Annotated Answer Key
ACLS Provider Course
Precourse Written Examination
1. Which of the following actions is done first to restore oxygenation and ventilation to an
unresponsive, breathless, near-drowning victim?
a. force water from the victim's lungs by performing the Heimlich maneuver
b. force water from the victim’s lungs by starting chest compressions
c. stabilize cervical spine with c-collar and spine board, then start the ABCs
d. open the airway with a jaw-thrust maneuver, provide in-line cervical stabilization, start the
ABCs
The correct answer is d.
Answer d is the only answer that directs the rescuer to first open the airway and provide rescue
breathing. Rescue breathing will restore oxygen to the lungs, so it should begin as soon as possible.
Start rescue breathing as soon as the airway is open and rescuer safety is ensured. If the victim
remains unresponsive and a pulse does not return, start chest compressions and rescue breathing.
Unless known otherwise, always treat submersion victims as trauma victims and assume a high
probability of cervical spine injury. The possible presence of cervical spine injury requires rescuers to
open the airway with the jaw-thrust maneuver and to provide in-line cervical stabilization.
Answer a is incorrect because there is no conclusive evidence that water must be drained from the
victim’s breathing passages before rescue breathing is started. Most submersion victims aspirate only a
small amount of water, which is quickly absorbed by the lungs. Use the Heimlich maneuver for
submersion victims exactly as it is used for any victim suspected of having an obstructed airway. The
Heimlich maneuver may cause expulsion of gastric contents, aspiration, and a variety of other injuries.
Perform the Heimlich maneuver only when 2 attempts to ventilate after repositioning the airway have
failed and you suspect complete foreign-body airway obstruction.
Answer b is incorrect because rescuers should not start chest compressions first. First provide 2 rescue
breaths and then start chest compressions when you find that the victim has no signs of circulation. If
you start rescue breathing in the water, continue until the victim is moved to a firm surface that can
sustain chest compressions.
Answer c is incorrect because the sequence of actions is incorrect. Opening the airway and starting
rescue breathing are always the highest priorities. It is true that submersion victims should be treated
like trauma victims, and rescuers should always suspect cervical spine injury. But c-spine collars and
backboards are unnecessarily elaborate for the first few minutes of the rescue attempt. Use the
acceptable alternatives of the jaw-thrust maneuver plus in-line manual spine stabilization while opening
the airway and starting rescue breathing.
,2. Tracheal intubation has just been attempted for a victim of respiratory arrest. During hand
ventilation with a bag, you hear stomach gurgling over the epigastrium, and oxygen
saturation (per pulse oximetry) fails to rise. Which of the following is the most likely
explanation for these findings?
a. intubation of the hypopharyngeal area
b. intubation of the left main bronchus
c. intubation of the right main bronchus
d. bilateral tension pneumothorax
The correct answer is a.
Intubation of the hypopharyngeal area is common. (The hypopharyngeal area extends from the back of
the throat and tongue down to the first section of the epiglottis and trachea.) Often tracheal tubes found
on later review to be in this region represent not only failed initial intubations but also successful tracheal
intubations that later were dislodged. Intubation of the hypopharyngeal area would be the most likely
explanation for hearing gurgling over the epigastrium but no breath sounds during hand ventilation. In
addition, the oxygen saturation has failed to rise. The other 3 choices would more likely than not be
associated with some successful oxygenation. The guidelines suggest that the rescuer perform a
5-point auscultation during hand ventilation as follows: “As the bag is squeezed, listen over the
epigastrium and observe the chest wall for movement. If you hear stomach gurgling and see no chest
wall expansion, you have intubated the esophagus” (page I-101).
Answer b is incorrect because if you intubated the left main bronchus you would definitely hear unilateral
breath sounds and see unilateral chest expansion over the left chest. In addition, oxygen saturation
would rise.
Answer c is incorrect because intubation of the right main bronchus should produce breath sounds and
chest expansion in the right chest but not the left chest. Also, oxygen saturation would rise.
