NREMT Test Bank Multiple Choice 2022 Answered/ reasoned.

NREMT Practice Test Bank - Multiple Choice A 3-year-old boy is found to be in cardiopulmonary arrest. As you begin one-rescuer CPR, your partner prepares the AED. The appropriate compression to ventilation ratio for this child is: • A:3:1 • B:30:2 • C:5:1 • D:15:2 ans: You selected B; This is correct! Reason:A universal compression to ventilation ratio of 30:2 is used for all one-rescuer CPR (adult, child, and infant), with the exception of the newborn. A compression to ventilation ratio of 3:1 is used for newborns (one- and two-rescuer). Two-rescuer infant and child CPR is performed at a compression to ventilation ratio of 15:2. In this scenario, you are performing one-rescuer CPR as your partner prepares the AED; therefore, you should give 30 compressions and 2 breaths. However, when you and your partner resume CPR, give 15 compressions and 2 breaths. A 3-year-old child has a sudden onset of respiratory distress. The mother denies any recent illnesses or fever. You should suspect: • A:lower respiratory infection. • B:foreign body airway obstruction. • C:croup. • D:epiglottitis. ans: You selected B; This is correct! Reason:You should suspect a foreign body airway obstruction in any child who presents with an acute onset of respiratory distress in the absence of fever. Croup, epiglottitis, and lower airway infections (ie, bronchiolitis, bronchitis) commonly present with a fever. If the child is experiencing a mild airway obstruction, in which he or she is moving adequate air, has a normal level of consciousness, and pink skin, do not attempt to relieve the airway obstruction; doing so may result in a severe airway obstruction. Offer oxygen and transport the child to the hospital without delay. If signs of a severe airway obstruction are present (ie, ineffective cough, decreased level of consciousness, cyanosis), you should perform abdominal thrusts until the object is expelled or the child becomes unresponsive. If the child becomes unresponsive, perform chest compressions. A 3-year-old female presents with respiratory distress. She is conscious, crying, and clinging to her mother. She has mild intercostal retractions and an oxygen saturation of 93%. The MOST effective way of delivering oxygen to her involves: • A:ventilations with a flow-restricted, oxygen-powered device. • B:gently restraining her and assisting her ventilations. • C:asking the mom to hold an oxygen mask near her face. • D:a nonrebreathing mask with the flow rate at 6 to 8 L/min. ans: You selected C; This is correct! Reason:Do not assume that a child will simply allow you to administer oxygen to him or her as you would to an adult. The child in this scenario, who is in respiratory distress and is mildly hypoxemic (SpO2 of 93%), should receive supplemental oxygen; however, it should be given in a nonthreatening manner. Agitating a sick or injured child causes an increase in oxygen consumption and demand, which may cause the child's condition to deteriorate. In this scenario, ask the child's mother to hold an oxygen mask near the child's face (blow-by oxygen). Closely monitor her condition and be prepared to assist her ventilations with a bag-mask device if she deteriorates. An oxygen flow rate of 6 to 8 L/min is too low for a nonrebreathing mask; a flow-rate of 12 to 15 L/min should be used. Do NOT use a flow-restricted, oxygen-powered ventilation device (FROPVD) on any child; doing so may cause severe gastric distention and lung injury. Allow the child to assume a position of comfort and transport. A 4-year-old boy ingested an unknown quantity of drain cleaner. He is alert, has a patent airway, and has adequate breathing. You should: • A:administer 1 g/kg of activated charcoal. • B:give 15 mL of ipecac and contact medical control. • C:contact poison control and give him oxygen. • D:give oxygen and perform a head-to-toe exam. ans: You selected C; This is correct! Reason:Once you determine that a poisoning has occurred, and have identified the poison, you should contact the poison control center at once: (800) 222-1222. Give the patient high-flow oxygen or assist his or her ventilations if necessary. Induction of vomiting with syrup of ipecac is no longer recommended because of the risk of aspiration. Activated charcoal is contraindicated in patients who have ingested a corrosive substance (eg, drain cleaner) or a petroleum product (eg, gasoline, motor oil). A head-to-toe exam is not practical in this situation, at least initially. Follow the directions given to you by the poison control center, transport the child without delay, and monitor his condition en route. A 4-year-old girl fell from a third-story window and landed on her head. She is semiconscious with slow, irregular breathing and is bleeding from her mouth and nose. You should: • A:suction her oropharynx, open her airway with the jaw-thrust maneuver, insert an oropharyngeal airway, and assist her ventilations. • B:open her airway with the jaw-thrust maneuver while manually stabilizing her head, suction her oropharynx, and assist her ventilations. • C:open her airway by carefully tilting her head back, suction her oropharynx, and administer high-flow oxygen via nonrebreathing mask. • D:manually stabilize her head, open her airway with the jaw-thrust maneuver, insert a nasopharyngeal airway, and suction her oropharynx. ans: The correct answer is B; Reason:In any semi- or unconscious patient with a head injury, you should manually stabilize the head and open the airway with the jaw-thrust maneuver. If there are any secretions in the mouth, suction the oropharynx. If possible, insert a simple airway adjunct. The patient in this scenario is semiconscious and likely has an intact gag reflex; therefore, you should not attempt to insert an oropharyngeal airway. Conversely, you should not insert a nasopharyngeal airway in patients with a head injury, especially if there is fluid or blood draining from the nose (a sign of a skull fracture). After ensuring a patent airway, you should turn your attention to the patient's breathing. Slow, irregular breathing will not provide adequate minute volume and should be treated with ventilatory assistance. A 5-year-old boy was struck by a car when he ran out into the street. When you arrive at the scene and approach the child, you see him lying supine approximately 15 feet from the car. Based on the child's age and mechanism of injury, which of the following should you suspect to be his PRIMARY injury? • A:Head injury • B:Upper thorax injury • C:Lower leg injury • D:Pelvic injury ans: The correct answer is D; Reason:Children are smaller than adults; therefore, when they are injured by the same mechanism of injury as an adult, the location of their injuries may differ from those of an adult. For example, when an adult is struck by a vehicle, the primary injury typically occurs at or below the knees, depending on the height of the bumper at the time of impact. Because the child is shorter, initial impact typically occurs at or near the pelvis. Secondary injury occurs when child's chest collides with the vehicle's grille. Tertiary injury occurs when the child strikes the side of his or her head on the pavement after being propelled away from the vehicle. In some cases, the child is pulled underneath the vehicle and is dragged. A 6-year-old boy complains of pain to the right lower quadrant of his abdomen. Assessment of this child's abdomen should include: • A:palpating the right lower quadrant first. • B:auscultating bowel sounds for 2 minutes. • C:avoiding palpation