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.

What is the recommended compression rate for adult CPR?

• a.60 to 80 per minute
• b.80 to 100 per minute
• c.140 to 160 per minute
• d.100 to 120 per minute✓

High-quality CPR uses a compression rate of 100 to 120 per minute. Rates that are too slow or too fast reduce cardiac output and coronary perfusion.

What is the correct compression-to-ventilation ratio for one-rescuer adult CPR?

• a.5:1
• b.10:2
• c.30:2✓
• d.15:2

Single-rescuer adult CPR uses 30 compressions to 2 breaths. This ratio maximizes chest compressions while still providing ventilation.

What is the minimum compression depth for an adult during CPR?

• a.About 3 inches (7.5 cm)
• b.About 1.5 inches (4 cm)
• c.At least 2 inches (5 cm)✓
• d.About 1 inch (2.5 cm)

Adult chest compressions should be at least 2 inches (5 cm) but not more than 2.4 inches (6 cm) deep. Adequate depth is essential to generate blood flow.

For two-rescuer CPR on a child, the compression-to-ventilation ratio is:

• a.30:2
• b.15:2✓
• c.5:1
• d.10:2

When two rescuers perform CPR on an infant or child, the ratio is 15:2. With a single rescuer, the child ratio is 30:2, the same as adults.

The single most important intervention to improve survival that an EMT can deliver for witnessed sudden cardiac arrest is:

• a.Rapid transport to the hospital before starting CPR
• b.Oxygen by non-rebreather mask before compressions
• c.A precordial thump followed by a pulse check
• d.Early defibrillation with an AED plus high-quality CPR✓

Early defibrillation combined with early high-quality CPR offers the best chance of survival in cardiac arrest from a shockable rhythm. Every minute of delay to defibrillation reduces survival. Loading and driving first only delays the shock, and a mask delivers no oxygen to the tissues while there is no circulation to carry it. A precordial thump is not part of EMT care and does not reliably convert a shockable rhythm.

When an AED advises 'no shock advised' but the patient remains pulseless, you should:

• a.Give a second analysis right away without CPR
• b.Wait 5 minutes before doing anything
• c.Immediately resume CPR starting with compressions✓
• d.Remove the pads and transport

A 'no shock advised' message means the rhythm is not shockable, so resume CPR immediately beginning with chest compressions. The AED will reanalyze after about two minutes of CPR.

How deep should chest compressions be for an infant?

• a.About 1 inch, because an infant chest is small
• b.At least 2 inches (5 cm), the depth used for adults
• c.About 1.5 inches (4 cm), roughly one third of chest depth✓
• d.3 inches, pressing as deeply as the chest allows

Infant compressions should be about 1.5 inches (4 cm), roughly one third the depth of the chest, delivered with two fingers or the two-thumb encircling technique. At least 2 inches (5 cm) is the adult depth and is too deep for an infant, while pressing only about an inch does not move enough blood, and pressing as hard as the chest allows risks injury without improving flow.

A conscious adult reports crushing chest pressure radiating to the left arm. After ensuring no contraindications, the EMT may assist with:

• a.Oral glucose
• b.Chewable aspirin✓
• c.A tourniquet
• d.Activated charcoal

For suspected acute coronary syndrome, EMTs may assist with chewable aspirin, which reduces clot formation, if the patient has no allergy or contraindication. Aspirin improves outcomes in heart attack.

Under a typical EMS protocol, before assisting a patient with their own prescribed nitroglycerin for chest pain, the EMT must confirm:

• a.That the chest pain has lasted longer than twenty minutes, since the drug is only for prolonged pain
• b.That the patient has no aspirin allergy, because aspirin is always given alongside nitroglycerin
• c.That the patient has eaten recently, because nitroglycerin irritates an empty stomach
• d.Adequate blood pressure (typically systolic above 90 to 100 mmHg) and no recent erectile dysfunction drugs✓

Nitroglycerin dilates blood vessels and can cause dangerous hypotension, so an adequate blood pressure must be confirmed first, and it is contraindicated after recent erectile dysfunction medication because the combination can drop pressure severely. How long the pain has lasted, whether the patient can tolerate aspirin, and when the patient last ate do not determine whether it is safe to assist with the dose.

During CPR, allowing the chest to fully recoil between compressions is important because it:

• a.Moves air in and out of the lungs, so fewer breaths are needed
• b.Lets the rescuer reach a faster compression rate with less effort
• c.Prevents broken ribs by lifting all pressure off the sternum
• d.Allows the heart to refill with blood, improving the next compression's output✓

Full chest recoil lets the heart refill with blood between compressions, so the next push moves more blood. Leaning on the chest reduces venous return and lowers CPR effectiveness. Recoil does not provide effective ventilation and does not replace rescue breaths, it does not make a faster rate the goal, and it does not prevent rib fractures.

If a patient in cardiac arrest has a transdermal medication patch on the chest where an AED pad must go, you should:

• a.Place the pad directly over the patch and press firmly
• b.Withhold defibrillation until a paramedic arrives
• c.Remove the patch and wipe the area before applying the pad✓
• d.Leave the patch in place and lower the shock energy

A medication patch under an AED pad can block energy delivery or cause a skin burn, so the patch is removed and the skin wiped before the pad goes on. Defibrillation should not be delayed waiting for a paramedic, and an automated external defibrillator selects its own energy, so there is no setting for the operator to turn down.

What is the compression rate for infant and child CPR?

• a.80 to 100 per minute
• b.60 to 80 per minute
• c.140 to 160 per minute
• d.100 to 120 per minute✓

The compression rate for infants and children is the same as for adults, 100 to 120 per minute. Consistent rate and depth are key to effective CPR at all ages.

The purpose of minimizing interruptions in chest compressions is to:

• a.Maintain coronary and cerebral blood flow✓
• b.Allow extra breaths between cycles
• c.Reduce the chance of breaking ribs
• d.Let the AED charge its capacitor faster

Blood flow generated by compressions falls quickly when compressions stop and takes time to rebuild. Minimizing interruptions keeps perfusion to the heart and brain as high as possible. Pausing to add breaths trades that perfusion for ventilation the arrested patient needs far less, and rib injury is not what the pause is meant to prevent. The AED charges on its own timer, which is why compressions continue while it charges.

A patient becomes unresponsive and pulseless while you are attaching monitoring equipment. Your immediate action is to:

• a.Give two rescue breaths first
• b.Begin high-quality chest compressions✓
• c.Search for a medical bracelet first
• d.Check blood glucose

For an unresponsive, pulseless adult, start chest compressions immediately following the compressions-airway-breathing sequence. Early compressions are the priority in cardiac arrest.

Under standard resuscitation guidance, AED pads for a small child when pediatric pads are unavailable should be:

• a.Cut down with trauma shears so the two pads fit without touching
• b.Placed using adult pads, one on the chest and one on the back if needed to avoid overlap✓
• c.Withheld entirely, because an adult shock dose is unsafe for a child
• d.Placed side by side on the upper chest so both stay off the abdomen

If pediatric pads or a pediatric setting are unavailable, adult pads may be used on a child, with one pad on the front of the chest and one on the back when that is what it takes to keep the pads from touching. Pads must not be cut or trimmed, because that changes the surface the current passes through, and defibrillation should not be withheld from a child in cardiac arrest.

Which is a classic sign that a patient may be having a heart attack in addition to chest pain?

• a.Sharp pain that worsens only when the chest wall is pressed
• b.Warm, dry, pink skin with a strong radial pulse
• c.Diaphoresis (heavy sweating), nausea, and shortness of breath✓
• d.Slow, deep, effortless breathing with normal skin color

Acute coronary syndrome often presents with heavy sweating, nausea, and shortness of breath alongside the chest discomfort, and recognizing those associated signs helps identify a heart attack when the chest pain itself is atypical. Pain reproduced by pressing on the chest wall more often points to a musculoskeletal cause, and warm, dry, pink skin with easy, unlabored breathing is not part of the classic picture.

Hands-only CPR by bystanders is encouraged for adults primarily because:

• a.Rescue breaths mostly fill the stomach and do more harm than good
• b.Continuous compressions maintain blood flow and bystanders are more willing to act✓
• c.Chest compressions alone restart the heart, so an AED is not needed
• d.Compression-only CPR is the preferred approach for young children too

For sudden cardiac arrest in an adult, continuous chest compressions keep blood moving and bystanders are far more willing to act when mouth-to-mouth is not required, which improves survival. Compressions do not restart the heart by themselves and do not replace defibrillation, and children in arrest more often need rescue breaths because the cause is usually respiratory.

Where should the heel of the hand be placed for adult chest compressions?

• a.On the upper sternum, just below the collarbones
• b.On the center of the chest, on the lower half of the sternum✓
• c.Over the left nipple, directly above the heart's apex
• d.On the upper abdomen just below the xiphoid process

Compressions are delivered on the lower half of the sternum in the center of the chest. Correct hand placement maximizes cardiac output and reduces injury. Compressing the upper sternum will not squeeze the ventricles effectively, and moving off to the left side pushes on ribs rather than on the sternum. Pressing on the upper abdomen compresses the liver and stomach instead of the heart and risks injury and regurgitation.

A conscious patient with a suspected heart attack should generally be placed in what position if no hypotension or altered mental status is present?

• a.Prone, to ease the work of breathing
• b.Flat and supine to rest the heart
• c.Head-down Trendelenburg position
• d.A position of comfort, often sitting up✓

A conscious cardiac patient who is not hypotensive is usually most comfortable sitting up, which can ease breathing and reduce the work of the heart. Lying flat, lying face down, or tipping the head down does not help and can make breathing harder. Keep the patient calm and limit exertion.

The main reason to switch compressors about every 2 minutes during CPR is to:

• a.Let the ventilator catch up on missed breaths
• b.Prevent rescuer fatigue that reduces compression quality✓
• c.Comply with the AED, which requires a new compressor
• d.Give the patient a rest from the pressure on the chest

Compression quality falls off with fatigue, often before the rescuer notices it, so compressors change about every two minutes, ideally during a rhythm check. The change is not driven by ventilations, not requested by the AED, and not a break for the patient.

After an AED delivers a shock, the rescuer should:

• a.Immediately resume chest compressions✓
• b.Wait for the AED to advise again before touching the patient
• c.Check for a pulse for 30 seconds
• d.Remove the pads

Immediately after a shock, resume CPR starting with compressions for about two minutes before the next rhythm analysis. This minimizes the pause in blood flow and improves outcomes.

For an unresponsive adult who is not breathing normally, how should you check for a pulse and for how long?

• a.Brachial pulse for up to 10 seconds
• b.Radial pulse for a full 30 seconds
• c.Apical pulse listened to for 60 seconds
• d.Carotid pulse for no more than 10 seconds✓

In an unresponsive adult, check the carotid pulse for no more than 10 seconds. If no definite pulse is felt within that time, begin chest compressions. The brachial site is the one used for an infant, and the radial pulse can be absent in a patient who still has a central pulse, so neither settles the question in an adult. Listening for an apical pulse takes equipment and time that a pulseless patient does not have.

What is the first-line method to control severe, life-threatening external bleeding from an extremity?

• a.Direct pressure, and a tourniquet if pressure fails or bleeding is massive✓
• b.Packing the wound with ice to constrict the bleeding vessels
• c.Elevating the injured limb well above the level of the heart
• d.Pressing a proximal arterial pressure point instead of the wound

Severe extremity bleeding is controlled first with firm direct pressure, and a tourniquet is applied if that fails or the bleeding is immediately life-threatening. Ice, elevation, and proximal pressure points do not reliably stop a major bleed and they delay the measures that do. Rapid hemorrhage control is a top priority in trauma.

When applying a commercial tourniquet, you should tighten it until:

• a.You can still slide a finger under the strap when it is set
• b.The distal pulse weakens but can still be felt
• c.The bright red bleeding stops and the distal pulse is eliminated✓
• d.The patient reports the pressure has become painful

A tourniquet must be tightened enough to stop arterial bleeding, which also eliminates the distal pulse. A tourniquet that only slows bleeding can worsen blood loss. A strap loose enough to admit a finger, or one that leaves a palpable pulse below it, still lets arterial blood into the limb while blocking venous return, so the wound keeps bleeding. Pain is not the endpoint either: a correctly applied tourniquet hurts, and a patient in shock may feel little.

Which are early signs of shock (hypoperfusion)?

• a.Falling blood pressure as the first sign
• b.High blood pressure and dry skin
• c.Rapid pulse; pale, cool, clammy skin; and anxiety✓
• d.Slow pulse and warm, flushed skin

Early shock produces a rapid, weak pulse with pale, cool, clammy skin and restlessness or anxiety. Falling blood pressure is a late sign because the body compensates first.

After applying a tourniquet, you should note and communicate:

• a.Only the amount of blood lost
• b.The patient's pain level instead
• c.The time the tourniquet was applied✓
• d.The brand of device applied

The application time of a tourniquet must be documented and reported so hospital staff know how long the limb has been without circulation. Write it clearly, often on the patient or the device. Estimated blood loss, pain and the type of device are all worth reporting, but none of them tells the receiving team how long the limb has been ischemic, which is what drives their decisions about the limb.