Answer d is incorrect because bag ventilations through a properly placed tracheal tube, even in a person
with bilateral tension pneumothoraces, would not produce stomach gurgling. Furthermore, the ventila-
tions would produce neither breath sounds nor chest expansion. Oxygen saturation would rise.
3. Which of the following patients needs immediate intubation?
a. an elderly woman with severe chest pain and shallow respirations at 30 breaths/min
b. a 55-year-old insulin-dependent diabetic with ST-segment elevation and runs of VT
c. an apneic patient whose chest does not rise with bag-mask ventilations
d. a subdued, alcohol-intoxicated college student with a reduced gag reflex
The correct answer is c.
In a person who is not breathing, bag-mask ventilation must produce adequate chest expansion and
bilateral breath sounds. To fail could be fatal. If bag-mask ventilation fails, tracheal intubation or some
alternative airway adjunct must accomplish the task of adequate ventilation. This answer matches
specific statements in Guidelines 2000 (page I-100): "Indications for tracheal intubation include
(1) inability of the rescuer to ventilate the unconscious patient with less invasive methods and (2) the
absence of protective reflexes (coma or cardiac arrest).” Nonetheless in skilled hands most apneic
patients will do quite well with bag-mask ventilation alone and do not need tracheal intubation.
Answer a is incorrect because the patient described does not have an indication for immediate
intubation. Shallow respirations at a rapid respiratory rate may do an adequate job of oxygenation and
ventilation. The severe chest pain may lead the unwary ACLS provider to think this patient has
"symptomatic" tachypnea and hypoxia and that something must be done about it.
, Answer b is incorrect because there is no stated reason for complete control of the airway with a
tracheal tube, although the patient seems seriously ill and definitely needs supplemental oxygen. The
presence of an acute coronary syndrome or premature ventricular contractions is not an indication for
control of the airway.
Answer d is incorrect because the patient still has a gag reflex, although it is reduced, and because she
is “subdued,” not unconscious or comatose. This patient needs to be closely watched under pro-
fessional observation.
4. When treating a trauma victim who is in shock and deeply comatose, which of the following
is the airway of choice?
a. a tracheal tube
b. the patient's own airway
c. a nasopharyngeal airway
d. an oropharyngeal airway
The correct answer is a.
The trauma victim described in this question meets the specific criteria for tracheal intubation listed in
ECC Guidelines 2000 (page I-100): "(1) inability of the rescuer to ventilate the unconscious patient with
less invasive methods and (2) absence of protective reflexes (coma or cardiac arrest).” This patient is
deeply comatose, which indicates possible brain injury that would affect central respiratory drives and
protective gag reflexes. The patient is also at risk for compromised oxygen delivery because of blood
loss, hypoventilation, and cardiothoracic injury. Indications for intubation of the trauma patient (page
I-245) include 2 that are present in this patient: severe head injury and inability to protect the upper
airway (eg, loss of gag reflex, depressed level of consciousness, coma).
Answer b is incorrect because a deeply comatose patient at risk for other injuries requires a patent
artificial airway through which oxygenation and ventilation can be more reliably supplied than they can
through the patient's airway.
Answers c and d are incorrect because these devices cannot support the level of oxygenation and
ventilation that are required in the injured and deeply comatose patient. Nonetheless these devices are
useful because they can provide an open, clear airway.
5. Which of these lists of CPR performance and AED operation is correct and in the right
sequence?
a. send someone to call 911, attach AED electrode pads, open the airway, turn on the AED,
provide 2 breaths, check for a pulse
b. wait for the AED and barrier device to arrive, open the airway, provide 2 breaths, check for a
pulse, if no pulse attach AED electrode pads, follow AED prompts
c. send someone to call 911, open the airway, provide 2 breaths, check for a pulse, if no
pulse attach the AED, follow AED prompts
d. provide 2 breaths, check for a pulse, if no pulse perform chest compressions for 1 minute, call
for the AED, when the AED arrives attach electrode pads
The correct answer is c.