of the abdomen. • D:palpating the left upper quadrant first. ans: You selected D; This is correct! Reason: When assessing the abdomen of any patient, you should determine the location of the pain and palpate that area last. Begin by palpating the abdomen furthest away from the area of pain; in this case, the left upper quadrant is furthest away from the right lower quadrant. Palpating the painful area first will interfere with the rest of your assessment because the patient will be in significant pain and will likely not remain still during the remainder of the assessment. This is especially true in children. Auscultation of bowel sounds is generally not performed in the prehospital setting; little, if any, information will be gained from doing so. A 7-year-old child has an altered mental status, high fever, and a generalized rash. You perform your assessment and administer supplemental oxygen. En route to the hospital, you should be MOST alert for: • A:respiratory distress. • B:combativeness. • C:hypotension. • D:convulsions. ans: The correct answer is D; Reason:High fever and an alerted mental status indicate sepsis (severe infection). A generalized rash should alert you to the possibility of meningitis—a condition caused by infection and inflammation of the meninges that protect the brain and spinal cord. Children with meningitis are at risk for seizures (convulsions), usually due to increased intracranial pressure (ICP) and/or high fever; therefore, you must continually monitor the child's condition en route to the hospital and be prepared to treat seizures if they occur. Remember that seizure deaths are caused by cerebral hypoxia. You should also be alert for vomiting, which can jeopardize the airway. Hypotension can occur in patients with sepsis and should also be of concern; however, seizures directly compromise adequate ventilation and oxygenation. A 9-year-old girl was struck by a car while she was crossing the street. Your assessment reveals a large contusion over the left upper quadrant of her abdomen and signs of shock. Which of the following organs has MOST likely been injured? • A:Kidney • B:Liver • C:Pancreas • D:Spleen ans: You selected D; This is correct! Reason:Abdominal trauma commonly occurs in children as the result of motor vehicle versus pedestrian accidents. The contusions over the left upper quadrant and the signs of shock suggest significant injury to the spleen. The liver lies in the right upper quadrant, and the pancreas and kidneys lie in the retroperitoneal space. Although the exact injury cannot be determined in the field, you must treat the patient for shock and provide rapid transport. A 16-year-old, 125-pound male ingested a bottle of aspirin approximately 20 minutes ago. Medical control orders you to administer activated charcoal in a dose of 1 g/kg. How much activated charcoal should you administer? • A:54 g • B:60 g • C:51 g • D:57 g ans: You selected D; This is correct! Reason: First, you must determine the patient's weight in kilograms (kg). Either of the following formulae can be used to convert pounds to kilograms: Formula 1: weight (in pounds) ÷ 2.2 = weight in kg. Formula 2: weight (in pounds) ÷ 2 - 10% = weight in kg. On the basis of the above formulae, a 125-pound patient weighs 57 kg. Using formula 1, the equation is as follows: 125 (weight in pounds) ÷ 2.2 = 56.81 (57 [rounded to the nearest tenth]). Using formula 2, the equation is as follows: 125 (weight in pounds) ÷ 2 = 62.5 (63 [rounded to the nearest tenth] - 6.3 (10% of 63) = 56.7 (57 [rounded to the nearest tenth]). Since the drug order is for 1 g/kg, you should administer 57 g of activated charcoal to your 125-pound patient. A 19-year-old female has a closed, swollen deformity to her left forearm. You are unable to palpate a radial pulse and the skin distal to the injury is cold and pale. Several attempts to contact medical control have failed and you are approximately 45 miles away from the closest hospital. You should: • A:apply an air splint to her forearm, keep her arm below the level of her heart, place an icepack over the injury, and transport. • B:begin transport at once, gently manipulate her arm en route until distal circulation is restored, and apply an air splint. • C:splint her entire arm with rigid board splints, elevate the limb above the level of her heart, and transport immediately. • D:make one attempt to restore distal circulation by applying gentle manual traction in line with the long axis of the limb. ans: The correct answer is D; Reason: Cold, pale skin and an absent distal pulse indicates that blood flow distal to the injury is compromised. You should notify medical control, who will likely direct you to attempt to restore distal circulation. However, if you are unable to contact medical control and your transport time will be lengthy, you should make ONE attempt to restore distal circulation by applying gentle manual traction in line with the long axis of the limb. Be careful, as excessive manipulation can worsen the vascular problem. If you are unsuccessful after one attempt, splint the limb in the most comfortable position for the patient and transport at once. If distal circulation is restored, splint the limb in whatever position allows the strongest distal pulse. You should elevate the limb above the level of the heart to help minimize swelling. An icepack may also help reduce pain and swelling. A 19-year-old male was assaulted and has trauma to multiple body systems. After performing your primary assessment and treating any immediate life-threatening injuries, you should: • A:obtain a full set of baseline vital signs. • B:transport at once and intercept with ALS. • C:perform a rapid head-to-toe assessment. • D:fully immobilize his spine and transport. ans: You selected D; The correct answer is C; Reason: After treating all life-threatening conditions found in the primary assessment, you should perform a rapid head-to-toe assessment (rapid body scan) to look for and treat other life threats. In many cases, patients with trauma to multiple body systems have other life-threatening injuries that are not readily apparent during the primary assessment. You should obtain baseline vital signs as soon as possible; however, this should not delay or interrupt your primary or rapid head-to-toe assessments. After performing the primary and rapid head-to-toe assessments, fully immobilize the patient's spine and transport to an appropriate hospital. Consider an advanced life support (ALS) intercept, as long as it does not cause a significant delay in transport. A 21-year-old male was bitten on the left forearm by a dog. He is conscious and alert and denies any other injuries. An animal control officer is at the scene and has contained the dog. Your assessment of the patient's arm reveals a large avulsion with a peeled back flap of skin. Distal circulation is adequate and the patient is able to feel and move his fingers. In addition to bleeding control, you should: • A:perform a rapid head-to-toe assessment. • B:irrigate the wound for at least 15 minutes. • C:replace the avulsed flap to its original position. • D:apply oxygen via a nonrebreathing mask. ans: The correct answer is C; Reason: An avulsion is an injury that separates various layers of soft tissue, usually between the subcutaneous layer and fascia, so that they become completely detached or hang as a flap. The patient's injury is isolated and not life-threatening; therefore, a rapid head-to-toe assessment is not indicated. Unless your protocols specify otherwise, oxygen is usually not necessary