Under a typical EMS protocol, a patient with a suspected spinal injury who is breathing adequately should be:

• a.Positioned with the head turned to the side
• b.Manually stabilized in a neutral, in-line position✓
• c.Asked to move the neck to test its range first
• d.Placed prone on the stretcher for transport

Suspected spinal injuries are managed with manual in-line stabilization keeping the head neutral until fully immobilized or cleared. Unnecessary movement risks worsening a spinal cord injury. Turning the head to the side or placing the patient prone moves the very segment being protected and makes reassessment of the airway and chest harder. Asking the patient to move the neck to find the limits of motion can convert an unstable fracture into a cord injury; tenderness and deficit are assessed without moving the spine.

How should a partial-thickness (second-degree) burn without gross contamination be initially covered?

• a.With ice packs applied directly on the skin
• b.With a tight elastic wrap
• c.With butter or ointment
• d.With a clean, dry sterile dressing✓

Burns are covered with a clean, dry sterile dressing to reduce contamination and pain. Avoid ointments, butter, ice, or breaking blisters, which can worsen injury or infection.

The 'rule of nines' is used to estimate:

• a.The Glasgow Coma Scale score after a head injury
• b.The percentage of total body surface area burned✓
• c.The respiratory rate in an injured patient
• d.The volume of blood lost from an open wound

The rule of nines estimates the percentage of total body surface area burned, which gauges burn severity and guides triage and transport decisions. It has nothing to do with scoring consciousness, counting respirations, or measuring blood loss.

An impaled object in a patient's forearm should generally be:

• a.Pushed in deeper for stability
• b.Removed quickly to control bleeding
• c.Stabilized in place with bulky dressings✓
• d.Wrapped tightly against the skin

Impaled objects are stabilized in place and not removed in the field, because removal can cause severe bleeding or further injury. The exception is an object obstructing the airway or interfering with CPR.

The most appropriate position for a hypotensive trauma patient in shock (without spinal injury) is generally:

• a.Walking the patient to keep the circulation moving
• b.Supine to maintain perfusion, keeping the patient warm✓
• c.Face down, to protect the airway from vomiting
• d.Sitting fully upright to make breathing easier

A patient in shock is generally kept supine to support perfusion of the vital organs, along with oxygen and steps to prevent heat loss, since losing heat makes shock worse. Walking a hypotensive patient can cause collapse, sitting fully upright reduces blood return to the brain, and lying face down makes assessment and airway management harder.

Under a typical EMS protocol, a patient with a suspected closed femur fracture should have the limb:

• a.Left unsplinted so the patient can hold the leg in whatever position hurts least
• b.Elevated above the level of the heart on pillows to limit swelling and bleeding
• c.Gently massaged and straightened by hand before the patient is moved to the cot
• d.Immobilized, ideally with a traction or rigid splint, checking distal pulse, motor, and sensation✓

A femur fracture is stabilized with a splint to limit pain, bleeding, and further injury, and distal pulse, motor function, and sensation are checked before and after splinting. A femur can bleed heavily into the thigh, so leaving the limb unsupported, elevating it on pillows, or manipulating it by hand increases both pain and blood loss.

Which finding suggests a serious chest injury requiring rapid transport?

• a.Mild chest soreness with clear, equal breath sounds
• b.Pink, warm skin with an unlabored, regular breathing pattern
• c.Severe difficulty breathing with unequal chest rise after chest trauma✓
• d.A small superficial scratch over the ribs with no tenderness

Severe difficulty breathing with unequal chest rise after chest trauma suggests a serious injury such as a collapsed lung and calls for oxygen and rapid transport. Mild soreness with clear and equal breath sounds, normal skin with easy breathing, or a superficial scratch do not carry that level of urgency.

Under a typical EMS protocol, an open chest wound (sucking chest wound) should be treated by an EMT with:

• a.Gauze packed deep into the wound and held with pressure
• b.An occlusive dressing, monitoring for worsening breathing✓
• c.A tight circumferential wrap around the whole chest
• d.Oxygen alone, leaving the wound open to the air

An open chest wound is covered with an occlusive dressing to prevent air entering the chest, while watching for signs of increasing pressure. If breathing worsens, a side of the dressing may be lifted to release trapped air. Packing gauze into a chest wound pushes material toward the lung and does not seal it, and a tight wrap around the chest limits the movement the patient needs to breathe. Leaving the wound open lets air continue to be drawn into the pleural space with every breath.

The primary goal of treating shock in a trauma patient in the field is to:

• a.Stay on scene until the blood pressure comes back up on its own
• b.Raise the blood pressure by having the patient drink fluids on scene
• c.Maintain oxygenation and perfusion and prevent heat loss during rapid transport✓
• d.Give small sips of water and something to eat to keep strength up

Field management of shock focuses on oxygenation and perfusion, controlling bleeding, preventing heat loss, and moving quickly to definitive care, because an EMT cannot reverse shock in the field. Waiting on scene for the blood pressure to improve wastes that time, and nothing is given by mouth to a patient who may vomit or who may need surgery.

Bright red blood that spurts from a wound in time with the pulse indicates:

• a.Minor bleeding that will stop on its own
• b.Venous bleeding
• c.Capillary bleeding
• d.Arterial bleeding✓

Spurting, bright red blood synchronized with the heartbeat is arterial bleeding, which is the most serious and rapid. It requires immediate control with direct pressure and possibly a tourniquet.

A helmet on a patient with a possible spine injury should generally be removed by EMTs when:

• a.The patient asks for it to be taken off, no matter how well it fits
• b.Never, because taking a helmet off will always worsen a spinal injury
• c.It interferes with airway management or assessment, or does not hold the head snugly✓
• d.Only after arrival at the hospital, where the staff can take it off

A helmet is removed when it blocks airway management or assessment, or when it does not hold the head snugly enough to help immobilize it. A well-fitting helmet that holds the head steady may be left in place with the head stabilized, so removal is neither automatic on request nor something that must wait for the hospital.

To estimate the severity of a head injury, an EMT commonly assesses:

• a.The blood pressure alone, watching for a rising reading
• b.Pupil size and reaction only, without tracking mental status
• c.Skin temperature and color alone, with no neurologic check
• d.Level of responsiveness (AVPU/GCS), pupils, and any change over time✓

Head injury severity is judged from level of responsiveness, pupil size and reaction, and how those findings trend over time, since a declining mental status is the critical warning sign of a worsening brain injury. Blood pressure, pupils, or skin findings taken by themselves miss that trend.

A diabetic patient who is conscious, able to swallow, and has an altered mental status with likely low blood sugar should receive:

• a.Nitroglycerin
• b.Aspirin
• c.Activated charcoal
• d.Oral glucose✓

A conscious diabetic with a protected airway and suspected hypoglycemia is treated with oral glucose. The patient must be able to swallow and protect the airway to receive anything by mouth.

The classic signs of a stroke can be quickly screened using:

• a.The Cincinnati Prehospital Stroke Scale (facial droop, arm drift, speech)✓
• b.The Glasgow Coma Scale, scoring eye, verbal, and motor response
• c.The rule of nines, which divides the body into percentages
• d.OPQRST alone, the mnemonic used to characterize pain

The Cincinnati Prehospital Stroke Scale checks for facial droop, arm drift, and abnormal speech, and any one abnormal finding suggests a possible stroke and the need for rapid transport. The Glasgow Coma Scale grades overall level of consciousness rather than screening for stroke, the rule of nines estimates burn area, and OPQRST is a way to describe pain.

Where the EMT's scope permits, for a patient having a severe allergic reaction (anaphylaxis) with prescribed medication available, the EMT may assist with:

• a.A tube of oral glucose
• b.Activated charcoal by mouth
• c.Chewable aspirin tablets
• d.An epinephrine auto-injector✓

Anaphylaxis is treated with epinephrine, and an EMT may assist a patient with their own prescribed auto-injector where protocol allows. Epinephrine reverses the airway swelling and low blood pressure caused by the reaction. Oral glucose treats low blood sugar, activated charcoal is used for some ingested poisons, and aspirin is used for suspected cardiac chest pain.

An epinephrine auto-injector is most commonly injected into the:

• a.Upper arm muscle
• b.Buttock or hip area
• c.Lateral (outer) thigh✓
• d.Abdomen or flank

The epinephrine auto-injector is delivered into the outer thigh muscle, which can be done through clothing and allows rapid absorption. The upper arm, the buttock, and the abdomen are not injection sites for an auto-injector.

The most important consideration before giving any oral medication or glucose is:

• a.The patient can swallow and protect their airway✓
• b.Whether the patient has eaten recently
• c.The patient's systolic blood pressure is normal
• d.The patient has taken the medication before

Anything given by mouth requires the patient to be able to swallow and protect the airway, so an unresponsive or severely altered patient should not receive oral medications or glucose. Recent food intake is worth recording in the history but does not by itself bar an oral medication, a normal blood pressure is a check tied to drugs such as nitroglycerin rather than a general requirement for anything oral, and having taken the medication before says nothing about whether the patient can swallow it now.

A tonic-clonic (grand mal) seizure is actively occurring. The EMT's priority is to:

• a.Hold the patient still and place a padded object between the teeth to protect the tongue
• b.Restrain the arms and legs firmly to stop the convulsive movements
• c.Insert an oropharyngeal airway during the convulsion to keep the airway open
• d.Protect the patient from injury and manage the airway, without forcing anything into the mouth✓

During an active tonic-clonic seizure, protect the patient from injury and manage the airway, but do not restrain the limbs and do not force anything between the teeth. Objects placed in the mouth risk broken teeth, airway obstruction and bitten fingers, forcible restraint can cause fractures and dislocations, and an oral airway cannot be placed safely against clenched jaws. After the seizure, place the patient in the recovery position and give oxygen as needed.

Activated charcoal may be indicated (per protocol/medical direction) for:

• a.Certain oral poisonings in an alert patient who can protect the airway✓
• b.Ingestion of a petroleum distillate such as gasoline or kerosene
• c.Ingestion of a strong acid or alkali such as drain cleaner
• d.Any unresponsive poisoning patient, to bind the drug early

Activated charcoal can bind some ingested poisons in an alert patient able to protect the airway, when directed by protocol or medical control. It is withheld after petroleum distillates because vomiting and aspiration injure the lungs worse than the swallowed product, after strong acids and alkalis because it does not bind them and it obscures the view for later endoscopy, and in patients with a decreased level of consciousness because they cannot protect the airway.

A postictal patient (after a seizure) is typically:

• a.Ready to walk and refuse care
• b.Combative and requiring restraint by default
• c.Confused, drowsy, and gradually improving✓
• d.Fully alert immediately with no confusion

The postictal phase after a seizure involves confusion, drowsiness, and gradual recovery of orientation. Support the airway, provide reassurance, and monitor as the patient recovers.

Time of symptom onset is especially critical to determine and report in patients with suspected:

• a.A minor sprain
• b.Motion sickness
• c.Stroke✓
• d.A common cold

Knowing when stroke symptoms began determines eligibility for time-sensitive treatments like clot-dissolving therapy. EMTs should establish and clearly report the last-known-well time.

The mnemonic SAMPLE is used to gather a patient's:

• a.The percentage of body surface burned, using the rule of nines
• b.History (Signs/symptoms, Allergies, Medications, Past history, Last intake, Events)✓
• c.The level of responsiveness, using Alert, Verbal, Painful, Unresponsive
• d.The character of the pain: onset, quality, region, severity and time

SAMPLE stands for Signs and symptoms, Allergies, Medications, Pertinent past history, Last oral intake, and Events leading up to the call, giving a structured medical history. Burned body surface is estimated with the rule of nines, level of responsiveness is graded with AVPU, and the character of pain is drawn out with OPQRST.

The OPQRST mnemonic is primarily used to assess:

• a.The characteristics of pain or a chief complaint✓
• b.The patient's past medical history and allergies
• c.The adequacy of the airway and breathing
• d.The extent of burns on the body surface

OPQRST (Onset, Provocation, Quality, Region and radiation, Severity, Time) explores the nature of pain or a chief complaint and helps characterize symptoms such as chest or abdominal pain. Past history and allergies come from SAMPLE, airway and breathing are judged in the primary assessment, and burn extent is estimated with the rule of nines.

A woman in her third trimester complains of dizziness when lying flat on her back. The best position is:

• a.Left lateral recumbent (tilted onto her left side)✓
• b.Sitting fully upright with the legs dependent
• c.Supine with the legs elevated (Trendelenburg)
• d.Right lateral recumbent, onto her right side

Late in pregnancy the uterus can compress the inferior vena cava when the mother lies supine, cutting venous return and causing dizziness and hypotension. Because the vena cava lies to the right of the spine, tilting her onto the left side lifts the uterus off it. Turning onto the right side does far less, sitting upright does not address caval compression, and raising the legs while she stays flat leaves the uterus resting on the vessel.

During normal childbirth, once the infant's head delivers, the EMT should:

• a.Apply firm traction to the head to speed the delivery
• b.Clamp and cut the cord before the shoulders deliver
• c.Hold the head back until the ambulance reaches a hospital
• d.Support the head and check whether the cord is around the neck✓

As the head delivers, support it gently and check for a nuchal cord (umbilical cord around the neck). Never pull on the infant; allow the body to deliver with the contractions. Pulling on the head can injure the infant's neck and brachial plexus, and cutting the cord before the body is out removes the infant's only source of oxygen while the chest is still compressed. Holding the head back to reach a hospital does not stop labor and risks injury to both mother and infant.