ACLS Provider Course
Precourse Written Examination
1. Which of the following actions is done first to restore oxygenation and ventilation to an
unresponsive, breathless, near-drowning victim?
a. force water from the victim's lungs by performing the Heimlich maneuver
b. force water from the victim’s lungs by starting chest compressions
c. stabilize cervical spine with c-collar and spine board, then start the ABCs
d. open the airway with a jaw-thrust maneuver, provide in-line cervical stabilization, start the
ABCs
The correct answer is d.
Answer d is the only answer that directs the rescuer to first open the airway and provide rescue
breathing. Rescue breathing will restore oxygen to the lungs, so it should begin as soon as possible.
Start rescue breathing as soon as the airway is open and rescuer safety is ensured. If the victim
remains unresponsive and a pulse does not return, start chest compressions and rescue breathing.
Unless known otherwise, always treat submersion victims as trauma victims and assume a high
probability of cervical spine injury. The possible presence of cervical spine injury requires rescuers to
open the airway with the jaw-thrust maneuver and to provide in-line cervical stabilization.
Answer a is incorrect because there is no conclusive evidence that water must be drained from the
victim’s breathing passages before rescue breathing is started. Most submersion victims aspirate only a
small amount of water, which is quickly absorbed by the lungs. Use the Heimlich maneuver for
submersion victims exactly as it is used for any victim suspected of having an obstructed airway. The
Heimlich maneuver may cause expulsion of gastric contents, aspiration, and a variety of other injuries.
Perform the Heimlich maneuver only when 2 attempts to ventilate after repositioning the airway have
failed and you suspect complete foreign-body airway obstruction.
Answer b is incorrect because rescuers should not start chest compressions first. First provide 2 rescue
breaths and then start chest compressions when you find that the victim has no signs of circulation. If
you start rescue breathing in the water, continue until the victim is moved to a firm surface that can
sustain chest compressions.
Answer c is incorrect because the sequence of actions is incorrect. Opening the airway and starting
rescue breathing are always the highest priorities. It is true that submersion victims should be treated
like trauma victims, and rescuers should always suspect cervical spine injury. But c-spine collars and
backboards are unnecessarily elaborate for the first few minutes of the rescue attempt. Use the
acceptable alternatives of the jaw-thrust maneuver plus in-line manual spine stabilization while opening
the airway and starting rescue breathing.
,2. Tracheal intubation has just been attempted for a victim of respiratory arrest. During hand
ventilation with a bag, you hear stomach gurgling over the epigastrium, and oxygen
saturation (per pulse oximetry) fails to rise. Which of the following is the most likely
explanation for these findings?
a. intubation of the hypopharyngeal area
b. intubation of the left main bronchus
c. intubation of the right main bronchus
d. bilateral tension pneumothorax
The correct answer is a.
Intubation of the hypopharyngeal area is common. (The hypopharyngeal area extends from the back of
the throat and tongue down to the first section of the epiglottis and trachea.) Often tracheal tubes found
on later review to be in this region represent not only failed initial intubations but also successful tracheal
intubations that later were dislodged. Intubation of the hypopharyngeal area would be the most likely
explanation for hearing gurgling over the epigastrium but no breath sounds during hand ventilation. In
addition, the oxygen saturation has failed to rise. The other 3 choices would more likely than not be
associated with some successful oxygenation. The guidelines suggest that the rescuer perform a
5-point auscultation during hand ventilation as follows: “As the bag is squeezed, listen over the
epigastrium and observe the chest wall for movement. If you hear stomach gurgling and see no chest
wall expansion, you have intubated the esophagus” (page I-101).
Answer b is incorrect because if you intubated the left main bronchus you would definitely hear unilateral
breath sounds and see unilateral chest expansion over the left chest. In addition, oxygen saturation
would rise.
Answer c is incorrect because intubation of the right main bronchus should produce breath sounds and
chest expansion in the right chest but not the left chest. Also, oxygen saturation would rise.