for patients with isolated, non-life-threatening soft tissue injuries. If the avulsed tissue is hanging from a small piece of skin, circulation through the flap may be at risk. If you can, replace the avulsed flap to its original position, as long as it is not visibly contaminated with dirt and/or other foreign materials, and then cover the wound with a dry sterile dressing. Unless the wound is grossly contaminated with dirt or debris, irrigation is usually deferred until the patient is evaluated by a physician. Furthermore, flushing an open wound may force dirt or other debris into the wound, increasing the risk of infection. A 21-year-old man partially amputated his right arm when the chainsaw he was using to trim trees slipped. You can feel a weak radial pulse and his arm is cool to the touch. Dark red blood is flowing heavily from the wound. You should: • A:control the bleeding, manipulate the arm to improve circulation, and apply a splint. • B:apply bulky compression dressings to the wound and splint the extremity. • C:carefully pack sterile dressings into the wound and fully splint the extremity. • D:apply a tourniquet proximal to the injury and tighten it until the bleeding stops. ans: The correct answer is B; Reason: When caring for a partially amputated extremity, control bleeding with bulky compression (pressure) dressings and splint the extremity to prevent further injury. If direct pressure does not immediately control the bleeding, however, a proximal tourniquet should be applied without delay. Never pack dressings into a wound; this may cause further damage and increases the risk of infection. Although your patient's radial pulse is weak, it is present and indicates blood flow distal to the injury. Do not manipulate his arm; doing so may lacerate or compress an artery and compromise distal circulation. A 22-year-old female fell on her knee and is in severe pain. Her knee is flexed and severely deformed. Her leg is cold to the touch and you are unable to palpate a distal pulse. You should: • A:carefully straighten her leg until you restore a distal pulse and then apply padded board splints. • B:apply gentle longitudinal traction as you straighten her leg and then apply a traction splint. • C:manually stabilize her injury and contact medical control for further stabilization instructions. • D:place a pillow behind her knee and stabilize the injury by applying padded board splints. ans: The correct answer is C; Reason: A dislocated knee occurs when the proximal end of the tibia completely displaces from its juncture with the distal femur. In some cases, the popliteal artery behind the knee may be compressed, resulting in compromised distal blood flow. Signs of this include absent distal pulses and a pale extremity that is cool or cold. Manually stabilize the knee and assess for distal pulses. If distal pulses are absent, contact medical control immediately for further stabilization instructions. Medical control may instruct you to make ONE attempt to realign the knee to reduce compression of the popliteal artery and restore distal circulation. If you are unable to restore distal circulation or medical control advises you not to manipulate the injury, splint the knee in the position it was found and transport promptly. Traction splints are contraindicated in any injury to or near the knee A 22-year-old female woman was shot by her husband. Law enforcement is at the scene and has the husband in custody. The patient is conscious, but extremely restless, and is pale and diaphoretic. As your partner administers high-flow oxygen, you should: • A:keep her warm by applying blankets. • B:take her BP to detect hypotension. • C:compare her carotid and radial pulses. • D:look for and control any bleeding. ans: You selected D; This is correct! Reason: The primary assessment of any patient includes ensuring a patent airway, assessing breathing adequacy, administering high-flow oxygen or assisting ventilations, assessing circulation, and controlling all active bleeding. You and your partner must work as a team; as your partner administers high-flow oxygen, you should be looking for her gunshot wound(s) and ensuring that all bleeding is controlled. After the primary assessment and management, begin treating her for shock (eg, applying a blanket, elevating her lower extremities [if local protocol permits]) and perform a rapid head-to-toe assessment to search for other injuries that may not have been obvious during the primary assessment. Assess the patient's vital signs after all life-threatening injuries or conditions have been identified and corrected. A 22-year-old man was stabbed in the chest with a large knife. The patient is pulseless and apneic, and the knife is impaled in the center of his chest. Treatment should include: • A:stabilizing the knife, starting CPR, and providing rapid transport. • B:removing the knife, applying an occlusive dressing, and providing rapid transport. • C:removing the knife, starting CPR, and providing rapid transport. • D:stabilizing the knife, applying an occlusive dressing, and providing rapid transport. ans: The correct answer is C; Reason: There are two indications for removing an impaled object: when the object is causing airway compromise and when the object interferes with your ability to perform CPR. A knife impaled in the center of the chest, which is where chest compressions are performed, in a patient who is in cardiac arrest must be carefully removed. Quickly cover the wound to control any bleeding (an occlusive dressing covered by a sterile dressing is preferred) and begin CPR immediately. A 23-year-old unrestrained female struck the steering wheel with her chest when her passenger car collided with a tree at a high rate of speed. Your assessment reveals that she is conscious, but has signs of shock and an irregular pulse. The MOST appropriate treatment for this patient includes: • A:high-flow oxygen, summoning a paramedic unit to the scene to assess her cardiac rhythm, a cervical collar, and transport as soon as possible. • B:insertion of an oral airway, assisted ventilations with a bag-mask device, full spinal precautions, and rapid transport. • C:applying an AED in case she develops cardiac arrest, high-flow oxygen, full spinal precautions, and rapid transport. • D:high-flow oxygen or assisted ventilations as needed, full spinal precautions, blankets to keep her warm, and rapid transport. ans: You selected D; This is correct! Reason: The cause of this patient's shock may be a myocardial contusion, or bruising of the heart muscle. Blunt trauma to the chest can injure the heart, making it unable to maintain adequate blood pressure. In a myocardial contusion, the pulse is often irregular, but dangerous rhythms (eg, V-Fib, V-Tach) are relatively uncommon. There is no special diagnostic test at this time, and there is no prehospital treatment for the condition. Therefore, waiting at the scene for a paramedic unit would only waste time. Apply high-flow oxygen, assist ventilations if the patient is breathing inadequately (eg, slow or fast respirations, shallow breathing [reduced tidal volume]), treat the patient for shock (eg, cover her with blankets, elevate her lower extremities [if local protocol permits]), and transport rapidly. Because of the mechanism of injury, full spinal precautions should be taken. The patient is conscious and likely has an intact gag reflex; therefore, an oral airway is contraindicated. The AED is only applied to patients who are in cardiac arrest A 24-year-old female presents with a rash to her left leg and