NREMT EMT — All Questions

What is the normal resting respiratory rate for a healthy adult?

• a.20 to 30 breaths per minute
• b.6 to 10 breaths per minute
• c.12 to 20 breaths per minute✓
• d.30 to 40 breaths per minute

A healthy adult at rest breathes about 12 to 20 times per minute. Rates persistently above or below this range suggest respiratory distress and warrant closer assessment and possible ventilatory support.

Which airway adjunct is contraindicated in a patient with an intact gag reflex?

• a.Bag-valve mask
• b.Oropharyngeal airway✓
• c.Nasal cannula
• d.Nasopharyngeal airway

An oropharyngeal (oral) airway stimulates the gag reflex and can cause vomiting or laryngospasm if the reflex is intact. It should only be used in patients who are unresponsive with no gag reflex.

A nonrebreather mask should generally be run at what oxygen flow rate?

• a.10 to 15 L/min✓
• b.1 to 2 L/min
• c.2 to 4 L/min
• d.4 to 6 L/min

A nonrebreather mask requires 10 to 15 L/min to keep the reservoir bag inflated and deliver a high oxygen concentration (roughly 80 to 90 percent). Lower flow rates fail to keep the reservoir filled between breaths.

A nasal cannula can deliver oxygen concentrations in approximately what range?

• a.50 to 60 percent
• b.24 to 44 percent✓
• c.60 to 70 percent
• d.80 to 90 percent

At 1 to 6 L/min a nasal cannula delivers roughly 24 to 44 percent oxygen. It is best for patients needing low-concentration oxygen who cannot tolerate a mask.

What is the correct first step when a responsive adult is choking and cannot speak, cough, or breathe?

• a.Deliver abdominal thrusts (Heimlich maneuver)✓
• b.Begin chest compressions immediately
• c.Lay the patient supine and start rescue breaths
• d.Perform a blind finger sweep

A responsive adult with a complete airway obstruction should receive abdominal thrusts until the object is expelled or the patient becomes unresponsive. Blind finger sweeps are avoided because they can push the object deeper.

How should you size an oropharyngeal airway before insertion?

• a.From the corner of the mouth to the earlobe (or angle of the jaw)✓
• b.By matching its width to the patient's little finger
• c.From the tip of the nose to the earlobe, as for a nasal airway
• d.By choosing the largest size that will pass the front teeth

An oral airway is measured from the corner of the mouth to the earlobe or angle of the mandible. A properly sized airway holds the tongue forward without obstructing the airway. Measuring from the nostril to the earlobe is how a nasopharyngeal airway is sized, and finger width is a rule of thumb sometimes taught for a nasal airway's diameter, not for the length of an oral one. Simply taking the largest device that fits past the teeth risks an airway long enough to reach the larynx and provoke vomiting.

Which finding best indicates adequate ventilation while using a bag-valve mask?

• a.The bag empties easily each time with little resistance
• b.Visible, gentle rise and fall of the chest with each breath✓
• c.A tight mask seal with no audible air leak around it
• d.A gradual swelling of the upper abdomen as air is given

Effective bag-valve-mask ventilation is confirmed by watching the chest rise gently with each squeeze. A bag that empties with little resistance often means air is escaping around the mask instead of reaching the lungs, and a good seal by itself says nothing about the volume actually delivered. A swelling upper abdomen is gastric distention, a sign that air is entering the stomach because ventilation is too fast or too forceful.

What maneuver is preferred to open the airway of an unresponsive patient with suspected cervical spine injury?

• a.Sniffing position with neck extension
• b.Recovery position roll
• c.Head-tilt/chin-lift
• d.Jaw-thrust maneuver✓

The jaw-thrust maneuver opens the airway while keeping the head and neck in a neutral, in-line position. This minimizes spinal movement compared with the head-tilt/chin-lift.

A patient breathing 6 times per minute with shallow effort is best managed by an EMT with:

• a.Positive-pressure ventilation with a bag-valve mask and supplemental oxygen✓
• b.Coaching the patient to breathe faster and more deeply on their own
• c.A nasal cannula at 2 L/min while watching the respiratory rate
• d.A nonrebreather mask alone at high flow, with no assisted breaths

A rate of 6 with shallow depth produces an inadequate minute volume, so the patient needs assisted positive-pressure ventilation rather than passive oxygen. Coaching cannot fix breathing that is already failing, and a nasal cannula or a nonrebreather enriches only the air the patient can move on their own; neither increases tidal volume.

Stridor, a high-pitched sound heard on inspiration, most commonly indicates:

• a.Fluid collecting in the lower airways
• b.Upper airway obstruction or narrowing✓
• c.A normal sound heard over the trachea
• d.A pneumothorax on the affected side

Stridor is produced by turbulent airflow through a narrowed upper airway, such as from swelling or a foreign body, and signals a potentially serious airway threat. Fluid in the lower airways produces crackles or wheezing instead, and a pneumothorax typically causes diminished sounds on one side rather than a high-pitched inspiratory noise.

Which patient is the best candidate for a nasopharyngeal airway?

• a.A semiconscious patient with an intact gag reflex who needs airway support✓
• b.A patient with suspected skull base fracture and clear fluid from the nose
• c.A patient in cardiac arrest with severe facial trauma
• d.A fully alert patient with no distress

A nasopharyngeal airway is tolerated by patients with an intact gag reflex, making it useful for semiconscious patients. It is avoided with suspected basilar skull fracture because of the risk of intracranial misplacement.

What is the appropriate ventilation rate for an apneic adult with a pulse (rescue breathing)?

• a.1 breath every 6 seconds (about 10 per minute)✓
• b.1 breath every 2 seconds (about 30 a minute)
• c.1 breath every 30 seconds (2 per minute)
• d.1 breath every 15 seconds (4 per minute)

For an adult in respiratory arrest with a pulse, deliver one breath about every 6 seconds, roughly 10 breaths per minute. Each breath should be given over about one second with visible chest rise. A breath every 2 to 3 seconds is the faster rate used for an infant or child with a pulse, and delivering it to an adult risks hyperventilation, gastric inflation and reduced venous return. Breaths spaced 15 or 30 seconds apart leave the apneic patient without effective ventilation between them.