The first priority for a newborn immediately after delivery is to:

• a.Clamp and cut the umbilical cord before doing anything else
• b.Suction the mouth and nose deeply before drying and warming
• c.Dry, warm, position, and stimulate the newborn, keeping the airway clear✓
• d.Check a blood glucose and give oral glucose if it is low

A newborn is dried, kept warm, positioned, and stimulated, with the airway cleared as needed, because preventing heat loss and getting the infant breathing are the immediate priorities. Cord clamping can wait until the infant is breathing and warm, deep suctioning is not routine and can provoke bradycardia, and glucose is not part of immediate newborn care in the field.

A patient exhibiting a behavioral emergency who is a potential danger requires the EMT to prioritize:

• a.Applying physical restraints to every such patient on arrival
• b.Leaving the patient alone in a quiet room until they calm down
• c.Completing a full head-to-toe physical exam before anything else
• d.Scene safety and their own and the patient's safety, requesting help as needed✓

Behavioral emergencies require attention to scene safety first, protecting the crew and the patient and summoning law enforcement or extra resources as needed. Restraint is a last resort for a patient who is a danger, applied only within local policy, leaving a potentially dangerous patient unattended abandons them and risks harm to them or to others, and a detailed physical exam is not possible until the situation is controlled.

Fruity (acetone) breath odor, deep rapid breathing, and excessive thirst in a diabetic suggest:

• a.A stroke causing an irregular breathing pattern
• b.Hyperglycemia / diabetic ketoacidosis (high sugar)✓
• c.Hypoglycemia from a missed meal after insulin
• d.An allergic reaction with airway involvement

Fruity breath, deep rapid (Kussmaul) breathing, and thirst point to high blood sugar and diabetic ketoacidosis, which develops gradually and requires oxygen support and transport. Low blood sugar instead comes on quickly with pale, sweaty skin and no fruity odor, a stroke produces focal deficits such as one-sided weakness or speech loss rather than thirst, and an allergic reaction brings hives, swelling and wheezing.

Which set represents normal adult vital sign ranges?

• a.Pulse 40 to 60, respirations 4 to 8, systolic BP about 60 to 80
• b.Pulse 20 to 40, respirations 40 to 50, systolic BP about 40 to 60
• c.Pulse 60 to 100, respirations 12 to 20, systolic BP roughly 90 to 140✓
• d.Pulse 120 to 160, respirations 30 to 40, systolic BP about 70 to 90

A typical resting adult has a pulse of 60 to 100, respirations of 12 to 20, and a systolic blood pressure roughly in the 90 to 140 range. Values well outside these suggest a problem requiring assessment. The fast pulse and fast respiratory rate in one of the other sets are closer to what is expected in an infant than in an adult, and the remaining sets pair a slow pulse and slow breathing with a systolic pressure low enough to signal shock.

A patient who responds only when you pinch their shoulder but does not respond to your voice is classified on the AVPU scale as:

• a.Alert and following commands
• b.Responsive to Painful stimulus✓
• c.Responsive to Verbal stimulus
• d.Unresponsive to all stimuli

AVPU stands for Alert, Verbal, Painful, Unresponsive. A patient who reacts only to a painful stimulus is scored as 'P' (Painful). An alert patient is awake and interacting before you touch them, and a verbal patient reacts when spoken to, which this patient did not. Unresponsive is reserved for a patient who does not react to a painful stimulus at all, so any reaction to the pinch rules it out.

Cool, clammy skin in a diabetic patient with a rapid onset of altered mental status most often indicates:

• a.Dehydration from vomiting
• b.Slowly rising blood sugar
• c.A brief fainting episode
• d.Low blood sugar (hypoglycemia)✓

Hypoglycemia commonly causes cool, clammy, sweaty skin with rapid onset of altered mental status. If the patient can swallow, oral glucose is indicated. A rising blood sugar builds over hours to days and usually presents with warm, dry skin and thirst rather than this sudden picture. Dehydration and a simple faint do not explain mental status that stays altered, and treating either one first delays the sugar this patient needs.

A patient with difficulty breathing and a history of asthma is prescribed a metered-dose inhaler. Under a typical EMS protocol with medical direction, the EMT may:

• a.Give the patient a family member's inhaler if it is the same drug
• b.Withhold all help because giving medication is outside the EMT role
• c.Assist the patient in using their own prescribed inhaler per protocol✓
• d.Give oral glucose, which relaxes the airway during an attack

EMTs may help a patient self-administer their own prescribed inhaler for respiratory distress, following local protocol and medical direction. Confirm the medication, dose, and expiration and that it is prescribed to that patient. An inhaler prescribed to someone else is not that patient's medication, whatever the label says, and refusing to help at all misreads the assisting role that protocols grant. Oral glucose treats low blood sugar and has no effect on bronchospasm.

Severe lower abdominal or shoulder pain, dizziness, and signs of shock in a woman of childbearing age with a missed period may indicate:

• a.A muscle strain from lifting, with referred pain
• b.A urinary tract infection with bladder pain
• c.A possible ectopic pregnancy with internal bleeding✓
• d.Ovulation pain in the middle of the cycle

A ruptured ectopic pregnancy bleeds internally and produces lower abdominal pain, shoulder pain from blood irritating the diaphragm, and shock, so it needs oxygen, shock care, and rapid transport. A muscle strain and ovulation pain do not cause shock, ovulation pain is also ruled out by the missed period, and a urinary tract infection typically brings burning on urination and fever rather than hypotension.

The primary treatment an EMT provides for most poisonings by inhalation is to:

• a.Enter immediately and begin ventilating the patient in place
• b.Move the patient to fresh air and provide oxygen once the scene is safe✓
• c.Administer activated charcoal to bind the inhaled toxin
• d.Induce vomiting to clear the poison from the stomach

For inhaled poisons, first ensure scene safety, then remove the patient to fresh air and give high-concentration oxygen. Entering a contaminated atmosphere without the right protection and training simply produces a second patient. Activated charcoal binds some swallowed poisons and does nothing about a gas already in the lungs, and inducing vomiting is no longer used for poisoning by any route.

A patient with a possible opioid overdose has slow, shallow breathing. The EMT's first priority is to:

• a.Check a blood glucose level before doing anything else
• b.Walk the patient around to keep them awake
• c.Support ventilation and oxygenation with a bag-valve mask✓
• d.Give oral glucose between the cheek and gum

The immediate life threat in opioid overdose is respiratory depression, so support ventilation with a bag-valve mask and oxygen first. Naloxone may follow where protocol allows, but airway and breathing come first. Walking a patient does not restore respiratory drive, anything placed in the mouth risks aspiration in a patient who cannot protect the airway, and a glucose reading, while worth obtaining, does not treat hypoventilation.

During delivery, if the umbilical cord presents first (prolapsed cord), the EMT should:

• a.Position the mother to relieve pressure (knees to chest or hips elevated), keep pressure off the cord, and transport rapidly✓
• b.Have the mother stand and walk to the ambulance so that gravity moves the baby down and delivery progresses
• c.Gently pull on the cord to move it aside, then deliver the baby normally on the scene and clamp the cord
• d.Push the cord back into the birth canal, hold it in place, and wait for the head to deliver on its own

A prolapsed cord is squeezed between the presenting part and the pelvis and cuts off the baby's oxygen supply, so relieve the pressure by positioning the mother hips-up or knees-to-chest, gently keep the presenting part off the cord, and transport immediately. Standing and walking increases the pressure on the cord, pulling on the cord can tear it or shear the placenta, and pushing it back inside does not relieve the compression while the delay costs the baby oxygen.

A patient reporting a sudden severe headache, described as the worst of their life, with vomiting should be evaluated for:

• a.Low blood sugar only
• b.Motion sickness
• c.A simple tension headache to ignore
• d.A possible stroke or brain bleed✓

A sudden severe headache, often called the worst of one's life, can indicate bleeding in the brain and is a possible stroke. This requires oxygen support, monitoring, and rapid transport.

Hives, itching, swelling of the face and tongue, and wheezing after a bee sting indicate:

• a.A systemic allergic reaction possibly progressing to anaphylaxis✓
• b.Hypoglycemia brought on by the stress of being stung
• c.An asthma attack triggered by exertion in the heat
• d.A local reaction confined to the area of the sting

Hives away from the sting site, facial and airway swelling, and wheezing are signs of a body-wide response, which marks a systemic allergic reaction that may become anaphylaxis. Prepare to assist with epinephrine and support the airway and breathing. A local reaction stays confined to the sting site, asthma alone does not cause hives or facial swelling, and low blood sugar produces altered mental status and sweating rather than hives.

A patient having a seizure that does not stop, or repeated seizures without regaining consciousness, is called:

• a.A febrile seizure caused by a high temperature
• b.A postictal state following a single seizure
• c.A simple partial seizure with awareness intact
• d.Status epilepticus, a life-threatening emergency✓

Status epilepticus is a prolonged seizure, or repeated seizures without recovery of consciousness in between, and is life-threatening because of the hypoxia it produces. It requires airway support, oxygen, and rapid transport for definitive treatment. A postictal state is the recovery period after a seizure has already stopped, a febrile seizure is a brief seizure in a young child with a fever, and a simple partial seizure involves one part of the body with awareness intact.

Nitroglycerin assists a cardiac patient primarily by:

• a.Dilating blood vessels to reduce the heart's workload✓
• b.Constricting blood vessels to raise blood pressure
• c.Dissolving a clot already in a coronary artery
• d.Slowing the heart rate to reduce oxygen demand

Nitroglycerin dilates blood vessels, reducing the workload on the heart and improving blood flow to the heart muscle. Because that same dilation lowers blood pressure, adequate pressure must be confirmed before assisting. It does not constrict vessels, it does not dissolve a clot that has already formed (that is the work of hospital fibrinolytics or catheter treatment), and it does not slow the heart rate.

In the START triage system, a patient who is not breathing but begins breathing after you open the airway is tagged:

• a.Immediate (red)✓
• b.Minor/walking wounded (green)
• c.Deceased/expectant (black)
• d.Delayed (yellow)

In START triage, a patient who only breathes after the airway is opened is classified Immediate (red). This indicates a critical patient needing the highest transport priority.

The very first priority when arriving at any emergency scene is:

• a.Obtaining a full SAMPLE history from the patient
• b.Ensuring scene safety for yourself, the crew, and bystanders✓
• c.Reaching the patient's side as quickly as possible
• d.Applying high-concentration oxygen to every patient

Scene safety comes before patient contact because an injured rescuer cannot help and becomes another victim. Assess for hazards such as traffic, violence, fire, unstable structures and toxins before approaching. Taking a history, reaching the patient's side, and giving oxygen all matter, but each of them happens only after the scene has been judged safe to enter.

Which type of consent applies to treating an unresponsive patient who cannot agree to care?

• a.Implied consent✓
• b.Involuntary consent
• c.Informed consent
• d.Expressed consent

Implied consent assumes that a reasonable unresponsive person would want life-saving care. It allows EMTs to treat patients who cannot give expressed consent.

In the START triage system, the first step to sort a large group of patients is to:

• a.Begin CPR on every patient who is found not breathing before moving on
• b.Direct everyone who can walk to a designated area (identifying the walking wounded)✓
• c.Check a radial pulse and capillary refill on each patient in turn
• d.Immobilize every patient on a long backboard before sorting them

START begins by asking everyone who can walk to move to a designated area, which quickly identifies the minor (green) patients and shrinks the number left to assess. The remaining patients are then sorted by respirations, perfusion, and mental status. CPR is not begun during START because it ties up rescuers still needed for sorting, checking every pulse one at a time is far too slow for a large group, and immobilization is treatment rather than sorting.

A competent adult refuses care after being informed of the risks. The EMT should:

• a.Respect the refusal, document it thoroughly, and encourage the patient to call back if needed✓
• b.Treat and transport the patient anyway, because the risk of harm is too high
• c.Leave the scene without documenting the contact or the refusal at all
• d.Have a family member sign the refusal form in place of the patient

A competent, informed adult has the right to refuse care, and the refusal must be clearly documented after the risks have been explained. Encourage the patient to call back if symptoms worsen and involve medical direction as local policy requires. Treating a competent adult over their refusal is battery, leaving no record destroys the evidence that the risks were explained, and a relative's signature does not substitute for the decision of the patient who holds it.

Which patient should be moved with an emergency move (before full assessment)?

• a.A stable patient with an isolated ankle injury who wants to leave
• b.A patient in immediate danger from fire, explosion, or an unsafe scene✓
• c.Any patient, whenever the crew is trying to save time on scene
• d.Every trauma patient, to move them clear of the vehicle quickly

An emergency move is used when there is an immediate threat to life, such as fire, explosion or hazardous materials, and it is accepted precisely because the danger of staying outweighs the reduced spinal protection during the drag. It is not chosen for stable patients, not chosen to save time, and not the routine method for trauma patients, who are better served by a non-urgent move that preserves stabilization.

When lifting a heavy patient or stretcher, proper body mechanics include:

• a.Keeping the back straight, lifting with the legs, and keeping the load close to the body✓
• b.Lifting quickly with the arms fully extended and the load held away from you
• c.Twisting at the waist while lifting so you can move in one motion
• d.Bending at the waist and lifting with the back muscles rather than the legs

Safe lifting uses the leg muscles with a straight back and the load held close to the body, avoiding twisting, which reduces the risk of back injury to the EMT. Holding the load away from the body multiplies the leverage acting on the spine, twisting under load loads the spine in the direction it tolerates worst, and bending at the waist shifts the work onto the back muscles instead of the legs.