swollen, painful knee joints. She tells you that she and her friends returned from a hiking trip in the mountains a week ago. She is conscious and alert with a blood pressure of 112/62 mm Hg, a pulse of 84 beats/min, and respirations of 14 breaths/min. Her symptoms are MOST likely the result of: • A:Rocky Mountain spotted fever. • B:tetanus. • C:Lyme disease. • D:a localized allergic reaction. ans: You selected C; This is correct! Reason:The patient's symptoms and her history of a recent hiking trip are consistent with Lyme disease, which was the result of a tick bite. Ticks can carry two infectious diseases: Lyme disease and Rocky Mountain spotted fever. Both are spread through the tick's saliva, which is injected into the skin when the tick attaches itself. The first symptom of Lyme disease, a rash that may spread to several parts of the body, begins about 3 days after the bite of an infected tick. The rash may eventually resemble a target bull's-eye pattern in one third of patients. After a few more days or weeks, painful swelling of the joints, particularly the knees, occurs. If recognized and treated promptly with antibiotics, many patients recover completely. Rocky Mountain spotted fever, which is not limited to the Rocky Mountains, occurs within 7 to 10 days after being bitten by an infected tick. Its symptoms include nausea, vomiting, headache, weakness, paralysis, and possibly cardiopulmonary failure. A 28-year-old woman has severe lower quadrant abdominal pain. When assessing her abdomen, you should: • A:encourage the patient to lie supine with her legs fully extended. • B:ask her where the pain is located and palpate that area first. • C:auscultate for bowel sounds for approximately 2 to 5 minutes. • D:ask her where the pain is located and palpate that area last ans: You selected D; This is correct! Reason:Assessment of a patient's abdomen includes asking where the pain is located and then palpating that area last. Palpating the painful area first may interfere with the rest of your assessment because of the significant pain the patient will be in. Bowel sounds are of little value in the field and generally are not included in the abdominal assessment. Patients with severe abdominal pain typically prefer to lie on their side with their knees drawn up into their chest (fetal position). Moving them from this position will aggravate their pain. A 29-year-old woman, who is 38 weeks pregnant, presents with heavy vaginal bleeding, a blood pressure of 70/50 mm Hg, and a heart rate of 130 beats/min. She is pale and diaphoretic, and denies abdominal cramping or pain. Her signs and symptoms are MOST consistent with a/an: • A:placenta previa. • B:abruptio placenta. • C:ruptured ectopic pregnancy. • D:ruptured ovarian cyst. ans: The correct answer is A; Reason:Of the conditions listed, placenta previa would be the least likely to present with abdominal pain, although some patients may have pain or cramping. Placenta previa is a condition in which the placenta develops over and covers some or all of the cervix. As the cervix dilates, the vasculature that attaches the placenta to the uterine wall tears, resulting in vaginal bleeding that is often severe enough to cause shock. By contrast, abruptio placenta is a condition in which the placenta prematurely separates from the uterine wall; it is characterized by tearing abdominal pain, heavy vaginal bleeding, and shock. Placenta previa and abruptio placenta occur during the later stages of pregnancy. A ruptured ovarian cyst typically causes lower abdominal pain, often unilateral. Ectopic pregnancy, a condition in which the egg implants and grows outside the uterus (usually in a fallopian tube), is a first trimester condition; it is typically discovered between 8 and 10 weeks of pregnancy. If the ectopic pregnancy ruptures, the patient often presents with a sudden stabbing pain in the lower abdomen and shock due to intraabdominal hemorrhage. A 30-year-old man sustained partial-thickness burns to the anterior chest and both anterior arms. Based on the Rule of Nines, what percentage of his body surface area has been burned? • A:36% • B:9% • C:18% • D:27% ans: The correct answer is C; Reason: According to the adult Rule of Nines, the anterior trunk (chest and abdomen) accounts for 18% of the total body surface area (TBSA) and each entire arm accounts for 9%. Therefore, the anterior chest, which is one half of the trunk, would account for 9% of the TBSA, and both anterior arms (4.5% each) would account for 9% TBSA, for a total of 18% TBSA burned. A 30-year-old man with a history of schizophrenia cut his wrists and is bleeding profusely. He is confused, combative, and has slurred speech. With the assistance of law enforcement personnel, you and your partner physically restrain him in order to provide care and transport. In this situation, a court of law would MOST likely: • A:conclude that you should have had a court order to restrain. • B:determine that the patient had decision-making capacity. • C:agree that you and your partner are guilty of assault and battery. • D:consider your actions in providing care to be appropriate. ans: You selected D; This is correct! Reason:An adult with decision-making capacity (ie, a mentally competent adult) has the legal right to refuse medical treatment, even if that treatment involves lifesaving care. In psychiatric cases, however, a court of law would likely consider your actions in providing lifesaving care to be appropriate, particularly if you have a reasonable belief that the patient would harm him- or herself or others without your intervention. In addition, a patient who is in any way impaired, whether by mental illness, medical condition, or intoxication, may not be considered competent to refuse treatment and transport. If you are unsure of a patient's decision-making capacity, err on the side of treatment and transport. Few would argue that it would be easier to defend why you treated a patient than to justify or defend why you abandoned a patient. A 30-year-old woman crashed her car into a tree at a high rate of speed. She is conscious and alert and has stable vital signs. She has some small lacerations and abrasions to her arms and face, but no obviously life-threatening injuries. As you are loading her into the ambulance, she tells you that she does not want to go to the hospital. You should: • A:advise her that she is probably too emotionally upset to be able to refuse EMS treatment and transport. • B:obtain a signed refusal from the patient and ask a law enforcement officer to transport her to the hospital. • C:advise the patient that she should be transported to the hospital because of the seriousness of the crash. • D:ask a law enforcement officer to administer a breathalyzer test to determine if she has been drinking alcohol. ans: You selected C; This is correct! Reason:The consequences of refusal should be explained to any patient who refuses EMS treatment and/or transport. After establishing that the patient can legally refuse treatment and transport (eg, he or she is of legal age AND has decision-making capacity), you must advise her that because of the significant mechanism of injury, the potential for critical injury or death exists, even though she may feel fine now. Once this is explained, and the patient understands and is willing to accept the possible consequences, obtain a signed refusal and ask an impartial person (eg, police officer) to witness the signed refusal. A 30-year-old woman has an open deformity to her left leg and is in severe pain. She is conscious and alert, has