Cyanosis (bluish skin, lips, or nail beds) is a sign of:

• a.Inadequate oxygenation✓
• b.Excellent perfusion
• c.Normal skin in cold weather with no clinical concern
• d.Hyperventilation only

Cyanosis reflects poor oxygenation of the blood and is a late, serious sign of hypoxia. It requires immediate airway management and oxygen therapy.

When suctioning an adult's airway, you should apply suction for no longer than:

• a.30 seconds at a time
• b.2 minutes at a time
• c.60 seconds at a time
• d.15 seconds at a time✓

Suction an adult for no more than 15 seconds per attempt because suctioning also removes oxygen and can cause hypoxia. Reoxygenate the patient between attempts.

Agonal respirations in an unresponsive patient should be treated as:

• a.Inadequate breathing requiring ventilatory support✓
• b.A sign that spontaneous breathing is returning
• c.Slow but adequate breathing that needs no support
• d.Obstruction that an oral airway alone will fix

Agonal (gasping) respirations are ineffective and do not provide adequate ventilation, often occurring around cardiac arrest. The patient needs assisted ventilation and, if pulseless, CPR. Gasping is a sign of a dying brainstem rather than of recovery, and it moves too little air to oxygenate no matter how it is counted. An oral airway only holds the tongue clear; it adds no volume, so it cannot correct agonal breathing on its own.

A patient with a history of COPD is in severe respiratory distress with low oxygen saturation. The EMT should:

• a.Provide high-concentration oxygen and support ventilation as needed✓
• b.Give only room air
• c.Give a nasal cannula at 1 L/min regardless of distress
• d.Withhold oxygen entirely to avoid suppressing respiratory drive

Never withhold needed oxygen from a hypoxic patient because of COPD concerns. Treat hypoxia with high-concentration oxygen and assist ventilations if breathing is inadequate.

Which sound suggests fluid in the lower airways, such as in pulmonary edema?

• a.Crackles (rales)✓
• b.Silence with good chest rise
• c.Snoring
• d.Stridor

Crackles, or rales, are produced by air moving through fluid in the alveoli and small airways. They are commonly heard in pulmonary edema and some pneumonias.

The primary purpose of the recovery position for an unresponsive, breathing patient without trauma is to:

• a.Raise the oxygen saturation without giving oxygen
• b.Slow the heart rate and lower the blood pressure
• c.Help keep the airway open and allow drainage of secretions✓
• d.Prevent heat loss from the patient during transport

The lateral recovery position lets the tongue fall forward and lets secretions or vomit drain from the mouth, protecting the airway. It does not change how much oxygen the blood carries, does not slow the heart, and does nothing for body temperature. It is used for unresponsive patients who are breathing adequately with no suspected spinal injury.

Accessory muscle use, nasal flaring, and tripod positioning are signs of:

• a.Anxiety with no true respiratory problem
• b.Adequate breathing requiring no intervention
• c.Increased work of breathing / respiratory distress✓
• d.Improving effort as distress resolves

These findings show the patient is working hard to breathe and is in respiratory distress. Early recognition allows oxygen therapy and ventilatory support before respiratory failure. Blaming the picture on anxiety, or calling breathing adequate because air is still moving, delays that support. These signs also mark worsening rather than improvement: as the patient tires, the effort falls away and the rate slows, which is a late and dangerous change.

What oxygen flow rate is typically used with a bag-valve mask to maximize delivered oxygen concentration?

• a.15 L/min✓
• b.4 L/min
• c.2 L/min
• d.6 L/min

A BVM connected to an oxygen reservoir at 15 L/min can deliver nearly 100 percent oxygen. Adequate flow keeps the reservoir bag full so each ventilation delivers high-concentration oxygen.

Why does a small child's airway obstruct more easily than an adult's?

• a.The child's cricoid cartilage is absent until adolescence, leaving the trachea unsupported
• b.The child's epiglottis is rigid and cannot fold over the glottic opening during swallowing
• c.Breathing depends mainly on the child's intercostal muscles, which tire quickly
• d.The tongue is proportionally larger and the trachea is narrower and more easily compressed✓

A child's tongue takes up proportionally more of the oral cavity, and the trachea is narrower and made of softer cartilage, so a small amount of swelling, a little secretion, or a neck flexed or hyperextended by careless positioning will close it. The epiglottis of a young child is floppier and more omega-shaped than an adult's, not rigid. Infants and small children are largely diaphragmatic breathers — the intercostal muscles are poorly developed, which is why retractions appear so early, but they are not what the child depends on. The cricoid ring is present from birth and is in fact the narrowest point of the airway in a young child, rather than being absent.

An adult is breathing 32 times per minute with very shallow chest movement. Why is this pattern inadequate even though the rate is high?

• a.A fast rate always means the patient is hyperventilating and blowing off carbon dioxide
• b.Much of each shallow breath only fills dead space and never reaches the alveoli✓
• c.Shallow breathing prevents the alveoli from taking up oxygen even when they are filled
• d.Rapid breathing leaves too little time for oxygen to cross the alveolar membrane

Minute volume is tidal volume multiplied by rate, and roughly the first 150 mL of every adult breath only fills the conducting airways — mouth, trachea and bronchi — which take no part in gas exchange. When each breath is barely larger than that anatomic dead space, almost nothing reaches the alveoli no matter how fast the patient breathes, so ventilation is assisted with a bag-valve mask. Diffusion across the alveolar membrane is very fast and is not the limiting step at a rate of 32; the limiting step is that the gas never arrives there. Alveoli that genuinely are filled do take up oxygen normally, and a fast rate on its own does not establish that a patient is hyperventilating.

Two EMTs are ventilating an apneic adult with a bag-valve mask. Why is the two-person technique generally preferred over one person doing both tasks?