Answer d is incorrect because bag ventilations through a properly placed tracheal tube, even in a person
with bilateral tension pneumothoraces, would not produce stomach gurgling. Furthermore, the ventila-
tions would produce neither breath sounds nor chest expansion. Oxygen saturation would rise.
3. Which of the following patients needs immediate intubation?
a. an elderly woman with severe chest pain and shallow respirations at 30 breaths/min
b. a 55-year-old insulin-dependent diabetic with ST-segment elevation and runs of VT
c. an apneic patient whose chest does not rise with bag-mask ventilations
d. a subdued, alcohol-intoxicated college student with a reduced gag reflex
The correct answer is c.
In a person who is not breathing, bag-mask ventilation must produce adequate chest expansion and
bilateral breath sounds. To fail could be fatal. If bag-mask ventilation fails, tracheal intubation or some
alternative airway adjunct must accomplish the task of adequate ventilation. This answer matches
specific statements in Guidelines 2000 (page I-100): "Indications for tracheal intubation include
(1) inability of the rescuer to ventilate the unconscious patient with less invasive methods and (2) the
absence of protective reflexes (coma or cardiac arrest).” Nonetheless in skilled hands most apneic
patients will do quite well with bag-mask ventilation alone and do not need tracheal intubation.
Answer a is incorrect because the patient described does not have an indication for immediate
intubation. Shallow respirations at a rapid respiratory rate may do an adequate job of oxygenation and
ventilation. The severe chest pain may lead the unwary ACLS provider to think this patient has
"symptomatic" tachypnea and hypoxia and that something must be done about it.
, Answer b is incorrect because there is no stated reason for complete control of the airway with a
tracheal tube, although the patient seems seriously ill and definitely needs supplemental oxygen. The
presence of an acute coronary syndrome or premature ventricular contractions is not an indication for
control of the airway.
Answer d is incorrect because the patient still has a gag reflex, although it is reduced, and because she
is “subdued,” not unconscious or comatose. This patient needs to be closely watched under pro-
fessional observation.
4. When treating a trauma victim who is in shock and deeply comatose, which of the following
is the airway of choice?
a. a tracheal tube
b. the patient's own airway
c. a nasopharyngeal airway
d. an oropharyngeal airway
The correct answer is a.
The trauma victim described in this question meets the specific criteria for tracheal intubation listed in
ECC Guidelines 2000 (page I-100): "(1) inability of the rescuer to ventilate the unconscious patient with
less invasive methods and (2) absence of protective reflexes (coma or cardiac arrest).” This patient is
deeply comatose, which indicates possible brain injury that would affect central respiratory drives and
protective gag reflexes. The patient is also at risk for compromised oxygen delivery because of blood
loss, hypoventilation, and cardiothoracic injury. Indications for intubation of the trauma patient (page
I-245) include 2 that are present in this patient: severe head injury and inability to protect the upper
airway (eg, loss of gag reflex, depressed level of consciousness, coma).
Answer b is incorrect because a deeply comatose patient at risk for other injuries requires a patent
artificial airway through which oxygenation and ventilation can be more reliably supplied than they can
through the patient's airway.
Answers c and d are incorrect because these devices cannot support the level of oxygenation and
ventilation that are required in the injured and deeply comatose patient. Nonetheless these devices are
useful because they can provide an open, clear airway.
5. Which of these lists of CPR performance and AED operation is correct and in the right
sequence?
a. send someone to call 911, attach AED electrode pads, open the airway, turn on the AED,
provide 2 breaths, check for a pulse
b. wait for the AED and barrier device to arrive, open the airway, provide 2 breaths, check for a
pulse, if no pulse attach AED electrode pads, follow AED prompts
c. send someone to call 911, open the airway, provide 2 breaths, check for a pulse, if no
pulse attach the AED, follow AED prompts
d. provide 2 breaths, check for a pulse, if no pulse perform chest compressions for 1 minute, call
for the AED, when the AED arrives attach electrode pads
The correct answer is c.