The purpose of providing a radio report to the receiving hospital is to:

• a.Serve as the legal record of the call for the run report
• b.Alert staff and allow them to prepare for the incoming patient✓
• c.Give the receiving staff the patient's full medical history
• d.Transfer responsibility for the patient before you arrive

A concise radio (MedComm) report gives the hospital key information so they can prepare appropriate staff and resources. It typically includes age, chief complaint, vital signs, treatment, and ETA. The written patient care report, not the radio call, is the legal record, and a full history belongs in that report and in the bedside handoff rather than on the air. Responsibility for the patient stays with the crew until care is formally transferred to hospital staff.

Standard precautions (body substance isolation) mean an EMT should:

• a.Wear personal protective equipment only during CPR and airway care
• b.Assume all blood and body fluids are potentially infectious and use appropriate PPE✓
• c.Base the level of protection on how sick the patient appears to be
• d.Wear gloves only for patients with a known infectious disease

Standard precautions treat every patient's blood and body fluids as potentially infectious, so appropriate PPE such as gloves and eye protection is used on all patient contacts. Reserving protection for CPR, for patients who look unwell, or for patients with a documented diagnosis all fail for the same reason: an infection is often unknown to the patient and to the crew at the time of contact.

Positioning an ambulance at a highway crash to shield the work area from traffic is an example of:

• a.Ongoing patient reassessment
• b.Patient care documentation
• c.Multiple-casualty incident triage
• d.Scene safety and hazard protection✓

Positioning the apparatus to block the work area protects the crew and the patients from being struck, which is part of scene safety and hazard control. Traffic is a leading hazard at roadway incidents. Reassessment, documentation and triage are all patient-facing tasks that do nothing about oncoming vehicles.

In a mass-casualty incident (MCI), the goal of triage is to:

• a.Do the greatest good for the greatest number of patients✓
• b.Transport patients in the order they are discovered
• c.Treat only the most severely injured, regardless of survivability
• d.Give the most care to the first patient found

MCI triage aims to do the greatest good for the greatest number by prioritizing patients most likely to benefit from limited resources. This differs from routine care that focuses fully on one patient.

Which is an example of expressed consent?

• a.Treating an unconscious adult who cannot answer questions
• b.A conscious, competent adult verbally agreeing to be treated✓
• c.Assuming a young child agrees without a parent present
• d.Starting care without asking during a true emergency

Expressed consent occurs when a competent, informed patient specifically agrees to care, verbally or otherwise. The patient must understand the nature of the treatment and its risks. Treating an unconscious adult, or acting at once in a true emergency, relies on implied consent, where the law presumes a reasonable person would agree. A young child generally cannot give consent at all; consent is sought from a parent or guardian, and care that cannot wait proceeds under implied consent.

Abandonment occurs when an EMT:

• a.Stops care of a patient without ensuring an equal or higher level of care takes over✓
• b.Documents a competent adult's informed refusal and then clears the scene
• c.Transfers care of the patient to a paramedic at the hospital door
• d.Contacts medical control for orders before giving a medication

Abandonment is terminating care without handing the patient to a provider of equal or higher training, or without an appropriate release, so proper transfer of care and documentation prevent abandonment claims. Documenting a competent adult's informed refusal ends the encounter lawfully, handing over to a paramedic or to hospital staff is a transfer to an equal or higher level of care, and contacting medical control is consultation, not termination.

During START triage, a patient with a respiratory rate over 30 per minute is tagged:

• a.Immediate (red)✓
• b.Delayed (yellow)
• c.Minor/green
• d.Deceased (black)

In START, a respiratory rate above 30 indicates a critical patient tagged Immediate (red). Respirations, perfusion, and mental status are the three assessments used to categorize patients.

A 24-year-old with type 1 diabetes is unresponsive after taking her usual insulin and skipping meals. She has snoring respirations and no gag reflex. Under the standard EMT scope of practice in most states, the crew should:

• a.Open the airway, ventilate as needed, and transport rapidly✓
• b.Administer 25 g of dextrose intravenously, the definitive treatment for hypoglycemia at every EMS level
• c.Place oral glucose gel between her cheek and gum, since buccal absorption does not require the patient to swallow
• d.Insert an oral airway before placing the glucose gel

An unresponsive patient with no gag reflex must receive nothing by mouth, so opening the airway, ventilating as needed and transporting rapidly is what the EMT scope offers here. Oral glucose gel is the tempting choice because it is described as absorbing through the mucosa, but it is still a bolus of gel in the mouth of a patient who cannot swallow or protect her airway, and inability to swallow is a stated contraindication. An oral airway holds the tongue forward but does nothing to stop aspiration, so it does not make gel safe, and intravenous dextrose requires vascular access and sits above the EMT level in essentially every system.

A conscious patient with a history of diabetes is confused but can follow simple commands and swallow. No blood glucose reading is available and the crew cannot tell whether the sugar is high or low. Under most EMS protocols the EMT should:

• a.Withhold sugar until the hospital can measure a blood glucose, because giving glucose to a hyperglycemic patient can trigger ketoacidosis
• b.Give oral glucose, since untreated hypoglycemia is the more immediate threat✓
• c.Assume hyperglycemia, which is far more common in insulin users
• d.Give oral glucose only once a glucometer reading confirms hypoglycemia

When the crew genuinely cannot tell high from low in a patient who is awake and able to swallow, most protocols favor giving oral glucose: hypoglycemia injures the brain within minutes, while a tube of glucose adds little to an already high sugar over a short transport. Withholding sugar until the hospital can measure it is the strongest competing choice, but ketoacidosis develops over hours to days and is not set off by one dose of oral glucose. Requiring a meter reading first is reasonable when a meter is at hand, but none is available here and treatment should not wait for one. Hyperglycemia being more common in insulin users does not make it the greater emergency.

A patient stung by a wasp has itching and hives. Which additional finding means the reaction should be treated as anaphylaxis rather than a mild or localized allergic reaction?

• a.Itching that began within five minutes of the sting
• b.A previous reaction to a sting several years ago
• c.Airway swelling or signs of shock✓
• d.Hives spreading over more than half the body

Anaphylaxis is defined by involvement beyond the skin: respiratory compromise such as stridor, wheezing or tongue and throat swelling, or circulatory compromise such as hypotension, dizziness and weak pulses. Widespread hives are the most tempting finding because they look dramatic, but skin findings alone, however extensive, remain a skin reaction. Rapid onset and a prior reaction raise suspicion without meeting the definition; persistent vomiting and cramping abdominal pain, on the other hand, do count as a second body system.

A patient in anaphylaxis improves dramatically minutes after an epinephrine auto-injector is used. He now feels well and asks to sign a refusal. The strongest medical reason to urge transport is:

• a.The epinephrine must be reversed at the hospital with a medication that blocks its effects
• b.Symptoms can return hours later in a biphasic reaction as the epinephrine wears off✓
• c.Any patient given a medication by EMS is legally required to be transported
• d.An auto-injector dose is too small for an adult and must be repeated

Anaphylaxis can recur hours after it appears to resolve, and epinephrine's effect is short-lived, so a patient who needed it requires evaluation and a period of observation. The belief that epinephrine has to be reversed at the hospital is the most common misconception in this scenario; there is no routine reversal agent and none is needed. A competent adult may still legally refuse, which is precisely why the crew has to explain the risk of a returning reaction rather than claim transport is mandatory, and the adult auto-injector delivers a full adult dose.

Ten minutes after an epinephrine auto-injector was used, a patient's wheezing and facial swelling are worsening again, and a second auto-injector prescribed to the patient is on scene. In most EMS systems the EMT should:

• a.Wait a full thirty minutes before any repeat dose, as that is the standard interval
• b.Contact medical direction about a second dose✓
• c.Give the second injection into the same thigh as the first
• d.Withhold more epinephrine, since only a paramedic may give a repeat dose

Anaphylaxis that worsens again after one dose is exactly the situation in which a repeat dose may be authorized, and in most systems that authorization comes from on-line medical direction or an explicit standing order rather than the crew's own judgment. Withholding epinephrine on the belief that only paramedics may repeat it is both wrong and dangerous, since EMTs administer or assist with epinephrine in many systems. There is no universal thirty-minute rule; re-dose intervals are set by protocol, and the customary practice is to use the other thigh rather than reinjecting the same spot.

A farm worker is found beside a pesticide sprayer with pinpoint pupils, heavy drooling and tearing, vomiting, and loss of bladder control. After the crew is protected and the patient has been decontaminated, the EMT's next priority is:

• a.Give activated charcoal to bind the pesticide remaining in the stomach
• b.Administer naloxone, since the pinpoint pupils point to an opioid overdose
• c.Frequent suctioning and assisted ventilation with oxygen✓
• d.Give oxygen by non-rebreather mask without suctioning

Organophosphate poisoning is a cholinergic crisis in which the airway fills with secretions and the patient dies of respiratory failure, so suctioning and ventilatory support come first. Naloxone is the tempting answer because of the pinpoint pupils, but it reverses opioids only and does nothing about the drooling, tearing and bronchial secretions; the antidotes are atropine and pralidoxime, which in most systems are carried at the ALS level or as auto-injectors an EMT may use only where protocol permits. A non-rebreather cannot push oxygen through an airway full of secretions and does not support failing ventilation, and activated charcoal has no role in an agent absorbed through skin and lungs.

A family is found drowsy with headaches in a garage where a gasoline generator has been running. On room air, each of them has a pulse oximeter reading of 99%. The correct interpretation is:

• a.A pulse oximeter cannot distinguish carboxyhemoglobin from oxyhemoglobin, so the reading is falsely reassuring✓
• b.The high reading confirms adequate oxygenation, so carbon monoxide poisoning is unlikely
• c.The reading is falsely high because carbon monoxide constricts the fingertip vessels, and warming the hand will correct it
• d.Carbon monoxide drives the reading below 90%, so these numbers argue against exposure

A standard pulse oximeter reads carboxyhemoglobin much as it reads oxyhemoglobin, so a poisoned patient can show 99% while the blood carries very little usable oxygen. The history — an engine running in an enclosed space and several people with the same headache and drowsiness — therefore outweighs the number entirely. Carbon monoxide does not push the displayed saturation down, and it does not work by constricting the fingertip vessels; poor perfusion does make an oximeter unreliable, but that is not what is happening here. Only CO-oximetry or a hospital blood level measures it, and field care is removal from the source plus high-concentration oxygen.

A 22-year-old is agitated and paranoid, with dilated pupils, drenching sweat, a heart rate of 148 and a blood pressure of 178/104, after taking an unknown drug. This pattern is most consistent with:

• a.Opioid overdose, given the sweating and altered mental status
• b.Benzodiazepine overdose with paradoxical excitement
• c.Stimulant (sympathomimetic) intoxication✓
• d.Organophosphate exposure, which also causes heavy sweating and agitation

Tachycardia, hypertension, dilated pupils, sweating and agitation form the sympathomimetic pattern seen with cocaine, amphetamines and similar drugs, and the EMT's concerns are hyperthermia, seizures and cardiac events. Organophosphate poisoning is the closest competitor because it also produces drenching sweat, but it constricts the pupils, slows the heart and floods the airway with secretions. Opioids cause pinpoint pupils with slow, shallow breathing, and sedatives depress rather than raise the heart rate and blood pressure.

A worker has spilled a dry powdered industrial chemical across both forearms. After putting on gloves and eye protection, the EMT should first:

• a.Wipe the powder away with a wet towel
• b.Flush immediately with large volumes of low-pressure water for twenty minutes
• c.Neutralize the powder with a mild acid or base before rinsing it away
• d.Brush the dry powder off the skin, then flush with water✓

Brushing the dry chemical away first removes most of the agent and avoids the violent reaction some dry chemicals have with water; irrigation follows once the bulk of the powder is gone. Immediate flushing is the strongest competing answer, because copious irrigation is correct for liquid chemical exposures, and it is exactly the step that can make a water-reactive powder worse. Wiping with a wet towel adds water for the same reason and grinds the chemical into the skin, and neutralizing is never a field maneuver, since acid-base reactions release heat and can add a thermal burn to the chemical one.

A man's slurred speech and right-sided weakness came on suddenly and then cleared completely over about twenty minutes. He now feels normal and does not want to be transported. The most accurate thing to tell him is:

• a.Symptoms that clear within twenty-four hours rule out a clot, so seeing his doctor next week is enough
• b.Because the weakness resolved on its own, this was almost certainly a migraine
• c.This may have been a transient ischemic attack, a warning that a stroke may follow soon✓
• d.He only needs to be seen if the weakness comes back on the same side

Deficits that resolve completely are typically a transient ischemic attack, and the risk of a completed stroke is highest in the days immediately afterward, so this patient needs urgent evaluation rather than reassurance. The most tempting error is treating resolution as proof that nothing happened; imaging and workup are what separate a transient attack from a small stroke, and no crew can make that call in the field. A competent adult may still refuse, so the crew should document the advice given and keep encouraging transport.

A bystander describes a witnessed collapse. Which feature most suggests a seizure rather than simple fainting?