a patent airway, and is breathing adequately. Your primary concern should be: • A:administering high-flow oxygen. • B:controlling any external bleeding. • C:assessing pulses distal to the injury. • D:covering the wound to prevent infection. ans: The correct answer is B; Reason: Initial care for any open injury involves controlling external bleeding. Further care involves manually stabilizing the injury site; applying a sterile dressing to keep gross contaminants from entering the wound; assessing distal perfusion (eg, a pulse), motor, and sensory functions; and stabilizing the injury with an appropriate splint. The patient in this scenario is conscious, alert, has a patent airway, and is breathing adequately. Depending on other assessment findings, oxygen may be indicated. Your primary concern, however, should be to ensure that all external bleeding has been controlled. A 32-year-old man who was stung by a bee has diffuse hives, facial swelling, and difficulty breathing. When he breathes, you hear audible stridor. What does this indicate? • A:Narrowing of the two mainstem bronchi • B:Swelling of the upper airway structures • C:Narrowing of the bronchioles in the lungs • D:Swelling of the lower airway structures ans: You selected B; This is correct! Reason:This patient is experiencing a severe allergic reaction (anaphylaxis). Stridor, which is a high-pitched sound heard on inhalation, indicates swelling of the structures and tissues of the upper airway. If not promptly treated, the patient's airway may close completely, resulting in respiratory arrest. Narrowing of the bronchioles in the lungs causes wheezing, a whistling sound that may be heard during inhalation, exhalation, or both. A 33-year-old factory worker was pinned between two pieces of machinery. When you arrive at the scene, you find him lying supine on the ground complaining of severe pain to his pelvis. He is restless, diaphoretic, and tachycardic. After performing a rapid head-to-toe assessment, you should: • A:perform a detailed secondary exam. • B:palpate his pelvis to assess for crepitus. • C:prepare for immediate transport. • D:carefully log roll him to check his back. ans: You selected C; This is correct! Reason: Based on the mechanism of injury and the presence of signs of shock (eg, restlessness, tachycardia, diaphoresis), you should suspect that the patient has a fractured pelvis and is bleeding internally. Therefore, after completing your primary assessment and initiating shock treatment (eg, high-flow oxygen, applying blankets), you should perform a rapid head-to-toe assessment to assess for other injuries and then prepare for immediate transport. Spinal precautions should be considered. Do not log roll the patient; doing so compresses the pelvis and may cause further injury. You should also avoid palpating his pelvis; this will only cause further pain and may cause further injury. Palpation of the pelvis is performed to assess its stability, not to elicit crepitus. A detailed secondary exam of a critically injured patient at the scene is not appropriate; it takes too long to perform and should be done en route to the hospital if time permits. A 33-year-old female presents with acute respiratory distress. She is conscious but anxious, and tells you that she has a history of asthma. She took two puffs of her albuterol inhaler prior to your arrival, but states that it did not help. Her oxygen saturation reads 89% and you hear diffuse wheezing while auscultating her lungs. You should: • A:give her 100% humidified oxygen to dilate her bronchioles, monitor her oxygen saturation, and transport her to an appropriate medical facility. • B:administer high-flow oxygen, contact medical control to request permission to assist her with another albuterol treatment, and prepare for transport. • C:ventilate her with a bag-mask device until her oxygen saturation is at least 94% and rapidly transport her to the closest appropriate medical facility. • D:assist her with a third albuterol treatment, contact medical control for further advice, give her high-flow oxygen, and transport her to the hospital. ans: You selected B; This is correct! Reason: Despite two albuterol treatments, the patient is still experiencing respiratory distress. Furthermore, the presence of wheezing indicates continued bronchospasm. After administering high-flow oxygen via a nonrebreathing mask, you should contact medical control and request permission to assist the patient with a third albuterol treatment. Drugs such as albuterol (Proventil, Ventolin) and metaproterenol (Alupent) stimulate beta-2 receptors in the lungs, resulting in bronchodilation. Up to three bronchodilator treatments are typically given in the prehospital setting. In most EMS systems, EMTs are not allowed to assist patients with their medication without medical control authorization. After assisting the patient with a third albuterol treatment, reassess her breath sounds and oxygen saturation and transport her promptly. A 33-year-old male struck a parked car with his motorcycle and was ejected from the motorcycle. He was not wearing a helmet. He is unresponsive, has a depressed area to his forehead, bilaterally deformed femurs, and widespread abrasions with capillary bleeding. Which of the following statements regarding this patient is false? • A:You should suspect that the patient has a skull fracture and increased intracranial pressure. • B:You must stop the bleeding from his abrasions immediately or he will die from hypovolemic shock. • C:Internal hemorrhage cannot be controlled in the field and requires prompt surgical intervention. • D:Femur fractures are a common injury when a motorcyclist is ejected from his or her motorcycle. ans: You selected B; This is correct! Reason: The patient's abrasions (road rash) and capillary bleeding are the least of his problems. Capillary bleeding, blood that oozes from the capillary beds, is the least severe type of external bleeding and will not kill your patient. Wasting time at the scene to cover his abrasions, however, will delay definitive care at a trauma center; this may kill him! The patient likely has a depressed skull fracture, and the fact that he is unresponsive indicates a traumatic brain injury with increased intracranial pressure. When a motorcyclist is ejected from his or her motorcycle, the femurs typically strike the handlebars, resulting in unilateral or bilateral fractures. You cannot control internal hemorrhage in the field, regardless of your level of training. Internal bleeding requires surgical intervention; therefore, you must transport the patient without delay. A 34-year-old female complains of persistent fever, fatigue, and night sweats. During your assessment, you note that she has purple blotches on her arms and legs. She MOST likely has: • A:HIV/AIDS. • B:chickenpox. • C:tuberculosis. • D:viral hepatitis. ans: You selected A; This is correct! Reason:Signs of human immunodeficiency virus (HIV) infection include persistent fever, weight loss, fatigue, a cough, and night sweats. The presence of purple skin blotches (malignant lesions called Kaposi's sarcoma) is consistent with acquired immune deficiency syndrome (AIDS), also known as late stage HIV infection. Patients with tuberculosis (TB) also present with fever, fatigue, weight loss, a cough, and night sweats; however, skin lesions are not common. Hepatitis is characterized by right upper quadrant abdominal pain, fever, nausea and vomiting, and a yellow tint to the skin and sclera (jaundice). Chickenpox is unlikely; the associated rash is characterized