• a.One rescuer can hold the mask seal with both hands while the other squeezes the bag✓
• b.It allows a faster ventilation rate to be delivered, which raises the oxygen level sooner
• c.It removes the need to insert an oropharyngeal airway, because the seal alone opens it
• d.One rescuer can apply cricoid pressure, which reliably prevents gastric inflation

A leaking mask is the most common reason bag-valve ventilation fails, and a two-handed seal with a second rescuer squeezing the bag delivers far more of each breath to the patient. An airway adjunct is still needed, since a mask seal does nothing to lift the tongue off the posterior pharynx. Ventilating faster is harmful rather than helpful. Cricoid pressure is what a well-prepared candidate has to weigh against the seal, and it is the weaker choice: routine cricoid pressure is no longer recommended during bag-valve-mask ventilation, it does not reliably prevent air from entering the stomach, and it can obstruct the airway — so freeing a hand for it is not the reason two rescuers are better.

During bag-valve-mask ventilation of an unresponsive adult, the abdomen is becoming visibly distended. What is the most likely cause and the correct correction?

• a.The distention is expected during positive-pressure ventilation and is relieved by pressing on the upper abdomen
• b.The mask seal is leaking, so each breath is squeezed harder to make up the lost volume
• c.The oropharyngeal airway is too long, so it is removed and ventilation continues without it
• d.Ventilations are too fast or too forceful, so they are slowed and each breath made smaller✓

Gastric distention during bag-valve ventilation usually means air is being pushed in faster or harder than the airway will accept, so the pressure rises above what the esophagus will hold shut. The correction is to deliver each breath more slowly, over about one second, and only until the chest visibly rises, while confirming the head position and the airway adjunct. Distention pushes the diaphragm up, makes ventilation harder, and invites regurgitation. Squeezing harder to compensate for a leak is the tempting wrong move — it raises airway pressure and worsens the distention, when the fix is to improve the seal. Pressing on the abdomen to expel the air is not done, because it forces stomach contents into the pharynx. An adjunct that is too long causes gagging or laryngospasm rather than gastric filling.

An unresponsive adult who has a permanent tracheostomy stoma following a total laryngectomy is not breathing. A tracheostomy tube is in place. How should the EMT ventilate this patient?

• a.Insert an oropharyngeal airway and ventilate through the mouth, since the upper airway still connects to the trachea
• b.Ventilate through the mouth and nose while an assistant seals the stoma with a gloved hand
• c.Remove the tracheostomy tube first, because the tube blocks air entering through the stoma
• d.Ventilate through the stoma, using the tracheostomy tube or a mask sealed over it✓

After a total laryngectomy the stoma is the only route to the lungs — the mouth and nose no longer connect to the trachea — so the bag is attached directly to the tracheostomy tube, or an infant or child mask is sealed over the stoma if no tube is present. Ventilating through the mouth and nose while an assistant occludes the stoma is the technique for a partial laryngectomy, where an upper connection still exists; it is a defensible-looking choice and the reason the history matters. An oropharyngeal airway achieves nothing in a patient with no connection between mouth and trachea. The tracheostomy tube is the airway, so it is suctioned rather than removed, and it is removed only if it is obstructed and local protocol permits an EMT to do so.

An EMT is about to suction thick secretions from an unresponsive adult's mouth with a rigid catheter. How is the insertion depth determined?

• a.Insert until resistance is felt so the catheter reaches the secretions at the back of the throat
• b.Insert no further than you can see, measuring from the corner of the mouth to the earlobe✓
• c.Insert until the tip touches the back of the throat, then withdraw slightly before suctioning
• d.Insert to a depth equal to the distance from the tip of the nose to the earlobe, then suction

A rigid (Yankauer) catheter is measured from the corner of the mouth to the earlobe and inserted only as far as the EMT can actually see, because deeper insertion stimulates the vagus nerve and can slow the heart, and can also provoke gagging and vomiting in a patient who cannot protect the airway. Advancing until resistance is felt, or deliberately touching the back of the throat, is how the soft tissue of the pharynx gets torn. Nose-to-earlobe is the measurement for a nasopharyngeal airway, not for a suction catheter. Suction is applied while withdrawing, not on the way in, and most EMS protocols cap a single adult suctioning attempt at roughly 10 to 15 seconds, with the exact limit set locally.

An EMT is checking a portable oxygen cylinder before a shift. Which practice is correct?

• a.Lubricate the regulator threads with a light oil each month so the fitting seats without cross-threading
• b.Keep oil and grease away from the valve and regulator, and change the cylinder before it empties✓
• c.Use the cylinder down to zero, since the regulator will stop the flow when it is empty
• d.Open the cylinder valve with the outlet pointed toward you so the gauge can be watched as it pressurizes

Two rules govern oxygen cylinders. No petroleum product — oil, grease or a petroleum-based lubricant — ever touches an oxygen valve, regulator or fitting, because oil in contact with high-pressure oxygen can ignite, so lubricating the threads is exactly the wrong maintenance habit. And the cylinder is swapped while a usable reserve pressure still remains, since running it to zero leaves nothing for the patient at the worst possible moment and can allow contaminants to be drawn into an empty cylinder. The valve is always cracked open with the outlet directed away from yourself, the patient and any bystanders, because a damaged seat or regulator can release gas violently.

A conscious adult in severe respiratory distress from pulmonary edema is alert and able to follow commands. Where local protocol permits an EMT to apply CPAP, which finding would make CPAP inappropriate?