• a.A few seconds of lightheadedness and nausea before the fall
• b.Pale, sweaty skin with color returning within a minute
• c.Prolonged confusion after the episode✓
• d.A brief jerking of the arms and legs during the collapse

A postictal period of minutes to tens of minutes of confusion, sleepiness or headache is the most reliable discriminator, because a syncope patient is usually oriented again within a minute of lying flat. Brief jerking during the event is the strongest competing finding and the classic trap: convulsive syncope from cerebral hypoperfusion produces a few seconds of twitching, so movement alone does not settle the question and the recovery pattern matters more. A lightheaded, nauseated warning and pale sweaty skin with color returning quickly both fit ordinary vasovagal syncope.

An EMT is treating a 70-year-old with new confusion and no sign of injury. Among the many causes of altered mental status, which one can an EMT most often both recognize and begin correcting in the field?

• a.An expanding subdural hematoma from an unwitnessed fall days earlier
• b.Low blood sugar, corrected with oral glucose✓
• c.Uremia from kidney failure, recognized by the odor of the breath
• d.Sepsis from a urinary tract infection

Hypoglycemia is the reversible cause an EMT is actually equipped for: it is common, the history and skin signs point to it, blood glucose measurement is within many EMT scopes, and oral glucose corrects it in a patient who can swallow. A subdural bleed is the strongest competing answer because it is common in older adults on blood thinners and changes the destination hospital, but nothing an EMT carries reverses it. Uremia and urinary sepsis also belong on the differential of new confusion in an older adult, yet an EMT can confirm and treat only the low sugar.

A 76-year-old woke at 2 a.m. severely short of breath and is now wheezing. Which additional finding points to congestive heart failure rather than an asthma attack?

• a.Swollen ankles and a need to sleep propped on several pillows✓
• b.A forty-year smoking history with a barrel-shaped chest
• c.A dry cough that started after he climbed the stairs
• d.Wheezing heard loudest on exhalation through pursed lips, easing with a rescue inhaler

Dependent edema and orthopnea, along with waking at night gasping for air, are the fluid-overload findings of heart failure, and the wheeze of so-called cardiac asthma comes from fluid in the airways rather than bronchospasm. Pursed-lip exhalation that responds promptly to a bronchodilator is the hardest finding to separate, since heart failure patients can also wheeze, but prompt relief from a rescue inhaler points to reactive airway disease. A long smoking history with a barrel chest suggests COPD, and an exertional cough is nonspecific.

A 4-year-old sits upright and very still, drooling, with a muffled voice, a high fever, and no cough. This presentation should raise the greatest concern for:

• a.An aspirated foreign body
• b.Epiglottitis✓
• c.Croup before the barking cough appears
• d.Asthma triggered by a viral illness

Drooling, a muffled voice, high fever, an absent cough and a child who insists on sitting still and upright form the classic epiglottitis picture. Croup is the strongest competitor because it is far more common at this age, but croup causes a barking cough with inspiratory stridor and usually a low-grade fever, and it does not typically produce drooling or a muffled voice, so an absent cough argues against croup rather than for an early stage of it. An aspirated foreign body can cause sudden distress and drooling but not a high fever, and asthma produces wheezing and lower airway findings. Management is what makes the distinction matter: keep the child calm and in a position of comfort with a caregiver, give blow-by oxygen only if it is tolerated, never inspect the throat or use a tongue depressor, and transport with airway equipment ready.

A 68-year-old man has sudden tearing abdominal pain radiating to his back, a pulsating mass above the umbilicus, and cool, mottled legs. The EMT should:

• a.Treat this as renal colic, since pain radiating to the back is typical of a stone
• b.Palpate the mass in all four quadrants to estimate how large it has become
• c.Apply firm pressure over the mass to slow the internal bleeding
• d.Avoid deep palpation, give oxygen if indicated, and transport rapidly✓

Tearing abdominal or back pain with a pulsatile mass and poor perfusion in the legs suggests an abdominal aortic aneurysm; nothing can be fixed in the field, so gentle handling, oxygen as indicated, shock care and rapid transport to a surgical center are the treatment. Kidney stone pain is the strongest competing explanation and can look identical at first, but a stone does not produce a pulsating mass or mottled legs, and treating this patient as low priority costs the diagnosis. Deep palpation and pressure over the mass risk rupture and are never used.

A patient reports several days of black, tarry, foul-smelling stools and now becomes dizzy when he stands up. This most likely indicates:

• a.Hemorrhoidal bleeding at the anus, which turns black as the blood dries
• b.A medication side effect rather than blood loss
• c.Bleeding low in the colon, where stool darkens as it sits
• d.Bleeding high in the digestive tract, such as from a stomach ulcer✓

Melena, meaning black tarry foul stool, is blood that has been digested during a slow passage from the upper gastrointestinal tract, classically a peptic ulcer or esophageal varices, and the dizziness on standing says enough volume has been lost to matter, so this is a shock patient. Hemorrhoidal bleeding is the tempting answer, but blood from the anus arrives undigested and bright red, and the same holds for the lower colon: it is stomach acid and digestive enzymes, not time sitting in the bowel, that turn blood black. Iron tablets and bismuth medicines also darken stool, which is why the foul odor and the orthostatic symptoms are the findings that push this toward true blood loss.

A man who missed his last two dialysis sessions is weak and short of breath. Which action is most appropriate?

• a.Lay him flat with the legs raised to relieve the weakness
• b.Take the blood pressure in the fistula arm, where the shunt gives a truer reading
• c.Encourage him to drink water, since dehydration causes the weakness
• d.Take the blood pressure in the arm without the fistula✓

The limb holding an arteriovenous fistula or graft is protected: no blood pressure cuff, no tourniquet and no venipuncture on that side, because pressure can clot the access the patient's life depends on. Missed dialysis leaves a patient volume overloaded and hyperkalemic, so shortness of breath here suggests pulmonary edema and he is at real risk of a lethal arrhythmia. That is also why laying him flat with the legs raised is the wrong instinct, since it shifts still more fluid into an already overloaded chest, and why encouraging him to drink is actively harmful. Sit him up, give oxygen as indicated, and transport promptly.

An 82-year-old nursing home resident is newly confused and weak, with a respiratory rate of 26, a heart rate of 112, warm skin, and a normal temperature. The EMT should most suspect:

• a.A stroke, since sudden confusion in an older adult usually means a bleed or clot
• b.Dehydration, since the nursing home may have missed her fluids
• c.Sepsis, since older adults often fail to mount a fever✓
• d.A reaction to a newly started medication

Older adults with serious infection often present with confusion, rapid breathing and a fast pulse and no fever at all, sometimes even with a low temperature, so a normal reading never excludes sepsis. Stroke is the tempting alternative because new confusion is dramatic, but strokes usually produce focal findings such as facial droop, one-sided weakness or speech loss rather than tachypnea and tachycardia. Dehydration and a new medication both belong on the list and are worth asking about, but they do not account for a respiratory rate of 26 with a heart rate of 112 and warm skin. Aging itself does not cause confusion: new confusion in an older adult is a symptom to be explained, not a baseline.

A large man is combative and incoherent, sweating profusely and appearing not to feel pain. Once law enforcement and enough personnel are on scene and restraint has been decided on, the EMT should:

• a.Secure him face down on the stretcher, which best protects the crew during the transport
• b.Apply metal handcuffs yourself and remove them only at the hospital
• c.Sandwich him between two long backboards to limit movement
• d.Restrain him supine or on his side rather than prone, and monitor breathing✓

Prone and hog-tie restraint is the position associated with restraint asphyxia deaths, because the chest cannot expand against the stretcher in a patient who is already hyperthermic, acidotic and exhausted. Restrain face up or on the side with no weight on the back, keep airway and breathing under continuous watch, and expect sudden deterioration, including cardiac arrest. Sandwiching a patient between boards is the strongest competing answer because it looks like it simply controls movement, but it splints the chest for the same reason prone restraint kills. Handcuffing is a law enforcement function, and an officer with a key rides along whenever cuffs stay on.

A runner collapses during a race on a hot, humid day. He is confused and combative, his skin is hot, and he feels extremely warm to the touch. The single most important field treatment is:

• a.Slow cooling with a fan alone, to avoid shivering and rebound heating
• b.Oral electrolyte drinks and rest in the shade until he improves
• c.Sponge him with rubbing alcohol to speed evaporation
• d.Immediate aggressive whole-body cooling✓

Altered mental status with a very high core temperature is heat stroke, and survival depends on how fast the temperature falls, so remove him from the heat, take off the clothing, and cool aggressively while transporting, using cold water immersion where it is available or wetting the skin with fans plus ice packs to the neck, armpits and groin. Cooling slowly to avoid shivering is the strongest competing answer, because shivering really does generate heat, but a delayed fall in core temperature is the far greater danger and shivering is managed rather than avoided. Alcohol sponging is a folk remedy that is absorbed through the skin and is not used, and nothing goes in the mouth of a confused patient, which rules out oral electrolyte drinks.

A woman in active labor says the baby is coming. Which single finding most reliably tells the EMT to prepare to deliver on scene rather than transport?

• a.Contractions about five minutes apart in a first pregnancy
• b.The membranes rupturing as the crew arrived on scene
• c.Crowning of the baby's head at the vaginal opening✓
• d.A bloody show of mucus passed about an hour ago

Crowning, meaning the presenting part is visible and bulging at the perineum with each contraction, means delivery is happening now, and preparing to deliver where the crew stands is safer than transporting through the birth. Contraction timing is the closest competitor and is worth recording, but contractions five minutes apart in a first labor commonly leave hours to go. Ruptured membranes and bloody show mark the progress of labor without predicting how soon the baby will arrive.

A woman at 34 weeks of pregnancy has a blood pressure of 168/110, marked swelling of the hands and face, a severe headache, and spots in her vision. Besides rapid transport, the EMT's most important action is:

• a.Transport quietly on her left side and be prepared for a seizure✓
• b.Have her walk out to the ambulance rather than wait for the stair chair
• c.Keep her supine and flat for the whole transport
• d.Give fluids and sugar by mouth for likely dehydration

This picture is severe preeclampsia, and the danger is an eclamptic seizure, so the EMT's contribution is minimizing stimulation with a quiet, dim, gentle ride while positioning her on her left side to keep the uterus off the vena cava, plus early hospital notification. Lying flat on the back is the closest competing position and is the trap here: at 34 weeks the uterus compresses the vena cava and drops cardiac output, which is why left lateral positioning is used instead. Exertion such as walking raises blood pressure rather than lowering it, and nothing goes by mouth for a patient who may seize or need urgent surgery.

The placenta has delivered and the mother continues to bleed heavily. Under most EMS protocols the EMT should first:

• a.Massage the uterus through the abdominal wall✓
• b.Pack the vagina firmly with sterile gauze to tamponade the flow
• c.Pull steadily on the cord stump to look for retained placenta
• d.Nurse the newborn at the breast and transport without doing anything else

A boggy uterus that will not contract is the usual cause of postpartum hemorrhage, and firm fundal massage with a cupped hand is the field treatment that works. Putting the newborn to the breast is the strongest competing answer and is genuinely useful, because suckling releases oxytocin and helps the uterus clamp down, but it is slower and less reliable than massage, so massage comes first and nursing is added alongside it rather than instead of it. Packing the vagina is specifically contraindicated because it conceals ongoing blood loss and invites infection, and traction on the cord stump risks tearing it or inverting the uterus. Treat the mother for shock, save any tissue that passes, and transport.

As the baby's head delivers, the EMT feels the umbilical cord looped around the newborn's neck. The first action should be:

• a.Gently slip the cord over the baby's head✓
• b.Push the head back slightly to take tension off the cord
• c.Clamp the cord in two places and cut between the clamps at once
• d.Support the head and transport at once

A nuchal cord is common and is usually handled by hooking a finger under it and easing it over the head so delivery continues normally. Clamping and cutting is the answer that feels decisive and is the strongest competitor, but it is reserved for a cord too tight to slip, because cutting ends the baby's oxygen supply before the chest has delivered and the newborn can breathe. Pushing the head back can injure mother and baby, and holding the delivery to transport does not stop labor.

Which set lists the five components of the APGAR score?

• a.Appearance, pulse, grimace, alertness and respiratory rate
• b.Appearance, pulse, grimace, activity and respiration✓
• c.Appearance, pulse, gestation, activity and tone
• d.Airway, pulse, grimace, tone and respiration

APGAR stands for appearance meaning color, pulse, grimace meaning reflex irritability, activity meaning muscle tone, and respiration, each scored zero to two for a maximum of ten, and it is assessed one minute and five minutes after birth. The version substituting alertness and respiratory rate is the common misremembering: what is graded is the newborn's tone and its response to stimulation, not its wakefulness. The score documents the newborn's condition, but resuscitation is driven by breathing effort, heart rate and color and is never delayed to finish scoring.

An EMT is assessing a responsive 58-year-old whose only complaint is chest tightness that began an hour ago. How does the secondary assessment of a medical patient like this normally differ from that of a patient with a significant mechanical injury?

