) Agitation and inability to protect the airway
C) Respiratory rate of 30 breaths/min
D) Use of accessory muscles
Correct Answer: B – Agitation, altered mental status, and inability to protect
the airway are absolute contraindications to NIPPV. Hypercarbia is an indication
for NIPPV in asthma/COPD; accessory muscle use and tachypnea are indications,
not contraindications.
, Rationale: NIPPV requires a cooperative, awake patient. Failure to protect the
airway necessitates intubation.
5. A 28-year-old with no past medical history presents with acute onset pleuritic
chest pain and dyspnea after an 8-hour flight. She is tachycardic, tachypneic,
and SpO2 91% on RA. ECG shows sinus tachycardia. CXR is normal. What is the
most appropriate next diagnostic test?
A) CT Pulmonary Angiography (CTPA)
B) D-dimer
C) Ventilation-Perfusion (V/Q) scan
D) Lower extremity venous duplex
Correct Answer: A – This patient has a high pre-test probability for Pulmonary
Embolism (PE) (long flight, acute dyspnea, hypoxia, tachycardia, normal CXR).
With high probability, CTPA is the test of choice. D-dimer is for low/moderate
probability; V/Q is second-line; duplex is insufficient.
Rationale: Wells’ criteria and PERC rule guide testing. High clinical probability
warrants immediate CTPA to confirm or exclude PE.
6. (SATA) A 70-year-old with CHF presents with acute pulmonary edema. He is
tachypneic, hypertensive (190/110), and oxygen saturation is 85%. Which of the
following are appropriate initial management strategies?
A) Nitroglycerin sublingual 0.4 mg
B) Furosemide 40 mg IV
C) High-flow oxygen or CPAP
D) Morphine 4 mg IV
E) Normal saline 1L bolus
Correct Answers: A, B, C, D – All are appropriate for acute pulmonary edema
except E (IV fluids would worsen volume overload). Nitroglycerin reduces preload
and afterload; furosemide promotes diuresis; CPAP improves oxygenation and
reduces preload; morphine reduces anxiety and preload.
Rationale: The mainstays of acute cardiogenic pulmonary edema are
afterload reduction (nitrates), diuresis (loop diuretics), and positive pressure
ventilation (CPAP/BiPAP). Morphine is used cautiously.
, 7. Which of the following findings on a chest X-ray is most suggestive of a large
pleural effusion?
A) Blunting of the costophrenic angle
B) Meniscus sign
C) Kerley B lines
D) Air bronchograms
Correct Answer: B – The meniscus sign (curved upper border of the fluid) is
classic for a large, free-flowing pleural effusion. Costophrenic blunting is seen
with small effusions. Kerley B lines are for pulmonary edema. Air bronchograms
are for pneumonia or atelectasis.
Rationale: A meniscus sign indicates at least 200-300 mL of fluid. Lateral
decubitus views are more sensitive for small effusions.
8. A 3-year-old presents with a "barking" cough, stridor, and drooling. He is
sitting upright and leaning forward. What is the most appropriate next step?
A) Direct laryngoscopy in the ED
B) Lateral neck X-ray
C) Nebulized racemic epinephrine
D) Prepare for immediate OR intubation
Correct Answer: D – This presentation (stridor, drooling, tripod position) is
classic for epiglottitis (especially in children, though now rare due to Hib vaccine).
Immediate airway support by anesthesia/ENT is required. Do not agitate the child;
no examination of the airway or X-ray in the ED unless immediately available.
Rationale: Epiglottitis is a life-threatening airway emergency. The child should
be kept calm, and a controlled, definitive airway should be established in the OR.
9. A 60-year-old smoker presents with a 3-week history of hoarseness and a
non-productive cough. He has a 30-pack-year history and now notes
hemoptysis. Which imaging finding is most associated with his underlying
diagnosis?
A) Solitary pulmonary nodule with spiculated margins
B) Bilateral hilar adenopathy
C) Cavitary lesion with air-fluid level
D) Pleural thickening with calcification
National Emergency Medicine Clerkship / In-Training
Curriculum
2026–2027 Academic Year
SECTION I: AIRWAY, RESPIRATORY & THORACIC
1. A 45-year-old with a history of COPD presents with acute respiratory distress.
He is tripoding, using accessory muscles, and has diminished breath sounds on
the right with hyperresonance to percussion. HR 130, BP 100/70, RR 36, SpO2
88% on 4L NC. Which of the following is the immediate next step?
A) Stat portable chest X-ray
B) Needle decompression of the right chest
C) Intubation with rapid sequence induction
D) Bilevel positive airway pressure (BiPAP)
Correct Answer: B – This is a tension pneumothorax (hyperresonance, absent
breath sounds, hypotension, tachycardia, hypoxia). Needle decompression
(second intercostal space, midclavicular line) is the immediate life-saving
intervention before CXR. BiPAP can worsen tension physiology; intubation is not
the first step if decompression can stabilize him.
Rationale: Tension pneumothorax compresses the vena cava, reducing
preload and causing obstructive shock. Immediate decompression is mandatory.
Do not wait for imaging.
2. A 22-year-old intubated motor vehicle crash victim has a post-intubation
SpO2 of 82% despite being placed on 100% FiO2. Breath sounds are absent on
the left with a deviated trachea to the right. BP 80/50. What is the definitive
management?