by pustules that crust over, not purple blotches. A 34-year-old woman, who is 36 weeks pregnant, is having a seizure. After you protect her airway and ensure adequate ventilation, you should transport her: • A:in a semisitting position. • B:in the prone position • C:on her left side. • D:in the supine position. ans: You selected C; This is correct! Reason:Initial care for any patient who is seizing—pregnant or otherwise—involves ensuring a patent airway, adequate ventilation, and administering high-flow oxygen. If the patient is breathing inadequately, ventilation assistance is indicated. Suction any secretions from the patient's mouth. The pregnant patient should be placed on her left side (lateral recumbent position); this will prevent supine hypotensive syndrome—a condition in which the pregnant uterus compresses the inferior vena cava and reduces cardiac output. A lateral recumbent position will also facilitate the draininge of oral secretions, thus minimizing the risk of aspiration. A 36-year-old male, who is a known diabetic, presents with severe weakness, diaphoresis, and tachycardia. He is conscious, but confused. His blood pressure is 110/58 mm Hg, pulse is 120 beats/min and weak, and respirations are 24 breaths/min. The glucometer reads error after several attempts to assess his blood glucose level. In addition to high-flow oxygen, medical control will MOST likely order you to: • A:transport only and closely monitor him. • B:assist the patient in taking his insulin. • C:give him a salt-containing solution to drink. • D:give at least one tube of oral glucose. ans: You selected D; This is correct! Reason:The patient's signs and symptoms indicate hypoglycemia. When you are in doubt as to a patient's blood glucose level, you should err on the side of caution and give sugar; this is what medical control will likely order you to do. The patient, although confused, is conscious and will likely be able to swallow. Insulin is not administered to patients in the field, even if hyperglycemia is documented; EMTs and paramedics are usually not familiar with all of the different types of insulin and their respective doses, and profound hypoglycemia, potentially resulting in death, can occur if too much insulin is given. After giving oral glucose, reassess the patient's mental status and vital signs. A 40-year-old man has burns to the entire head, anterior chest, and both anterior upper extremities. Using the adult Rule of Nines, what percentage of his total body surface area has been burned? • A:18% • B:45% • C:36% • D:27% ans: You selected D; This is correct! Reason: Using the adult Rule of Nines, the head accounts for 9% of the total body surface area (TBSA), the anterior chest for 9% (the entire anterior trunk [chest and abdomen] accounts for 18%), and the anterior upper extremities for 4.5% each (each entire upper extremity is 9% of the TBSA). On the basis of this, the patient has sustained 27% TBSA burns A 40-year-old man was hit in the nose during a fight. He has bruising under his left eye and a nosebleed. After taking standard precautions, you should: • A:place a chemical icepack over his nose. • B:apply direct pressure by pinching his nostrils together. • C:ensure that he is sitting up and leaning forward. • D:determine if he has any visual disturbances. ans: You selected C; This is correct! Reason: During a nosebleed (epistaxis), much of the blood may pass down the throat into the stomach as the patient swallows; this is especially true if the patient is lying supine. Blood is a gastric irritant; a person who swallows a large amount of blood may become nauseated and vomit, which increases the risk of aspiration. Therefore, your first action should be to ensure that the patient is sitting up and leaning forward. This will prevent blood from draining down the back of the throat. Next, apply direct pressure by pinching the fleshy part of the nostrils together; you or the patient may do this. Placing a chemical icepack over the nose may further help control the bleeding by constricting the nasal vasculature. After controlling the nosebleed, continue your assessment, which includes assessing for facial deformities and visual disturbances. A 40-year-old woman presents with widespread hives that she noticed about 45 minutes after taking penicillin. She is conscious and alert and denies difficulty breathing. Her breath sounds are clear to auscultation bilaterally, her vital signs are stable, and her oxygen saturation is 94%. She tells you she is allergic to wasps and has an epinephrine auto-injector. You should: • A:assist her in administering epinephrine via her auto-injector. • B:give high-flow oxygen and administer 100 mg of Benadryl. • C:give supplemental oxygen and transport her to the hospital. • D:advise her that she can probably drive herself to the hospital. ans: You selected C; This is correct! Reason:The patient is experiencing an allergic reaction, but she is not in anaphylactic shock. Urticaria (hives) is common to all allergic reactions, regardless of severity; however, wheezing and hypotension, which she does not have, are specific to anaphylaxis. Although she carries an epinephrine auto-injector for her allergy to wasps, she was not stung by a wasp. Furthermore, the absence of wheezing and hypotension negates epinephrine administration. Give supplemental oxygen (in a concentration sufficient to maintain an SpO2 of greater than 94%) and transport her to the hospital. Because it can take up to an hour for signs of a severe allergic reaction to manifest, the patient should not drive herself. Diphenhydramine (Benadryl), an antihistamine, is an appropriate drug based on her presentation; however, it is not typically carried on a BLS unit. Furthermore, the correct dose is 25 to 50 mg. A 42-year-old male presents with fever, a severe headache, and a stiff neck. He is conscious, but confused. His wife tells you that he does not have any medical problems and does not take any medications. You should be MOST suspicious for: • A:acute stroke. • B:influenza. • C:meningitis. • D:tuberculosis. ( ans: You selected C; This is correct! Reason:Meningitis is an inflammation of the protective coverings of the brain and spinal cord (meninges). Common signs and symptoms of meningitis include fever, headache, neck stiffness (nuchal rigidity), and vomiting. An altered mental status is common in severe cases. Meningococcal meningitis, caused by a bacterium, is the most contagious and potentially fatal type of meningitis. The patient's signs and symptoms are not consistent with acute stroke, tuberculosis (TB), or influenza (the flu). Although fever is common with both TB and the flu, neither causes neck stiffness. Acute stroke may be associated with a headache, especially a hemorrhagic stroke; however, stroke patients typically do not have a fever. A 42-year-old man was ejected from his car after it struck a bridge pillar at a high rate of speed. You find him in a prone position approximately 50 feet from his car. He is not moving and does not appear to be breathing. You should: • A:manually stabilize his head. • B:administer high-flow oxygen. • C:use the jaw-thrust maneuver. • D:assess his breathing effort. ans: You selected A; This is correct! Reason: When a trauma patient is found in a prone (face-down) position, especially if he or she is unresponsive, your first action should be to manually stabilize his or her head; this action is based on the assumption that he or she has a spinal injury. Next, log roll the patient to a supine position (while continuing to manually stabilize the