• a.It is focused on the system suggested by the complaint and driven by the history✓
• b.It is a rapid full-body survey carried out before any history is taken from the patient
• c.It is limited to vital signs, because a medical patient has nothing to find on examination
• d.It is the same head-to-toe examination that every patient receives

For a responsive medical patient the history is the assessment: the complaint tells the EMT which body system to examine, so the exam is focused rather than head-to-toe. The rapid full-body survey is the strongest competitor and is genuinely correct for a significant injury mechanism or for an unresponsive medical patient, where no history is available and the crew has to search the body for clues instead. Giving every patient an identical head-to-toe examination spends time that a focused complaint does not justify, and confining the assessment to vital signs alone throws away findings such as leg swelling, an irregular pulse or crackles at the lung bases that change what the crew does next.

A patient with difficulty breathing is being transported. Under the reassessment guidance taught in most EMS systems, how often should the EMT repeat the vital signs and reassess the patient?

• a.Once on arrival
• b.Every fifteen minutes
• c.Only if his breathing changes noticeably
• d.About every five minutes✓

The interval commonly taught is roughly every five minutes for an unstable patient and roughly every fifteen minutes for a stable one, and respiratory distress puts this patient in the unstable group. Fifteen minutes is the most tempting answer because it is a real number from the same rule, but it is the stable-patient interval and it can let a deterioration run unnoticed for a quarter of an hour. Waiting for the patient to announce a change is unreliable, because a tiring patient often goes quiet just before failing, and a single set of numbers recorded on arrival says nothing about the trend, which is the whole point of reassessment. The four options here are deliberately bare intervals so that no wording gives the answer away.

A crew forms a general impression of a patient who is grey, sweaty and struggling to speak in full sentences, and decides this is a 'load and go' situation. For a medical patient, what does that decision mean in practice?

• a.That the physical examination is skipped and only vital signs are recorded on the way in
• b.That the ambulance is driven to the hospital with warning lights and the siren running
• c.That on-scene time is kept short and most of the assessment happens during transport✓
• d.That the patient is moved to the ambulance before the primary assessment is completed

Load and go describes limiting time on scene for a time-critical patient: the primary assessment and any immediate life-saving care are done where the patient lies, and the history, the focused exam and the reassessments are completed in the moving ambulance. Warning lights and siren are the closest competitor, and they often accompany the decision, but transport mode is a separate judgement that usually saves only a couple of minutes while raising crash risk, and plenty of load-and-go patients are driven in without them. Moving the patient before the primary assessment is finished is not load and go but the way an unmanaged airway or an uncontrolled bleed leaves the scene, and nothing about the decision licenses skipping the physical examination.

Road noise in a moving ambulance makes it impossible to hear Korotkoff sounds, so an EMT takes the blood pressure by palpation instead. What does this technique give the EMT?

• a.Both numbers, but each of them reads slightly lower than it would by auscultation
• b.A mean arterial pressure
• c.A diastolic reading only
• d.A systolic reading only✓

Palpation detects the pressure at which the radial pulse reappears as the cuff deflates, and that is the systolic pressure; it is documented in a form such as 88 over P to show that no diastolic was obtained. The idea that both numbers come through, each a little low, is the common misconception and it is wrong for a specific reason: the diastolic is defined by hearing the sounds disappear, and there is nothing to feel at that moment. A palpated systolic does tend to run a few millimetres of mercury below the auscultated value, and no mean pressure can be derived by feel, so palpation is a legitimate technique when noise or motion defeats the stethoscope but the reading should be repeated by auscultation once conditions allow.

A patient with a gastrointestinal bleed is pale, cold and clammy, with a thready radial pulse. The pulse oximeter reads 88% on one attempt and then will not pick up a signal at all. The EMT should:

• a.Record 88% as accurate and titrate oxygen precisely to bring that number up to 94%
• b.Treat the clinical picture, recognizing that poor perfusion makes the reading unreliable✓
• c.Move the probe to a different finger and withhold oxygen until a stable number is displayed
• d.Document that no reading was obtainable, which by itself confirms respiratory failure

A pulse oximeter needs a pulsatile arterial signal at the sensor, so shock, cold extremities and vasoconstriction make it read low or fail entirely, and a shocked patient gets oxygen and rapid transport on clinical grounds whatever the number says. Moving the probe is a reasonable troubleshooting step and is the strongest competing answer, but withholding oxygen while chasing a better waveform is the part that makes it wrong. A failed reading is a statement about perfusion at the fingertip rather than proof of respiratory failure, and a normal reading would not have excluded shock either, since a patient who has lost a large volume of blood can saturate the hemoglobin he has left perfectly well.

An EMT checks orthostatic vital signs on a patient with several days of vomiting and diarrhea who is normotensive while lying down. What finding would suggest significant fluid loss?

• a.A blood pressure that rises by a few points on standing, as gravity loads the leg veins
• b.A pulse that stays within a few beats of the supine rate after standing for two minutes
• c.A marked rise in pulse or fall in blood pressure on sitting or standing up✓
• d.A respiratory rate that increases when the patient stands up

A hypovolemic patient can hold a normal pressure while lying flat and only reveal the deficit when the circulation is challenged by sitting or standing, which shows up as the pulse climbing or the pressure dropping; the thresholds usually taught are a systolic fall of about twenty millimetres of mercury or a pulse rise of about twenty beats per minute, and services differ on the exact cut-off. A pulse essentially unchanged after two minutes of standing is the reassuring result rather than the positive one, which is what a hurried candidate mistakes for a positive test. A small rise in pressure on standing is ordinary physiology, and respiratory rate is not part of the test. Orthostatic readings are not attempted on a patient who is already hypotensive, unstable or unable to stand safely.

An unresponsive patient with no history of trauma has one pupil that is clearly larger than the other and slow to react to light. This finding should most raise concern for:

• a.Hypoxia, as the oxygen level keeps falling
• b.An opioid overdose, as the breathing slows
• c.A lifelong difference in pupil size
• d.Rising pressure inside the skull✓

A newly unequal, sluggish pupil in an unresponsive patient suggests pressure inside the skull compressing the nerve that controls that pupil, as happens with an expanding bleed or a large stroke, and it calls for airway support and rapid transport to a hospital with neurosurgical capability. A minority of people do have a small lifelong difference between their pupils, which is the genuinely tempting alternative, but that variation is slight, both pupils still react briskly, and it can never be assumed in a patient who cannot tell you it has always been that way. Hypoxia and opioids act on the pair rather than on one side: falling oxygen eventually dilates both pupils and opioids constrict both, so neither accounts for one large sluggish pupil.

A 71-year-old has sudden right-sided weakness and slurred speech that began forty minutes ago. His blood glucose reads 104 mg/dL. What does that reading tell the EMT?

• a.That the deficits come from a sugar too low for an older brain
• b.That glucose should be given anyway, since sugar protects the brain in stroke
• c.That hypoglycemia is excluded, so the patient is managed as a stroke✓
• d.That glucometer readings are unreliable in stroke patients and should be disregarded

Checking the sugar matters because hypoglycemia is the great stroke mimic, and 104 mg/dL sits within the normal range, so the reading removes that explanation and leaves the crew with a stroke to transport urgently with a documented time of last known well. Giving glucose anyway is the most tempting error: raising the sugar of a patient who is not hypoglycemic does not protect brain tissue, and higher glucose in acute stroke is associated with worse outcomes. Age does not shift what counts as a normal glucose, and the reading is meaningful precisely because it is what rules the mimic out rather than something to disregard.

An 84-year-old woman with long-standing diabetes has sudden weakness, nausea and shortness of breath that began while she was sitting quietly. She denies any chest pain at all. The EMT should treat this as a possible:

• a.Gastrointestinal upset from something she ate
• b.A panic attack brought on by anxiety
• c.A heart attack✓
• d.The normal effect of ageing on an 84-year-old

Older adults and people with diabetes frequently have a myocardial infarction without chest pain, presenting instead with sudden weakness, breathlessness, nausea, sweating, fainting or simply feeling unwell, so the absence of pain lowers the odds of the diagnosis being made rather than the odds of it being present. A digestive cause is the closest competitor because the nausea is prominent, and it is exactly the reasoning that gets these patients transported without urgency; anxiety is the other common misattribution and is not a diagnosis anyone can make in the field. New weakness in an older adult is a symptom that needs an explanation, never a normal feature of ageing. The four options are bare diagnoses on purpose, so none of them argues for itself.

An EMT finds a confused patient alone at home with no history available. The home medicine bottles are glipizide, metformin and lisinopril. What is the most useful immediate conclusion?

• a.Nothing can be concluded, as medication bottles are unverified
• b.The patient is being treated for diabetes, so the blood sugar should be checked now✓
• c.The metformin is the likely cause of the confusion, as it drives blood sugar very low
• d.The lisinopril proves the confusion came from a blood pressure that fell too far

A medication list is often the only history available, and two oral diabetes drugs make hypoglycemia the first thing to check and the one cause of confusion an EMT can begin to correct in a patient who can protect his own airway and swallow. Blaming the metformin is the trap, and the distinction is worth knowing: sulfonylureas such as glipizide commonly cause hypoglycemia, while metformin taken on its own rarely does. Lisinopril treats blood pressure but does not by itself establish that a low pressure caused this episode, and bottles remain valuable evidence even though they are not proof of what was actually swallowed or when.

A patient with abdominal pain speaks almost no English. Her nine-year-old son speaks both languages fluently and offers to translate. The best approach for the EMT is to:

• a.Have the son translate throughout, since he is fluent and knows his mother's history
• b.Ask a bilingual neighbour who has come in to translate instead
• c.Use the service's interpreter line, addressing the patient directly✓
• d.Skip the history and rely on the physical examination and the vital signs by themselves

A trained or telephone interpreter is the standard, because clinical questions about pain, bleeding, pregnancy or drug use are ones a young child cannot render accurately and should not be made to hear, and the EMT should keep looking at and speaking to the patient rather than to the interpreter. Using the son is the genuinely tempting option, and an adult family member is a reasonable stopgap when nothing else can be reached, but a nine-year-old is not. The neighbour is the harder call: better than the child, still an untrained stranger who will afterwards know the patient's private history, so she is a fallback and not the answer when an interpreter line exists. Abandoning the history altogether throws away the part of the assessment that matters most in a medical complaint.

A 17-year-old collapsed briefly while sprinting at football practice on a warm day and is now alert with normal vital signs. His parents ask whether he really needs to go to hospital. The most important point is that:

• a.Collapsing in warm weather during exercise is heat-related and needs only fluids and rest
• b.Fainting during exertion suggests a cardiac cause and needs evaluation✓
• c.A full recovery with normal vital signs means he can stay home
• d.The brief jerking of his limbs during the collapse means epilepsy

Fainting that happens during exertion rather than after it is a recognized warning sign for structural heart disease or an arrhythmia in a young person, and normal vital signs afterwards are expected and reassure nobody, so this patient needs to be seen. Heat and exertion is the strongest competing explanation and it is common, but here it is a diagnosis of exclusion, and acting on it in the field is precisely how a cardiac cause gets missed in a young athlete. Brief jerking of the limbs is common in ordinary fainting from a short drop in cerebral blood flow and does not establish epilepsy.

A patient has a blood pressure of 224/126 together with a severe headache, blurred vision and new confusion. Under a typical EMS protocol the EMT should understand that:

• a.The reading alone defines the emergency, so a patient without symptoms is equally urgent
• b.An extra dose of his own blood pressure tablet should be taken now to bring it down
• c.Lying him head-down improves the blood flow to his brain and should be done during transport
• d.The symptoms of organ injury make this urgent, and the EMT does not lower the pressure✓

What separates a hypertensive emergency from a merely high reading is evidence that organs are being injured, such as headache with visual change, confusion, chest pain, breathlessness or focal weakness, and field care under typical EMS protocols is calm handling, oxygen if indicated, monitoring and prompt transport rather than any attempt to bring the pressure down. The idea that the number by itself defines the emergency is the most common misconception, and it matters because a symptom-free patient with a similar reading is handled far less aggressively. Extra doses of home medication are not an EMT intervention and lowering a pressure too fast can itself cause a stroke, and a head-down position raises pressure inside an already stressed skull.

A 20-year-old is breathing very fast after an argument and reports tingling in her fingers and around her mouth, with spasm of her hands. Her oxygen saturation is 100%. The EMT should:

• a.Have her rebreathe into a paper bag until the tingling settles
• b.Coach her breathing calmly while still looking for a medical cause✓
• c.Treat the tingling and hand spasm as proof of anxiety
• d.Withhold oxygen for the rest of the call because her saturation is already 100%

Reassurance and coaching a slower rate is the safe field response, but only alongside continued assessment, because pulmonary embolism, diabetic ketoacidosis, aspirin overdose, sepsis and myocardial infarction all present with fast breathing and can look like panic. Paper-bag rebreathing is the classic wrong answer and is no longer taught: it can cause dangerous hypoxia and has killed patients whose fast breathing turned out to be compensation for a serious illness. A saturation of 100% at this moment neither settles the cause nor licenses a decision to withhold oxygen for the remainder of the call, and the tingling and hand spasm come from the low carbon dioxide of overbreathing, whatever is driving the overbreathing.

A 2-year-old began coughing forcefully while eating grapes. He is sitting up, crying loudly between coughs, and his color is normal. The EMT should:

• a.Begin back blows and chest thrusts straight away
• b.Sweep a finger through his mouth to remove the grape
• c.Give abdominal thrusts until the grape comes out
• d.Let him keep coughing and avoid upsetting him✓

A forceful cough, a loud cry and normal color mean air is moving, and a child's own cough clears an object better than anything a rescuer can do, so the crew keeps him calm in his parent's arms, gives oxygen if he tolerates it and transports while watching for deterioration. Abdominal thrusts are the strongest competitor, because they are indeed the right technique for a choking child over one year old, but only once the obstruction becomes complete and the child can no longer cough, cry or breathe. A blind finger sweep is specifically avoided in children because it commonly drives the object deeper, and back blows with chest thrusts are the sequence for an infant under one year, not for a two-year-old.