• a.A respiratory rate of 32 with audible crackles heard throughout both lung fields
• b.A blood pressure of 168/96 and a heart rate of 120 with obvious anxiety
• c.A history of congestive heart failure with three pillows used to sleep at night
• d.A deteriorating level of consciousness with an inability to protect the airway✓

CPAP requires a patient awake enough to follow instructions, keep the mask on, and protect their own airway, so a falling level of consciousness is a contraindication and that patient is ventilated with a bag-valve mask instead. The vital signs are the option worth pausing over: hypotension is the other common contraindication, because the raised pressure inside the chest reduces venous return — but 168/96 is high, not low, and a hypertensive, anxious, tachycardic patient is the typical presentation of the flash pulmonary edema CPAP is meant for. A fast rate with crackles and a pillow-orthopnea history likewise describe the intended patient rather than a reason to withhold it. Whether an EMT may apply CPAP at all is set by state scope of practice and local protocol.

A firefighter pulled from a structure fire has a pulse oximeter reading of 99 percent but is confused and has a headache. How should the EMT interpret the reading?

• a.The reading is falsely high because the patient is breathing rapidly after the exertion
• b.The reading is accurate, so the confusion must have a cause unrelated to any inhaled gas
• c.The reading is unreliable, because the device cannot distinguish carbon monoxide from oxygen✓
• d.The reading rules out carbon monoxide, because carboxyhemoglobin would have driven the number down

A standard pulse oximeter reads carboxyhemoglobin as though it were oxygenated hemoglobin, so a poisoned patient can show a reassuring or even a high number while the blood is carrying very little usable oxygen. That is also why the reading cannot be used to rule carbon monoxide out — the number does not fall, which is the trap in a fire scene with a confused, headachy patient. Treatment is driven by the history and the symptoms: remove the patient from the source and give high-flow oxygen by nonrebreather; a CO-oximeter is what actually measures carboxyhemoglobin. Poor perfusion, cold fingers, motion and nail polish are other causes of unreliable readings, but exertion and a fast respiratory rate do not create a falsely high saturation.

An adult who was choking becomes unresponsive and slides to the floor. What should the EMT do next?

• a.Continue abdominal thrusts with the patient supine until the object is expelled
• b.Perform a blind finger sweep of the mouth to remove the object before anything else
• c.Begin chest compressions, and look in the mouth each time before giving a breath✓
• d.Deliver five back blows between the shoulder blades with the patient rolled onto one side

Once a choking adult becomes unresponsive the sequence changes to CPR beginning with chest compressions, and the mouth is inspected each time the airway is opened for a breath so that a visible object can be removed with the fingers. The compressions themselves generate the intrathoracic pressure that may dislodge the obstruction. A blind finger sweep — reaching in when nothing can be seen — can push the object deeper and is not performed. Abdominal thrusts belong to the still-responsive patient, and while some conscious-choking protocols include back blows, neither manoeuvre is used once the adult is unresponsive and on the ground.

A 6-month-old infant is choking on a piece of food, is conscious, and cannot cry or cough. What is the correct technique?

• a.Abdominal thrusts delivered with two fingers just above the navel, repeated until it clears
• b.Chest compressions at the same rate used for CPR while holding the infant face up on a forearm
• c.A finger sweep of the mouth followed by two rescue breaths, repeated until the chest rises
• d.Five back blows followed by five chest thrusts, repeated while the infant stays conscious✓

A conscious choking infant receives repeated cycles of five back blows and five chest thrusts. Abdominal thrusts are not used at this age because the liver sits low and largely unprotected below the rib margin and is easily injured. A blind finger sweep can drive the object further in and is not performed at any age. Chest compressions are the technique once the infant becomes unresponsive, not while the infant is still awake, and rescue breaths are not given to a conscious infant.

Why is ventilating an apneic patient too rapidly harmful rather than simply unnecessary?

• a.It raises pressure in the chest, which reduces blood returning to the heart✓
• b.It exhausts the oxygen cylinder faster than the patient's transport time will allow
• c.It washes out so much carbon dioxide that the patient stops breathing spontaneously
• d.It produces a respiratory alkalosis, which is the main danger of ventilating too quickly

Each positive-pressure breath raises the pressure inside the chest, and delivering breaths too often leaves no time for that pressure to fall between them, so venous return falls and cardiac output with it — a particular danger during cardiac arrest, where perfusion depends on compressions filling a heart that must first be able to fill. Excess ventilation also forces air into the stomach. Respiratory alkalosis attracts candidates who have studied blood gases, and blowing off carbon dioxide does shift the blood that way, but in a rescuer-ventilated apneic patient the hemodynamic collapse is the harm that kills first. An apneic patient has no spontaneous drive left to suppress, and cylinder duration is a logistical concern rather than the physiological harm.

A patient is receiving oxygen by simple face mask. Why must the flow rate be kept above a minimum level with this device?

• a.To flush exhaled carbon dioxide out of the mask so it is not rebreathed✓
• b.To keep the reservoir bag on the mask from collapsing during each inhalation
• c.To prevent the oxygen from drying the mucous membranes of the nose and mouth
• d.To hold the one-way exhalation valves on the sides of the mask open during exhalation

A simple face mask holds a volume of exhaled gas against the face, so the flow has to be high enough to wash that carbon dioxide out between breaths; too low a flow means the patient rebreathes it, which is why a simple mask is generally run at no less than about 6 L/min. A simple mask has no reservoir bag — that is what distinguishes it from a nonrebreather — and it has no one-way valves either; its side ports are open holes. Drying of the mucous membranes is a real complaint on prolonged oxygen therapy, but it is managed with humidification rather than by raising the flow.

A two-year-old with respiratory distress becomes frightened and fights the oxygen mask, crying and pushing it away. What is the best approach?

• a.Hold the mask firmly against the child's face until the crying settles and it is accepted
• b.Use blow-by oxygen held near the face, often with a parent holding the tubing✓
• c.Withhold oxygen until the child settles, since agitation raises oxygen demand more than the mask helps
• d.Switch to a nasal cannula and tape the prongs in place so the child cannot pull them out

Fighting a mask increases a child's work of breathing and oxygen demand, so oxygen is delivered blow-by — tubing, a mask, or oxygen through a cup held a short distance from the face, ideally by the parent, whose presence children tolerate far better than a stranger's hands. The observation that agitation raises oxygen demand is correct, which makes withholding oxygen the tempting wrong answer; the conclusion does not follow, because blow-by keeps the oxygen flowing without the struggle rather than forcing a choice between the two. Forcing the mask is counterproductive, and taping a cannula in place provokes the same fight.