A) Left-sided chest tube thoracostomy
B) Needle decompression of the left chest
C) Emergency pericardiocentesis
D) Endotracheal tube repositioning
, Correct Answer: A – This is a tension pneumothorax in a ventilated patient. In
an intubated patient, needle decompression is a temporizing measure; definitive
management is a tube thoracostomy (chest tube) because positive pressure
ventilation causes rapid reaccumulation.
Rationale: Intubated patients with a tension pneumothorax require chest
tube placement after initial needle decompression (if performed). The tracheal
deviation indicates severe mediastinal shift.
3. Which of the following is the most reliable sign of proper endotracheal tube
placement in a cardiac arrest patient?
A) Bilateral breath sounds
B) Mist in the endotracheal tube
C) End-tidal CO2 (ETCO2) ≥ 10 mmHg
D) Chest X-ray showing the tip above the carina
Correct Answer: C – In cardiac arrest, ETCO2 (capnography) is the most
reliable confirmation of tube placement. A waveform capnography showing a
sustained reading confirms placement in the trachea. Breath sounds can be
misleading; chest X-ray takes time.
Rationale: During CPR, ETCO2 levels reflect pulmonary blood flow. Even a low
but detectable ETCO2 (≥10) confirms tracheal placement. Esophageal intubation
yields zero ETCO2.
4. A 55-year-old with asthma presents in status asthmaticus. He is speaking only
2-word sentences. Which of the following is a contraindication to Non-Invasive
Positive Pressure Ventilation (NIPPV) in this patient?
A) Hypercarbia (PaCO2 50 mmHg)
B) Agitation and inability to protect the airway
C) Respiratory rate of 30 breaths/min
D) Use of accessory muscles
Correct Answer: B – Agitation, altered mental status, and inability to protect
the airway are absolute contraindications to NIPPV. Hypercarbia is an indication
for NIPPV in asthma/COPD; accessory muscle use and tachypnea are indications,
not contraindications.
, Rationale: NIPPV requires a cooperative, awake patient. Failure to protect the
airway necessitates intubation.
5. A 28-year-old with no past medical history presents with acute onset pleuritic
chest pain and dyspnea after an 8-hour flight. She is tachycardic, tachypneic,
and SpO2 91% on RA. ECG shows sinus tachycardia. CXR is normal. What is the
most appropriate next diagnostic test?
A) CT Pulmonary Angiography (CTPA)
B) D-dimer
C) Ventilation-Perfusion (V/Q) scan
D) Lower extremity venous duplex
Correct Answer: A – This patient has a high pre-test probability for Pulmonary
Embolism (PE) (long flight, acute dyspnea, hypoxia, tachycardia, normal CXR).
With high probability, CTPA is the test of choice. D-dimer is for low/moderate
probability; V/Q is second-line; duplex is insufficient.
Rationale: Wells’ criteria and PERC rule guide testing. High clinical probability
warrants immediate CTPA to confirm or exclude PE.
6. (SATA) A 70-year-old with CHF presents with acute pulmonary edema. He is
tachypneic, hypertensive (190/110), and oxygen saturation is 85%. Which of the
following are appropriate initial management strategies?
A) Nitroglycerin sublingual 0.4 mg
B) Furosemide 40 mg IV
C) High-flow oxygen or CPAP
D) Morphine 4 mg IV
E) Normal saline 1L bolus
Correct Answers: A, B, C, D – All are appropriate for acute pulmonary edema
except E (IV fluids would worsen volume overload). Nitroglycerin reduces preload
and afterload; furosemide promotes diuresis; CPAP improves oxygenation and
reduces preload; morphine reduces anxiety and preload.
Rationale: The mainstays of acute cardiogenic pulmonary edema are
afterload reduction (nitrates), diuresis (loop diuretics), and positive pressure
ventilation (CPAP/BiPAP). Morphine is used cautiously.
, 7. Which of the following findings on a chest X-ray is most suggestive of a large
pleural effusion?
A) Blunting of the costophrenic angle
B) Meniscus sign
C) Kerley B lines
D) Air bronchograms
Correct Answer: B – The meniscus sign (curved upper border of the fluid) is
classic for a large, free-flowing pleural effusion. Costophrenic blunting is seen
with small effusions. Kerley B lines are for pulmonary edema. Air bronchograms
are for pneumonia or atelectasis.
Rationale: A meniscus sign indicates at least 200-300 mL of fluid. Lateral
decubitus views are more sensitive for small effusions.
8. A 3-year-old presents with a "barking" cough, stridor, and drooling. He is
sitting upright and leaning forward. What is the most appropriate next step?
A) Direct laryngoscopy in the ED
B) Lateral neck X-ray
C) Nebulized racemic epinephrine
D) Prepare for immediate OR intubation
Correct Answer: D – This presentation (stridor, drooling, tripod position) is
classic for epiglottitis (especially in children, though now rare due to Hib vaccine).
Immediate airway support by anesthesia/ENT is required. Do not agitate the child;
no examination of the airway or X-ray in the ED unless immediately available.
Rationale: Epiglottitis is a life-threatening airway emergency. The child should
be kept calm, and a controlled, definitive airway should be established in the OR.
9. A 60-year-old smoker presents with a 3-week history of hoarseness and a
non-productive cough. He has a 30-pack-year history and now notes
hemoptysis. Which imaging finding is most associated with his underlying
diagnosis?
A) Solitary pulmonary nodule with spiculated margins
B) Bilateral hilar adenopathy
C) Cavitary lesion with air-fluid level
D) Pleural thickening with calcification