A ventilator-dependent patient at home with a tracheostomy tube is in obvious distress and the ventilator's high-pressure alarm is sounding. His caregiver reports thick secretions all morning. Where the EMT's state scope and local protocol permit tracheostomy suctioning, the first action should be:

• a.Seal the stoma with a dressing and ventilate by mask over the mouth and nose instead
• b.Pull the tracheostomy tube out of the stoma so that the obstruction leaves with the tube
• c.Disconnect the ventilator and ventilate through the tube with a bag-valve device
• d.Suction the tracheostomy tube✓

A tube blocked by thick secretions is the most common cause of sudden distress in a tracheostomy patient, and a high-pressure ventilator alarm is what an obstruction between the ventilator and the lungs looks like, so clearing the tube by suction is the fix that addresses the cause. Note the qualifier in the stem: suctioning an established tracheostomy tube is within the EMT scope in many states and services and outside it in others, where the caregiver suctions or an ALS crew is required, so a candidate must know the local rule rather than a national one. Disconnecting and bagging through the tube is the strongest competitor and is the right next step if distress continues after suction, but forcing gas down a plugged tube does not move the plug. Ventilating over the mouth and nose is what a crew reaches for out of habit and can be useless here, because this patient breathes through the neck and the upper airway may be surgically separated from the lungs; if the tube cannot be cleared, ventilation is delivered at the stoma. Removing the tube is not the EMT's first move.

While suctioning a patient, an EMT gets a splash of blood-tinged secretions into her unprotected eye. Under a compliant exposure control plan, she should:

• a.Notify the on-duty officer first and wait for direction before flushing
• b.Finish the shift and report it later only if she develops symptoms in the weeks that follow
• c.Ask the receiving nurse whether the patient carries a bloodborne infection
• d.Flush the eye with water at once, then report the exposure through her service✓

The bloodborne pathogens standard requires the employer to ensure that mucous membranes are flushed with water immediately or as soon as feasible after contact, and to make a confidential post-exposure medical evaluation available, so the sequence is flush first and report immediately afterwards. Reporting first and waiting for direction is the genuinely tempting order, because reporting feels like the compliance step, and it is wrong only on timing: the flush costs seconds, needs no permission, and every minute of delay leaves material on the conjunctiva. Waiting until the end of the shift, or until symptoms appear weeks later, forfeits both post-exposure prophylaxis, whose value depends on starting quickly, and the documentation that supports any later claim. The source patient's status is established through the exposure process, not by a crew member asking a nurse at the bedside.29 CFR 1910.1030

A patient with several weeks of cough, night sweats and weight loss is being transported for suspected tuberculosis. Which respiratory protection is appropriate?

• a.Gowns and gloves for the crew, with no mask needed
• b.A surgical mask for the crew and one for the patient
• c.A fitted N95 respirator for the crew✓
• d.A fitted N95 respirator on the patient, with a surgical mask for the crew

Tuberculosis spreads by airborne particles small enough to stay suspended in the air, so the crew needs a fit-tested N95 or better, the patient wears a surgical mask to contain what he exhales, and the ambulance is ventilated with outside air. Surgical masks all round is the answer that catches candidates who remember droplet precautions for influenza, and it fails for a specific reason: a surgical mask does not seal to the face and does not filter fine airborne particles, which makes it the right item for the patient and the wrong one for the crew. Reversing the two puts the harder-to-breathe-through respirator on a sick patient and leaves the crew unprotected, and gowns and gloves guard against a contact route this organism does not use.

A 19-year-old with sickle cell disease has severe pain in both thighs and his back, of the kind he gets with a crisis. He is alert, with a fever and a mild cough. Appropriate EMT care includes:

• a.Keeping him warm, giving oxygen if he is hypoxic, and transporting✓
• b.High-flow oxygen for every sickle cell crisis regardless of the saturation
• c.Treating his pain report as drug-seeking and limiting care
• d.Ice packs on the painful limbs to reduce the inflammation

Warmth, oxygen when the patient is hypoxic or working to breathe, gentle handling, a position of comfort and prompt transport for fluids and analgesia are the supportive measures that fit the EMT scope in a sickling crisis. Oxygen for every crisis regardless of the number is the closest competitor and is worth being precise about: hypoxia does promote sickling, so a hypoxic patient must be oxygenated, but routinely giving oxygen to a patient who is already well saturated has not been shown to shorten a crisis, and the trigger is therefore the saturation and the work of breathing rather than the diagnosis. Ice is the specific trap, because cold causes vasoconstriction and can extend the sickling and the pain rather than relieve it. Fever with cough in a sickle cell patient raises the possibility of acute chest syndrome, which is life-threatening and makes this a time-critical transport, and treating a patient's reported pain as drug-seeking is a well-documented bias that delays care in exactly this population.

An 80-year-old on an anticoagulant struck her forehead on a cupboard door. She never lost consciousness, is fully oriented, has no headache, and wants to stay home. The EMT should tell her that:

• a.Not losing consciousness and having a clear head now rules out any dangerous bleeding
• b.Bleeding can start hours later on this medication, so she should be seen today✓
• c.A check with her own doctor sometime in the coming week would be perfectly adequate here
• d.She should stop the anticoagulant tonight to make bleeding less likely

Anticoagulants let a small tear go on bleeding slowly, so a patient can look and feel entirely normal for hours and then deteriorate, which is why even a minor head strike on these drugs warrants same-day assessment and imaging and why this refusal needs a careful conversation, a clear warning about what to watch for, and documentation. The belief that a clear examination and no loss of consciousness excludes a bleed is exactly the reasoning that leads crews to accept a refusal too easily, and it is the strongest competitor here. Deferring to a routine appointment next week misses the window in which a growing bleed can be found and treated, and an EMT never advises a patient to alter a prescribed medication, since stopping an anticoagulant carries its own risk of clot or stroke.

A patient receiving chemotherapy has an implanted chest port and is being transported for weakness. Under the EMT scope of practice used in the United States, the EMT should:

• a.Flush it with sterile saline so that it does not clot off en route
• b.Draw a blood sample from it for the hospital laboratory
• c.Leave it alone✓
• d.Access it with the home nurse's telephone permission

Accessing, flushing or drawing from a central venous catheter or an implanted port sits outside the EMT scope under the National EMS Scope of Practice Model, which gives the EMT no vascular access skills at all; the device is left undisturbed, the site is looked at and protected, and any vascular access needed is established by a provider whose scope includes it. Permission from a home nurse, or from the patient, is the tempting escape and it does not work, because consent cannot enlarge a scope of practice that the state has defined. Ports are also a route for bloodstream infection, so redness, swelling or tenderness at the site is worth reporting in the handover for a patient who is on chemotherapy and now weak.

An EMT is called for a woman who reports having been sexually assaulted an hour ago. She has minor injuries and is alert. Alongside her medical care, the crew should:

• a.Carry out a detailed examination of the genital area and record the findings
• b.Discourage washing or changing clothes, and handle clothing as little as possible✓
• c.Encourage her to shower and change into clean clothes before transport
• d.Hold off on all treatment until officers have arrived and finished interviewing her fully

Washing, changing clothes, drinking or using the toilet can destroy evidence, so the crew explains why and asks her to wait, disturbs clothing only as far as treatment requires, and puts any clothing that must be removed into a paper rather than a plastic bag, because plastic traps moisture and degrades biological evidence. Helping her clean up and change is the humane instinct and is the strongest competing answer, which is why it has to be talked through rather than simply refused: she decides, and the crew's job is to make sure she is deciding with the information. A genital examination is the trap: an EMT examines only what is needed to treat injury or bleeding, and the forensic examination belongs to trained clinicians. Medical care is never delayed for a police interview, and offering a provider of her preferred gender and a private, unhurried manner matters as much as anything clinical.

A 26-year-old who is about nine weeks pregnant has heavy vaginal bleeding with cramping and has passed some tissue. She is pale, with a pulse of 118 and a blood pressure of 96/60. Under most EMS protocols the EMT should:

• a.Assume an uncomplicated miscarriage, since passing tissue accounts for the bleeding and the pain
• b.Have her sit on the toilet during the bleeding so that any tissue can be collected cleanly
• c.Treat her for shock, apply an external pad, and take the passed tissue to hospital✓
• d.Discard the tissue she has passed, as it has no value once expelled

The pale skin, the pulse of 118 and the pressure of 96/60 make this a patient in shock, so field care is oxygen if she is hypoxic or poorly perfused, warmth, a position of comfort or supine as local protocol directs, an external pad with a count of how many are soaked so the hospital can gauge the loss, and rapid transport; the passed tissue travels with her because it helps the hospital establish what happened. Assuming a straightforward miscarriage because the passed tissue seems to explain everything is the dangerous shortcut and the strongest competitor, since a ruptured ectopic pregnancy presents in these same weeks with bleeding, cramping pain and shock, is a surgical emergency, and can shed decidual tissue that looks like a miscarriage. A patient in shock does not belong on a toilet, where she may faint and where the blood loss cannot be measured, and nothing is ever packed into the vagina.

A 14-month-old had a brief generalised seizure at home during a febrile illness. The seizure has stopped, he is sleepy but breathing well, and his frightened parents ask whether he still needs to go to hospital. The EMT should:

• a.Reassure the parents that a febrile seizure is harmless and that no evaluation is needed
• b.Put him in a cold bath to bring the temperature down fast
• c.Give his fever medicine by mouth now that the seizure has stopped
• d.Protect his airway, keep him comfortable, and transport for evaluation✓

A first febrile seizure needs a source for the fever to be found, so the crew supports the airway, positions him on his side, keeps the environment calm and transports, while explaining to the parents what happened, because a seizure in their child is terrifying and their calm helps him. Telling them no evaluation is needed is the tempting error, since most febrile seizures really are benign, but that is a conclusion available only after meningitis and other causes have been excluded by someone able to exclude them, and the parents keep the right to refuse once they have been told this. Cold immersion causes shivering and distress without safely lowering the temperature, and a drowsy postictal child should not be given anything by mouth.

A 9-year-old boy with autism who does not use speech is ill at home and becomes increasingly distressed as the crew works around him. The most effective approach is to:

• a.Lower the noise and lighting and ask his mother how he communicates✓
• b.Separate him from his mother so that the assessment is not influenced by her answers
• c.Restrain him early on, because a child who does not speak will not cooperate
• d.Speak loudly and repeat each question, since repetition helps

Reducing the sensory load, keeping the trusted caregiver present, having one person speak in short concrete phrases, explaining each touch before it happens and allowing a familiar comfort object are what actually make an assessment possible in an autistic patient, and the caregiver is the expert on this particular child's signals and pain behavior. Separating him from his mother is the strongest wrong answer, because it borrows a rule meant for a suspected-abuse interview and here removes the only person who can interpret him. Restraint escalates distress and is reserved for genuine danger to the patient or the crew, and volume and repetition add to exactly the sensory overload that is driving the behavior.

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 applies a hemostatic gauze to a bleeding wound that a tourniquet cannot reach. What must accompany its use?

• a.Packing the gauze into the wound and holding direct pressure for the stated time✓
• b.Irrigating the wound with sterile saline first so the agent is not diluted by contaminated blood
• c.Removing and replacing the gauze every few minutes so a fresh dose of the agent is applied
• d.Laying the gauze over the wound and covering it with a pressure bandage, without packing it

Hemostatic dressings work only when they are packed down into the wound so the agent contacts the bleeding vessel, then held under uninterrupted direct pressure for the time the manufacturer specifies — commonly three minutes for the products carried on ambulances. Lifting the dressing to look, or replacing it for a fresh dose, tears away the clot that is forming and restarts the bleeding. Laying gauze on the surface leaves the vessel deep in the wound untamped, and irrigating first delays the pressure that is what actually stops the hemorrhage.

A patient has an open tibia fracture with bone visible in the wound. How should the EMT manage it?

• a.Cover with a sterile dressing, splint as found, and do not push the bone back in✓
• b.Irrigate the exposed bone with sterile saline and then draw it gently back under the skin
• c.Apply traction to the leg until the bone end retracts, then splint the limb in alignment
• d.Apply a tourniquet proximal to the wound, since every open fracture bleeds significantly

An open fracture is covered with a sterile dressing and splinted in the position found, and protruding bone is neither pushed nor pulled back inside, because that carries surface contamination deep into the wound and into the bone itself. Distal pulse, motor function and sensation are checked before and after splinting, and the fact that the bone may slip back under the skin as the limb is splinted is documented and passed on. Traction splinting is for a closed midshaft femur fracture, not a way to reduce exposed tibia. A tourniquet is reserved for bleeding that direct pressure cannot control — most open fractures do not bleed at that rate, and applying one routinely causes avoidable ischemia.

A patient has an obvious shoulder dislocation with the arm held away from the body and a strong radial pulse. What is the appropriate field management?