Which finding best distinguishes adequate breathing from inadequate breathing in an adult?

• a.Equal chest rise with an adequate depth, a normal rate, and speech in full sentences✓
• b.The absence of any audible wheezing or crackles when the chest is auscultated
• c.A respiratory rate that falls anywhere inside the normal published range for adults
• d.A pulse oximetry reading above ninety-four percent while the patient is on room air

Adequacy is judged on rate, depth and effort together — even chest rise, enough tidal volume to move air past the dead space, and the ability to speak a full sentence without pausing for breath. A rate inside the normal range is the closest competing answer and the reason shallow breathing is so often missed: it says nothing about depth, and a patient at 16 breaths a minute can be ventilating inadequately. Clear lung sounds and a reassuring oximetry number can both accompany failing ventilation, the oximetry reading most dangerously in carbon monoxide poisoning.

An EMT is inserting a nasopharyngeal airway in an unresponsive adult. Which insertion technique is correct?

• a.Insert it dry, because lubricant lets the airway slide too far and enter the esophagus
• b.Insert it only in a patient who has no gag reflex
• c.Aim the tip upward toward the bridge of the nose, then turn it downward once the resistance eases
• d.Lubricate it and advance it straight back along the floor of the nostril✓

A nasal airway is coated with a water-soluble lubricant and advanced straight back along the floor of the nasal cavity, perpendicular to the plane of the face, with the bevel turned toward the nasal septum; it is sized from the nostril to the earlobe and should fit the nostril without blanching the skin. Aiming upward toward the bridge of the nose drives the tip into the turbinates and causes bleeding that then has to be suctioned. Inserting it dry tears the mucosa. Tolerance in a patient who still has a gag reflex is the main advantage of a nasal airway over an oral one, not a restriction on its use.

An unresponsive head-injured patient has snoring respirations. Which finding would lead most EMS protocols to avoid a nasopharyngeal airway?

• a.A gag reflex that is still intact when the mouth is opened
• b.Clear fluid draining from the nose✓
• c.A history of chronic obstructive pulmonary disease with home oxygen
• d.Snoring that stops when the jaw is lifted forward

Clear or blood-tinged fluid from the nose or ear after a head injury suggests cerebrospinal fluid leaking through a basilar skull fracture, and most protocols avoid the nasal route in that situation because the floor of the cranial vault may no longer be intact. Raccoon eyes and bruising behind the ear point the same way. An intact gag reflex rules out an oral airway, not a nasal one. Snoring that clears with a jaw lift shows the tongue is the obstruction, which is a reason to place an adjunct rather than to withhold one, and lung disease has no bearing on the choice of adjunct.

An EMT is inserting an oropharyngeal airway in an unresponsive 3-year-old. Which technique is recommended at this age?

• a.Depress the tongue with a tongue blade and insert the airway in its anatomical position✓
• b.Insert it upside down and rotate it 180 degrees once the tip reaches the back of the throat
• c.Hyperextend the head first so the airway follows the curve of the pharynx
• d.Use a nasal airway instead, since oral airways are not used under eight years of age

In a small child the palate and posterior pharynx are soft and are easily torn by the rotation method, so the tongue is held down with a tongue blade and the airway is slid in following the natural curve of the mouth, curve down. Inserting it upside down and rotating it is the adult technique and is the answer most candidates carry over. Hyperextending a young child's head kinks the soft trachea and obstructs rather than opens the airway, which is why a neutral position is used. An oral airway is appropriate at any age once the gag reflex is absent, sized from the corner of the mouth to the earlobe or the angle of the jaw.

An unresponsive patient thrown from a motorcycle has snoring respirations, and a jaw-thrust maneuver does not open the airway. Under current resuscitation guidance, the EMT should:

• a.Continue the jaw thrust and ventilate with greater force to push air past the obstruction
• b.Roll the patient onto one side so the tongue falls forward
• c.Use a head-tilt/chin-lift, accepting the spinal risk in order to obtain an open airway✓
• d.Keep the jaw thrust and add an oral airway without moving the head

Resuscitation guidance is explicit that when a jaw thrust fails to open the airway of a patient with suspected spinal injury, the rescuer uses a head-tilt/chin-lift, because an airway that will not open kills far faster than the small additional risk of moving the neck. Adding an oral airway is the answer worth weighing and is reasonable alongside the maneuver, but an adjunct lies along the tongue and does nothing for soft tissue that a failed jaw thrust has left obstructing, so it cannot be the substitute for opening the airway. Ventilating harder raises airway pressure, inflates the stomach and still does not move air past a closed airway. Rolling a patient with a possible spinal injury to manage the tongue is neither necessary nor safe when a manual maneuver will do it.

A 9-month-old lying on a firm flat backboard keeps flexing the head forward, and bag-valve-mask ventilation is becoming difficult. What should the EMT do?

• a.Place padding under the infant's shoulders and back to bring the head neutral✓
• b.Tilt the head as far back as it will go, since a fully extended neck opens the small airway
• c.Slide a folded towel under the back of the head, the way an adult is placed in the sniffing position
• d.Turn the head to one side so the tongue falls forward

An infant's occiput is large relative to the body, so lying flat on a hard surface pushes the head forward and closes the airway; padding under the shoulders and torso lifts the body to meet the head and restores a neutral position. Padding behind the head is the adult adjustment and makes an infant's flexion worse, which is exactly the trap here. Hyperextending an infant's neck kinks the soft trachea and obstructs it. Turning the head does not lift the tongue off the posterior pharynx and would be unacceptable if any spinal injury were suspected.