head), open the airway with the jaw-thrust maneuver, clear the airway with suction if needed, and assess for breathing. It would be extremely difficult to adequately open the patient's airway while he or she is in a prone position. Depending on the patient's breathing effort, administer high-flow oxygen or ventilate using a bag-mask device. A 44-year-old male experienced burns to his anterior trunk and both arms. He is conscious and alert, but is in extreme pain. Assessment of the burns reveals reddening and blisters. This patient has ________________ burns that cover _____ of his total body surface area. • A:first-degree, 27% • B:full-thickness, 18% • C:second-degree, 45% • D:partial-thickness, 36% ans: The correct answer is D; Reason: Partial-thickness (second-degree) burns damage the epidermis and part of the dermis, and are characterized by blistering and severe pain. Areas of superficial (first-degree) burns, which cause reddening of the skin, commonly surround a partial-thickness burn. The anterior trunk (chest and abdomen) accounts for 18% of the total body surface area (TBSA) and each entire arm accounts for 9%. Therefore, this patient has partial-thickness burns that cover 36% of his TBSA. Full-thickness (third-degree) burns are characterized by charred or white, leathery skin. Because the entire dermis, including the nerves, is destroyed, full-thickness burns are usually painless. The surrounding areas of partial-thickness burns, however, are very painful. A 44-year-old woman was bitten on the ankle by an unidentified snake while working in her garden. She is conscious and alert, has stable vital signs, and denies shortness of breath. Her only complaint is a burning sensation at the wound site. Your assessment reveals two small puncture wounds, redness, and swelling. You should: • A:conclude that envenomation likely did not occur, provide reassurance, and allow a friend to take her to the hospital. • B:give supplemental oxygen, splint her leg to decrease movement, and keep her leg below the level of her heart. • C:elevate her leg, cover the wound with a dry sterile dressing, and apply an ice pack to reduce pain and swelling. • D:administer high-flow oxygen, apply a constricting band proximal to the bite, and use ice to prevent venom spread. ans: You selected B; This is correct! Reason:Given the fact that the snake was not identified, you should assume that it was poisonous. Furthermore, the presence of puncture wounds, burning, redness, and swelling are suggestive of envenomation. Therefore, you should provide emergency care and transport the patient to the hospital. Treatment for a snake bite involves keeping the patient calm, administering oxygen, splinting the affected extremity to decrease movement (helps slow the spread of venom), keeping the extremity below the level of the heart, and transporting the patient to the hospital. Do NOT apply ice to a snake bite; it may constrict the blood vessels and force venom further into the bloodstream. The use of a proximal constricting band is controversial; if one is used, it should be loose, not tight. En route to the hospital, monitor the patient's vital signs and mental status, and be alert for vomiting. A 46-year-old man presents with generalized weakness and shortness of breath after he was bitten on the leg by a rattlesnake. His blood pressure is 106/58 mm Hg and his pulse rate is 112 beats/min. In addition to supplemental oxygen, further treatment for this patient should include: • A:ice packs to the wound and splinting. • B:proximal arterial constricting band and splinting. • C:splinting and lowering of the affected part. • D:elevation of the affected part and ice packs. ans: The correct answer is C; Reason:Care for a patient with a bite from a pit viper (rattlesnake, copperhead, water moccasin) includes keeping the patient calm, administering supplemental oxygen, splinting the affected part, and keeping it below the level of the heart. Do NOT apply ice to a snakebite; this will cause local vasoconstriction and may force the venom deeper into the patient's circulation. If a constricting band is applied, it should be proximal to the bite and should be tight enough to slow venous return only, not cut off arterial supply. A 48-year-old male became acutely hypoxic, experienced a seizure, and is now postictal. The MOST effective way to prevent another seizure is to: • A:dim the lights in the back of the ambulance. • B:place him in the recovery position. • C:administer high-flow supplemental oxygen. • D:give him oral glucose if he can swallow. ans: You selected C; This is correct! Reason:You should administer high-flow oxygen to all patients who are actively seizing and to patients who experienced a seizure and are postictal. This is especially true if the seizure was caused by hypoxia. Increasing the oxygen content of the blood, which minimizes hypoxia, may prevent another seizure. The recovery position is appropriate for uninjured patients with a decreased level of consciousness and adequate breathing; it will help maintain the airway and facilitate drainage of secretions from the mouth, but will not prevent another seizure. Oral glucose may prevent another seizure if hypoglycemia was the cause of the seizure. You should dim the lights in the back of the ambulance to help prevent any seizure, not just those that are caused by hypoxia. A 50-year-old female complains of severe pain to the right lower quadrant of her abdomen. You should: • A:palpate the left upper quadrant of her abdomen first. • B:keep her supine with her legs fully extended. • C:quickly palpate that area first to assess for rigidity. • D:suspect that she has an acute problem with her liver. ans: You selected A; This is correct! Reason:When assessing a patient with abdominal pain, determine where the pain is most severe (in this case, the right lower quadrant) and then palpate the quadrant furthest from that area first (in this case, the left upper quadrant). If you palpate the painful area first, the patient is less likely to allow you to assess the remainder of his or her abdomen; it also causes the patient unnecessary pain. Pain to the right lower quadrant suggests a problem with the appendix (eg, appendicitis), not the liver. Patients with abdominal pain commonly prefer to lie on their side with their legs drawn into their abdomen; this position often provides pain relief by taking pressure off of the abdominal muscles. If the patient prefers this position, do not discourage it. A 50-year-old man presents with crushing chest pain of sudden onset. He is diaphoretic, apprehensive, and tachypneic. You should: • A:obtain baseline vital signs. • B:ask him if he takes nitroglycerin. • C:perform a complete physical exam. • D:apply supplemental oxygen. ans: You selected D; This is correct! Reason: All of the interventions and assessments listed in this question should be performed on a patient who presents with chest pain, pressure, or discomfort. However, supplemental oxygen is indicated for any patient with a potential cardiac problem and should be given as soon as possible; this is especially true when the patient has potential respiratory involvement as well (ie, dyspnea, tachypnea). Administer oxygen in a concentration sufficient to maintain an oxygen saturation of 94% or greater. Aspirin (up to 325 mg) should also be administered as soon as possible, unless the patient is allergic to it. After applying oxygen and administering aspirin, you should perform a physical exam and obtain baseline vital signs. You would inquire about any prescription medications