Under current American Heart Association guidance, an apneic 4-year-old who still has a strong pulse should receive rescue breaths at about:

• a.One breath every 2 to 3 seconds✓
• b.One breath every 6 seconds, the same as an adult
• c.Two breaths after every 30 chest compressions
• d.One breath every 3 to 5 seconds, matching a child's normal rate

The 2020 guidelines raised rescue breathing for infants and children with a pulse to 20 to 30 breaths a minute, which is one breath every 2 to 3 seconds. One breath every 3 to 5 seconds, or 12 to 20 a minute, was the previous recommendation and is still printed in many older study guides, which makes it the answer worth pausing over; it was superseded. One every 6 seconds is the adult rate. Compressions are not started for a child who has a strong pulse, although they are added if the pulse falls below 60 with signs of poor perfusion despite oxygenation and ventilation.

How much volume should an EMT deliver with each bag-valve-mask breath to an adult, and over what time?

• a.The full contents of the bag, squeezed with both hands to guarantee an adequate volume
• b.Enough to make the chest just visibly rise, delivered over about one second✓
• c.Half the bag over about three seconds, so that airway pressure stays low
• d.As much as the bag delivers before resistance is felt

Each breath is given over about one second and only until the chest visibly rises, which is roughly 500 to 600 mL in an average adult. Larger or faster breaths raise pressure in the airway above what the esophagus holds shut, inflate the stomach and reduce the blood returning to the heart. Slowing each breath to three seconds is the tempting answer because a slower breath does lower peak pressure, but it delivers far more volume than the lungs need and, during CPR, keeps compressions interrupted for too long. Squeezing until resistance is felt means the lungs are already full and the excess is going into the stomach.

Why does a bag-valve mask running on oxygen need its reservoir bag attached?

• a.It vents excess pressure so a forceful squeeze cannot inflate the stomach
• b.Without it, the bag refills partly with room air, roughly halving the oxygen delivered✓
• c.Without it, the bag cannot be squeezed fast enough to keep up with a high ventilation rate
• d.It shows the rescuer that the mask seal is holding on each breath

The reservoir fills with oxygen between squeezes so the next breath is drawn from oxygen rather than from room air: with a reservoir and 15 L/min a bag-valve mask delivers roughly 90 percent or more, against about 40 to 60 percent without one. Pressure relief is the job of a pop-off valve fitted to some bags, particularly pediatric ones, and it is a separate part from the reservoir. The rate at which a bag can be refilled is not what the reservoir addresses, and the adequacy of the mask seal is judged by watching the chest rise.

An EMT is holding the mask for bag-valve-mask ventilation of a 5-year-old. Which part of the technique most often obstructs a child's airway?

• a.Ventilating with a bag intended for adults rather than a pediatric bag
• b.Pressing the fingers into the soft tissue under the chin✓
• c.Using a mask that covers the mouth and nose but not the eyes
• d.Holding the mask down with the thumb and index finger in a C shape

The fingers lifting the jaw must sit on the bony ridge of the mandible; pressed into the soft tissue under the chin they push the tongue up against the palate and close the airway, and a child's floor of mouth is small enough that this happens easily. A mask that covers the mouth and nose without covering the eyes or overhanging the chin is the correct fit, and the thumb and index finger forming a C over the mask with the remaining fingers on the jaw is the standard grip. An adult bag may be used on a child provided the squeeze stops as soon as the chest rises, because the delivered volume is controlled by the rescuer's hand rather than by the size of the bag.

While an EMT is suctioning a 4-year-old's airway, the heart rate falls from 130 to 68. What should the EMT do?

• a.Stop suctioning at once and ventilate the child with oxygen✓
• b.Continue suctioning until the airway is clear, since the secretions are what caused the drop
• c.Reduce the vacuum setting and continue the attempt
• d.Switch to a soft catheter and continue

Suctioning removes oxygen along with the secretions, and stimulating the posterior pharynx can produce a vagal bradycardia, which children show readily; stopping and oxygenating addresses both mechanisms at once. Continuing because the secretions caused the bradycardia is the choice worth weighing, and it is true that hypoxia from an obstructed airway is the commonest cause of bradycardia in a child, but the child cannot be oxygenated while the catheter is in the airway, so the safe order is to stop, oxygenate, then resume in short attempts. Lowering the vacuum or changing to a softer catheter leaves the child unoxygenated for just as long.

An unresponsive adult is vomiting large amounts of partly digested food, and the rigid suction catheter keeps clogging. What should the EMT do?

• a.Set the vacuum to its maximum and keep suctioning with the rigid catheter until the mouth clears
• b.Change to a soft flexible catheter, which passes more easily through the debris
• c.Ventilate through the vomit with the bag-valve mask to clear it
• d.Log-roll the patient as a unit and suction through the wide-bore tubing with the tip removed✓

Vomit with solid particles exceeds what any catheter tip will pass, so the tip is taken off and the wide-bore tubing used directly, while the patient is rolled so that gravity does most of the work; where spinal injury is possible the roll is done as a unit with the head and body in line. Raising the vacuum does not widen the catheter and the clog stays where it is. A soft catheter has a narrower lumen still and clogs sooner, which is why it is reserved for the nose and for suctioning through a tube. Ventilating over the vomit drives it into the lungs.

An unresponsive adult has loud gurgling with every breath. What is the EMT's immediate action?

• a.Suction the airway✓
• b.Perform a jaw-thrust maneuver to lift the tongue off the pharynx
• c.Apply a nonrebreather mask at 15 liters per minute
• d.Insert an oropharyngeal airway and begin bag-valve-mask ventilation

Gurgling is the sound of liquid in the airway, and nothing is delivered into that airway until the liquid is removed, because ventilating or running oxygen over it pushes the fluid into the lungs. Snoring is the sound that a jaw thrust or an adjunct relieves, which is why the two noises must be told apart rather than treated alike. Suction is applied while withdrawing the catheter, in short attempts commonly taught as roughly 10 to 15 seconds in an adult with the exact limit set by local protocol, and the patient is reoxygenated between attempts.

In an EMS system whose EMTs use waveform capnography, what does it show that pulse oximetry does not?

• a.The oxygen concentration the bag-valve mask is delivering
• b.The percentage of the patient's hemoglobin that is carrying oxygen right now
• c.Whether carbon monoxide is bound to the hemoglobin instead of oxygen
• d.How effectively the patient is being ventilated, breath by breath✓

Capnography measures the carbon dioxide the patient breathes out, so it reports ventilation, normally about 35 to 45 mmHg, and it changes within a breath or two of the patient's condition changing. A pulse oximeter reports the saturation of hemoglobin with oxygen, and it lags behind events by a minute or more, so a patient whose ventilation has just failed still reads well. Carbon monoxide bound to hemoglobin is detected by a CO-oximeter, and neither device reports the concentration of oxygen a bag or mask is delivering, which is a property of the device and the flow rate.

During CPR on an adult with waveform capnography in place, end-tidal carbon dioxide rises abruptly from 11 to 42 mmHg and stays there. What does this most likely mean?

• a.The rescuer is ventilating too rapidly and carbon dioxide is accumulating
• b.Compressions have become too shallow to circulate blood
• c.The airway device has been displaced and ventilation is now ineffective
• d.Circulation may have returned✓

A sudden sustained rise in end-tidal carbon dioxide during CPR usually means blood is circulating again and carrying carbon dioxide back to the lungs, so the finding is confirmed at the next scheduled rhythm check rather than by stopping compressions to feel for a pulse. A displaced airway makes the waveform disappear or fall toward zero, which is the opposite change. Ventilating too fast blows carbon dioxide off and lowers the number. Shallow or tiring compressions likewise show a persistently low value, often under 10 mmHg, and are a prompt to change compressors rather than an explanation for a rise.

A 19-year-old in a severe asthma attack was agitated and wheezing loudly on arrival. Ten minutes later he is drowsy, breathing 8 shallow times a minute, and the wheeze is barely audible. The EMT should:

• a.Keep the nonrebreather in place and let him rest, as the calmer breathing shows improvement
• b.Sit him upright and coach him to slow his breathing
• c.Assist him with a second dose from his inhaler before doing anything else
• d.Begin bag-valve-mask ventilation with high-flow oxygen and transport urgently✓

Drowsiness, a falling rate and a chest that has gone quiet are the signs of a patient who is exhausted and about to arrest, not of a patient improving: the wheeze fades because too little air is moving to make the sound. Ventilation with a bag-valve mask, oxygen and rapid transport is what this patient needs. Assisting the inhaler is the option worth weighing, since a bronchodilator is the treatment for the bronchospasm itself, but a drowsy patient cannot generate the inspiratory flow a metered-dose inhaler requires, and where scope permits, medication follows assisted ventilation rather than replacing it. Coaching a rate of 8 to slow further would worsen an already inadequate minute volume.

Where local protocol allows an EMT to apply CPAP for pulmonary edema, how does it help the patient?

• a.It delivers a set number of breaths each minute, so the patient's own effort is no longer needed
• b.It drives warm dry oxygen across the alveolar walls, which absorbs the fluid in the lungs
• c.It holds the alveoli open and pushes fluid out of them, easing the work of breathing✓
• d.It raises the oxygen concentration far beyond what a nonrebreather can supply

CPAP keeps a continuous pressure in the airway through the whole breathing cycle, which holds open alveoli that would otherwise collapse, drives edema fluid back across into the circulation and cuts the effort each breath takes. The patient goes on breathing for themselves, which is why they must be awake and cooperative. It is not a ventilator delivering set breaths. Raising the oxygen concentration is the tempting explanation, but a nonrebreather already gives a high concentration and does nothing for the patient whose alveoli are flooded, so concentration is not the mechanism. Nothing about the device dries the lungs out.

An EMT is preparing to assist an asthmatic patient with her own prescribed metered-dose inhaler, where protocol permits. Which finding means the EMT should not assist?

• a.She used the inhaler once about an hour ago with partial relief
• b.She is too drowsy to follow instructions✓
• c.Her heart rate has risen to 118 with the effort of breathing
• d.She is wheezing on both sides of the chest rather than one

Assisting with an inhaler requires a patient alert enough to seal her lips on the mouthpiece, inhale on cue and hold the breath; a drowsy patient cannot do any of that and needs her ventilations assisted instead. A dose an hour earlier is the finding worth pausing over, because protocols do cap how many doses may be assisted in a given period, but one dose an hour ago is normally within that limit and the number permitted is set by local protocol and medical direction. Wheezing on both sides and a tachycardia from the work of breathing are expected in an attack. The EMT must still confirm the inhaler is prescribed to this patient and is in date.

A patient on a nonrebreather mask is breathing deeply, and the reservoir bag collapses completely with each breath. What should the EMT do?

• a.Remove the mask and change to a nasal cannula, which the patient's breathing can keep up with
• b.Nothing, because a bag that empties shows the patient is receiving all the oxygen delivered
• c.Detach the reservoir bag so room air can be drawn in
• d.Increase the oxygen flow until the bag stays partly inflated✓

The reservoir must not empty; when it does, the patient is pulling room air in around the mask and the delivered concentration falls, so the flow is raised within the range the device is run at, commonly 10 to 15 L/min, and the bag is filled before the mask goes on the face. A collapsing bag looks like efficient use of the oxygen, which is why doing nothing is the tempting answer, but it means demand has outrun supply. Changing to a nasal cannula lowers the concentration for a patient who evidently needs more, and taking the reservoir off turns the device into a simple face mask.

A patient punched in the face is bleeding heavily into his mouth, has loose teeth and is spitting blood. He is alert and sitting up, and nothing suggests a spinal injury. What is the airway priority?