the patient is taking (eg, NTG) during the SAMPLE history. A 50-year-old man, who fell approximately 20 feet and landed on a hard surface, is semiconscious. You should: • A:gently tilt the patient's head back to assess for breathing. • B:stabilize his head while performing the jaw-thrust maneuver. • C:check for a carotid pulse if the patient is breathing rapidly. • D:begin positive-pressure ventilations with a bag-mask device. ans: You selected B; This is correct! Reason: Because of the significant mechanism of injury (fall of greater than 15 feet), spinal injury should be assumed. The first step in managing this patient is to manually stabilize his head in a neutral position and open his airway with the jaw-thrust maneuver, both of which can be performed simultaneously. After the patient's airway is open, assess the rate and quality of his breathing and treat accordingly. The head tilt-chin lift maneuver should not be used on a patient with a possible spinal injury unless the jaw-thrust maneuver does not adequately open his or her airway. The patient in this scenario is semiconscious; therefore, he has a pulse (pulseless patients are unresponsive). If an uninjured patient is found to be unresponsive, you should quickly assess for breathing by visualizing the chest. If the patient is not breathing or only has agonal gasps, you should check for a carotid pulse. A 50-year-old woman who is conscious and alert complains of a severe migraine headache. When caring for her, you should generally avoid: • A:transporting her in a supine position. • B:shining a light into her pupils. • C:dimming the lights in the ambulance. • D:applying ice packs to her forehead. ans: You selected B; This is correct! Reason:Patients with migraine or cluster headaches typically have photophobia (light sensitivity). Any type of bright light, especially if shone directly into the eyes, will cause the patient with a headache unnecessary severe pain. Dimming the lights in the ambulance and making the patient as comfortable as possible are the treatments of choice for a patient with a headache. Some patients benefit from ice packs applied to the forehead; just be sure to wrap the ice pack with roller gauze. Oxygen also should be administered as needed. Typically, the patient will prefer to lie supine or on the side A 50-year-old woman with a history of epilepsy is actively seizing. Care for this patient should focus primarily on: • A:protecting her from injury and ensuring adequate ventilation. • B:administering high-flow oxygen and requesting an ALS ambulance. • C:frequently suctioning her airway and carefully restraining her. • D:placing a bite block in between her molars and giving her oxygen. ans: You selected A; This is correct! Reason:Seizure deaths are most frequently the result of hypoxia. When a person is actively seizing, he or she is not breathing adequately. Your primary focus when treating a seizure patient is to protect him or her from injury and to ensure adequate ventilation and oxygenation. Many seizing patients require assisted ventilation. Suction the oropharynx only if the patient has secretions in his or her mouth. Do NOT insert anything into the mouth of a seizing patient; doing so may cause an airway obstruction or damage the soft tissues of the mouth, resulting in bleeding. Do not attempt to restrain an actively seizing patient; doing so may result in musculoskeletal injuries. Request an ALS ambulance per your local protocols. A 52-year-old woman crashed her minivan into a tree. She is pinned at the legs by the steering wheel and is semiconscious. After gaining access to the patient, you should: • A:have the fire department disentangle the patient and quickly remove her from the car. • B:perform a primary assessment and provide any life-saving care before extrication. • C:rapidly assess her from head to toe, obtain vital signs, and apply a cervical collar. • D:immediately apply high-flow oxygen to the patient and allow extrication to begin. ans: You selected B; This is correct! Reason:Unless there is an immediate threat of fire, explosion, or other danger, you should perform a primary assessment and begin any live-saving care as soon as you have gained access to the patient. If you wait to do this until after the patient has been disentangled, it may be too late; the patient may already be dead. After you have assessed the patient and treated any immediate threats to life, allow extrication to commence. Once the patient has been freed from the vehicle, continue any life-saving care and perform a rapid head-to-toe assessment to identify and treat other life-threatening injuries. Another EMT can obtain vital signs as you rapidly assess the patient. Prepare for immediate transport after the rapid head-to-toe assessment has been performed and the appropriate spinal precautions have been taken. A 55-year-old woman with a history of diabetes is found unresponsive with rapid, shallow respirations. The patient's husband tells you that he does not know when his wife last took her insulin. Management of this patient should include: • A:subcutaneous injection of insulin and 100% oxygen. • B:oral glucose and oxygen via nonrebreathing mask. • C:assisted ventilations and oral glucose. • D:assisted ventilations and rapid transport. ans: You selected D; This is correct! Reason:Without knowing if and when the patient last took her insulin, it is difficult to determine if she is experiencing diabetic coma or insulin shock. Nonetheless, her rapid, shallow respirations—which are likely not producing adequate tidal volume—should be treated with ventilation assistance. Because she is unresponsive and obviously unable to swallow, oral glucose is contraindicated. Assess the patient's blood glucose level and pass this information along to the hospital; if possible, arrange for a paramedic intercept so she can receive intravenous dextrose. If the patient is experiencing diabetic coma, insulin is what she truly needs; however, insulin is rarely, if ever, administered in the prehospital setting—even by paramedics. After ensuring adequate oxygenation and ventilation, transport the patient without delay. A 56-year-old man has labored, shallow breathing at a rate of 28 breaths/min. He is responsive to pain only. You should: • A:insert a nasopharyngeal airway and begin assisting his ventilations. • B:place him on his side and administer oxygen via nonrebreathing mask. • C:suction his mouth for 15 seconds and insert an oropharyngeal airway. • D:ventilate him with a bag-mask device at a rate of 30 breaths/min. ans: You selected A; This is correct! Reason: This patient in this scenario is not breathing adequately. He is responsive to pain only, and his respirations are rapid, labored, and shallow. You should insert a nasopharyngeal airway, which is usually well-tolerated in patients who are semiconscious and have a gag reflex, and assist his ventilations with a bag-mask device. When assisting a patient's breathing, you should squeeze the bag-mask device to ensure that he or she receives 10 to 12 adequate breaths per minute. Do not hyperventilate the patient as this increases the risks of vomiting and aspiration. Hyperventilation also increases intrathoracic pressure, which may impair venous return to the heart (preload) and cause a decrease in cardiac output. Oxygen via nonrebreathing mask is appropriate for patients who are breathing adequately, but are suspected of being hypoxic. The recovery position (patient is placed on his or her side) is appropriate for unresponsive, uninjured patients with adequate breathing.