• a.Pack the bleeding sockets and the mouth with gauze to control the bleeding
• b.Suction as needed and let him sit leaning forward so blood drains out✓
• c.Insert a nasopharyngeal airway so blood drains down it instead of into the pharynx
• d.Lay him flat and apply direct pressure to the face

With bleeding into the mouth the airway is kept clear by suction and by gravity: an alert patient with no spinal concern is left sitting up and leaning slightly forward, with suction in the EMT's hand and the unit running. Packing the mouth is the answer that tempts a candidate who has learned direct pressure for bleeding elsewhere, but gauze in the mouth obstructs the very airway the crew is protecting and can be aspirated. A nasal airway is avoided when the midface may be fractured. Lying him flat lets blood pool in the pharynx and is the fastest way to lose the airway.

A patient has full-thickness burns encircling the entire chest. Apart from the burn injury itself, what makes this patient a high priority?

• a.The stiff burned skin can restrict chest movement and limit ventilation✓
• b.Burned skin over the chest loses so much fluid that shock develops within minutes
• c.The burn will have destroyed the nerves that supply the diaphragm
• d.Circumferential burns bleed heavily beneath the eschar

A full-thickness burn right around the chest leaves a rigid, inelastic eschar, and as the tissue underneath swells the chest wall can no longer expand, so tidal volume falls even though the airway itself is clear; chest rise, effort and oxygenation are watched closely and the patient goes to a facility that can perform an escharotomy. Fluid loss from burns is real but develops over hours and is not what threatens this patient's breathing in the first minutes. The phrenic nerves arise in the neck and reach the diaphragm from inside the chest, out of reach of a skin burn. Full-thickness burns are typically dry and insensate rather than heavy bleeders.

A patient in anaphylaxis has a swollen tongue and audible stridor. Why will inserting an airway adjunct not relieve the obstruction?

• a.The obstruction in anaphylaxis is in the small lower airways, where an adjunct cannot reach
• b.The swelling narrowing the airway is at the larynx, past where any adjunct ends✓
• c.Adjuncts are contraindicated once epinephrine has been given
• d.An adjunct can only be used in an unresponsive patient, and this patient is still alert

An oral or nasal airway ends in the pharynx, above the vocal cords, while the swelling that produces stridor in anaphylaxis sits at and below the larynx, so the adjunct simply stops short of the narrowing; epinephrine is the treatment that reverses it, given as early as scope and protocol allow. The point about an alert patient is the one to weigh, because an oral airway genuinely would not be tolerated here, but a nasal airway usually is tolerated and even an unresponsive patient's laryngeal swelling would not be bypassed, so tolerance is not the reason. Bronchospasm in the lower airways does occur in anaphylaxis, but stridor is an upper-airway sound. Epinephrine does not contraindicate an adjunct.

A woman in the last month of pregnancy is choking, cannot speak or cough, and is still standing. Which technique should the EMT use?

• a.Chest thrusts over the middle of the sternum✓
• b.Abdominal thrusts with the woman lying on her left side
• c.Abdominal thrusts placed higher, above the enlarged uterus
• d.Lay her down at once and start chest compressions

In late pregnancy, and in a patient too large for the rescuer's arms to encircle, thrusts are delivered on the chest with the hands on the middle of the sternum and repeated until the object comes out or the patient becomes unresponsive. Moving the hands higher on the abdomen is the tempting adaptation, but the uterus fills the abdomen at this stage and thrusts there would compress it without generating the pressure needed to expel the object. Lying her on her side does not solve the same problem and gives the rescuer a worse position. Compressions belong to the patient who has become unresponsive, and this one is conscious and standing.

A bystander relieved an adult's airway obstruction with abdominal thrusts. The patient is now alert, breathing normally, and says she feels fine and does not want to go to hospital. What should the EMT tell her?

• a.She should be examined, because the thrusts can injure organs inside the abdomen✓
• b.She needs to be seen only if the object was never coughed up
• c.She can stay if she remains well for twenty minutes
• d.She cannot refuse care after a choking episode, because consent is implied once EMS is called

Abdominal thrusts generate enough force to injure the liver, spleen or stomach or to fracture ribs, and material may also have been aspirated, so evaluation is advised even for a patient who now feels well. A competent adult may still decline, and the EMT explains the risk, documents an informed refusal and makes clear she can call back. Implied consent applies to a patient who cannot consent, not to an alert one, so telling her she has no choice is both wrong and likely to end the conversation. Watching her for a set number of minutes on scene does not exclude an internal injury that can declare itself hours later, and whether the object was recovered says nothing about injury from the thrusts.

A patient who breathes through a permanent neck stoma is short of breath and needs supplemental oxygen. How should it be delivered?

• a.Over the mouth and nose with a nonrebreather, because the upper airway still humidifies
• b.Over the stoma, using a small mask or a tracheostomy mask✓
• c.Through a nasal cannula, so that secretions can be cleared from the stoma
• d.Over the mouth and nose at 15 liters per minute

Oxygen has to go where the air goes, and in a neck breather that is the stoma, so a tracheostomy mask or a small pediatric mask is placed over it; the mask can be lifted for suctioning when secretions build up. Delivering oxygen to the face is the classic error with these patients, and the reasoning about warming and humidifying is backwards: air reaching a stoma bypasses the nose entirely, which is why these patients need humidification rather than a route through the nose. A nasal cannula sends oxygen to a passage that in a total laryngectomy does not connect to the lungs at all.

A standard nasal cannula is generally not run above about 6 liters per minute. Why?

• a.Flows that high suppress the drive to breathe in most patients
• b.Higher flows force air down the esophagus and inflate the stomach
• c.The tubing of a cannula cannot withstand the pressure of a higher flow
• d.Higher flows dry the nose without adding useful oxygen✓

Above roughly 6 L/min a standard cannula adds little to the delivered concentration, because the amount of room air the patient entrains around it is what sets the concentration, while the higher flow dries and irritates the nasal mucosa and quickly becomes intolerable. A patient who needs more than that is moved to a mask. The suppressed respiratory drive belongs to a different and much-overstated concern in chronic lung disease, not to a flow ceiling on a device. Cannula tubing tolerates far higher flows than any portable regulator delivers, and oxygen at these flows does not inflate the stomach; that happens with positive-pressure ventilation.