• a.Reduce the dislocation by applying steady traction until the joint returns into place
• b.Splint the arm in the position found and support it with padding✓
• c.Move the arm to the patient's side and secure it with a sling and swathe for comfort
• d.Apply ice and move the joint gently through its range to confirm that it is truly dislocated

A dislocated joint is splinted in the position in which it is found, padded and supported — often with a pillow in the gap between the arm and the chest — and distal pulse, motor function and sensation are checked before and after. A sling and swathe is the competing answer, and it is right for many arm injuries, but it requires bringing the arm to the chest wall; forcing a dislocated shoulder into that position can stretch or compress the axillary nerve and vessels and convert a stable injury into a limb-threatening one. Reduction is not an EMT skill except where the distal pulse is absent and local protocol specifically authorizes it, and moving the joint to test it risks further damage.

An electrician was shocked by a high-voltage line and has small burns on one hand and one foot. Why does this patient need a high level of concern despite the small visible burns?

• a.Current travelling between the wounds can injure deep tissue and disturb the heart rhythm✓
• b.The main risk is fluid loss from the burned surface, so shock follows the burned area
• c.The entry and exit wounds show the full extent of the injury and are treated as burns
• d.The patient will be in severe pain, which by itself causes shock in electrical injuries

The wounds mark only where the current entered and left; everything along the path between them — muscle, blood vessels, nerves and the heart's conduction system — may be destroyed with no external sign, so the patient is monitored for dysrhythmias and transported even when the skin looks almost normal. Massive deep muscle destruction also releases myoglobin, which can injure the kidneys. Sizing the injury by burned surface area is the classic underestimate, and fluid loss from two small burns is not what threatens this patient. Pain does not by itself cause shock.

Which finding on a blunt abdominal trauma patient most strongly suggests significant internal injury?

• a.A single small abrasion across the lower abdomen from the lap portion of a seat belt
• b.Nausea reported by the patient with no tenderness anywhere on gentle palpation
• c.A soft abdomen that is mildly tender directly over the site of the reported impact
• d.A rigid, distended abdomen with a rising pulse and a falling blood pressure✓

Rigidity and distention together with a rising pulse and a falling blood pressure indicate blood accumulating in the abdomen — a load-and-go finding rather than something to keep assessing on scene. A seat-belt mark is the answer worth weighing against it, because it is a genuine red flag for bowel, mesenteric and lumbar-spine injury and should be reported; but it describes a risk of injury, whereas the rigid abdomen with failing vital signs is evidence that bleeding is already happening. Mild localized tenderness and nausea are common after any blunt impact and do not distinguish anything on their own.

An alkaline drain cleaner has splashed into a patient's eye. What is the correct field care?

• a.Irrigate for one minute, then patch the eye so the cornea is protected during transport
• b.Cover both eyes with dry sterile dressings and transport without irrigating the eye at all
• c.Irrigate continuously with water or saline from the inner corner outward, and keep irrigating en route✓
• d.Instill a neutralizing solution into the eye first, then irrigate once the reaction has stopped

Chemical eye injury is treated with immediate, continuous irrigation that carries on throughout transport, directed from the bridge of the nose outward so that runoff does not wash the chemical into the unaffected eye. Alkalis are the worst case because they keep penetrating the cornea for as long as they remain in contact with it, so time is the whole treatment. Stopping after a minute or patching the eye seals the chemical against the cornea, and dry dressings with no irrigation do the same. A neutralizing agent is never instilled, because the neutralization reaction itself releases heat into an already injured eye.

A trauma patient with significant blood loss is being packaged on a warm summer evening. Why does the EMT still work to keep the patient warm?

• a.Because shivering raises the patient's blood pressure and helps compensate for the loss
• b.Because warmth speeds the body's replacement of the red blood cells that were lost
• c.Because a cold patient's blood clots poorly, which worsens the bleeding✓
• d.Because a warm patient tolerates the ambulance ride with less pain and less anxiety

Clotting depends on enzymes that work poorly as the patient cools, so hypothermia, acidosis and impaired clotting reinforce one another in a bleeding patient — which is why blankets and a warm patient compartment are treatment rather than comfort. A patient who is bleeding cools quickly even in warm weather, especially once clothing has been cut away and cool air is blowing over the skin. Shivering consumes oxygen and generates acid rather than helping, and red cells are not replaced in the timeframe of an ambulance call. Comfort is a real benefit, but it is not why this is done.

After an explosion, which injury pattern is caused by the primary blast wave rather than by debris or by being thrown?

• a.Penetrating wounds to the torso and limbs from fragments propelled by the explosion
• b.Fractures and head injury sustained when the patient was thrown against a solid wall
• c.Injury to air-filled organs such as the lungs, middle ear, and bowel✓
• d.Burns to exposed skin and airway from the fireball that followed the detonation

The primary blast wave compresses and then releases gas-filled structures, so the lungs, tympanic membranes and bowel take the damage, and blast lung can develop with no external mark at all. Fragment wounds are secondary injuries, being thrown against a surface is tertiary, and burns, crush injury and inhaled toxins are grouped as quaternary. Recognizing the primary pattern matters precisely because it is the one that leaves nothing to see, so a patient who looks unhurt after a blast is still watched for worsening breathing.

An 84-year-old fell at home and has a shortened, externally rotated right leg with pain in the hip. How should the EMT package this patient?

• a.Apply a traction splint to the injured leg, since the mechanism and deformity match its use
• b.Support the leg with padding in the position found and move the patient as one unit✓
• c.Apply a pelvic binder, since a shortened, rotated leg after a fall indicates an unstable pelvis
• d.Straighten the leg into anatomical alignment and secure both legs together with cravats

A shortened, externally rotated leg with hip pain after a low-energy fall in an elderly patient is the classic proximal femur fracture. It is supported with padding in the position of comfort and the patient is moved as a single unit with a scoop stretcher or a sheet, so that the fracture is not manipulated. A traction splint is the answer that catches candidates who match the words shortened and rotated to a femur: traction splints are indicated for a midshaft femur fracture and are contraindicated when the injury is at the hip or the pelvis, because pulling on it can worsen the fracture and the bleeding. A pelvic binder is for a suspected unstable pelvic ring injury, which presents with pelvic pain and instability rather than an isolated painful hip. Weight bearing is never used to test for a fracture.

Which patient most clearly meets the kind of physiological criterion that trauma triage guidelines use to direct transport to the highest-level trauma center available?

• a.A patient with a two-inch scalp laceration that has already been controlled by pressure
• b.A patient with an isolated closed forearm fracture who reports the pain as severe
• c.A patient with a systolic blood pressure of 82 and a decreased level of consciousness✓
• d.A patient involved in a rollover crash who is alert with entirely normal vital signs

Field triage guidelines are worked through in order, and the first step is physiological: a Glasgow Coma Scale of 13 or less, a systolic blood pressure below 90 mmHg, or a respiratory rate below 10 or above 29. A systolic pressure of 82 is below that 90 mmHg threshold, and a decreased level of consciousness meets the mental-status criterion, so this patient satisfies the first step twice over. A rollover crash is the closest competing answer, and it does raise suspicion, but it is a mechanism criterion — mechanism sits below physiology and anatomy in the sequence precisely because normal vital signs after a dramatic crash are common. An isolated closed forearm fracture and a controlled scalp laceration meet no criterion in any category. Thresholds and the actual destination are set by each region's trauma system and local protocol.

Direct pressure has not controlled bleeding from a deep wound in the groin, and the site is too high for a tourniquet. Under a typical EMS protocol, what should the EMT do next?

• a.Pack the wound with gauze and hold firm pressure directly over the packed site✓
• b.Apply a tourniquet as far up the thigh as it will reach and tighten it fully
• c.Elevate the leg above the level of the heart and apply pressure over the femoral artery
• d.Apply a bulky pressure dressing over the first one and wrap it tightly with an elastic bandage

A junctional wound at the groin, axilla or neck is packed with plain or hemostatic gauze and held under firm, continuous pressure, because a tourniquet cannot be placed proximal to it. The high-thigh tourniquet is the tempting answer, and a tourniquet is right for a limb wound, but a device that sits below the bleeding vessel controls nothing. Stacking dressings hides ongoing blood loss and moves the pressure away from the source. Elevation and pressure points are no longer taught as bleeding-control steps, because neither was ever shown to control severe hemorrhage.

A patient has been struck in the chest and has distended neck veins, absent breath sounds on one side, and a falling blood pressure. Which type of shock does this pattern represent?

• a.Hypovolemic shock
• b.Distributive shock
• c.Obstructive shock✓
• d.Cardiogenic shock

Rising pressure inside the chest keeps blood from returning to the heart, so the heart has nothing to pump; that is obstructive shock, and the likely cause here is a tension pneumothorax. Hypovolemic shock is the close call, because a hemothorax also follows blunt chest trauma and also takes away breath sounds on one side — but blood loss flattens the neck veins instead of distending them, and that single finding separates the two. Distributive shock follows widespread vasodilation, as in anaphylaxis or neurogenic shock, and would not silence one lung. Cardiogenic shock follows pump failure; a blow to the chest can bruise the myocardium, but that does not produce unilateral absent breath sounds.

A child has been rescued from a house fire. Which finding most strongly suggests an inhalation injury that will need aggressive airway management?

• a.Superficial burns across both forearms sustained while shielding the face
• b.Anxiety and restlessness with a heart rate of 130 after being carried from the smoke
• c.A respiratory rate of 30 with clear lung sounds throughout both fields
• d.Soot around the nostrils with singed nasal hair and a hoarse, strained voice✓

Soot in the nose or mouth, singed nasal or facial hair, and a hoarse or stridorous voice point to thermal and chemical injury to the upper airway, which can swell shut over the following hour. Restlessness with a fast heart rate is the finding worth a second look, since it can be early hypoxia — but it is a reason to reassess oxygenation, not evidence that the airway itself is burned. Superficial burns on the forearms and a raised respiratory rate are both expected after a fire and neither localises the injury to the airway.

A worker has dry lime powder spilled across a forearm. What is the correct first step in caring for this chemical burn?

• a.Flush immediately with copious water for at least twenty minutes, then cover the arm
• b.Neutralize the lime with a weak acid solution before any water is applied to the skin
• c.Brush the dry powder off the skin first, then flush the area with copious running water✓
• d.Cover the arm with a dry sterile dressing and let the emergency department remove the powder

A dry chemical is brushed off first, because water applied to dry lime activates it and can deepen the burn; once the powder is off, the site is irrigated with large volumes of running water. Immediate flushing is the genuinely tempting answer, and it is correct for a liquid chemical, but with a dry powder the brushing step comes first. Neutralizing agents are not applied in the field, since the neutralization reaction itself generates heat. Leaving the powder in place lets it keep reacting with moisture on the skin all the way to the hospital.

An adult has partial-thickness burns covering the entire front and back of one leg and the entire front of the torso. Using the adult rule of nines, what percentage of body surface area is burned?

• a.18 percent
• b.36 percent✓
• c.27 percent
• d.54 percent

In the adult rule of nines an entire lower limb is 18 percent (9 percent front plus 9 percent back) and the anterior trunk is 18 percent, so 18 + 18 = 36 percent. Counting only one surface of the leg and only half the anterior trunk gives 9 + 9 = 18. Counting the leg correctly at 18 but the anterior trunk as 9 gives 27, and treating the anterior trunk as a single 9 is the most common slip. Counting the whole trunk, front and back, gives 18 + 36 = 54, but the posterior trunk is not burned in this patient.

An EMT is preparing to splint a forearm that is obviously deformed. Which step must be performed both before and after the splint is applied?

• a.Straightening the angulation so the limb lies in normal anatomical position
• b.Checking pulse, motor function, and sensation distal to the injury✓
• c.Padding the voids between the limb and the splint before securing the straps
• d.Covering any open wound with a sterile dressing to reduce contamination

Distal pulse, motor function and sensation are documented before the splint goes on and rechecked immediately afterward, because a splint applied too tightly can compromise circulation that was intact a minute earlier. Padding the voids and covering an open wound are both real and necessary steps, which is what makes them tempting, but each is done once, before the splint, and neither is repeated as a circulation check. Realigning an angulated limb is done only when the distal pulse is absent and local protocol permits, so it is not a routine step at all.

Under typical EMS protocols and traction-splint manufacturer instructions, which finding is a contraindication to applying a traction splint to a suspected midshaft femur fracture?

• a.A closed fracture with obvious deformity and shortening of the injured leg
• b.Significant pain and swelling of the thigh with an intact distal pulse
• c.An associated injury to the pelvis, knee, or lower leg on the same side✓
• d.A distal pulse that is weaker on the injured side than on the other

A traction splint pulls against the pelvis at one end and the ankle at the other, so a fracture or dislocation of the pelvis, hip, knee, tibia, fibula or ankle on that side is a contraindication — the device would drag force through a second injury. The weak distal pulse is the option that catches prepared candidates: it demands careful reassessment and rapid transport, but it is not a reason to withhold traction, since restoring length often improves distal circulation. A closed midshaft femur fracture with deformity and shortening is the classic indication, and severe pain with an intact pulse is simply the expected presentation.

A patient struck in the head is initially alert but over ten minutes becomes drowsy, with a rising blood pressure, a slowing pulse, and irregular breathing. What does this pattern indicate?

• a.Hypovolemic shock from bleeding into the scalp
• b.Rising intracranial pressure✓
• c.A vasovagal reaction to the pain
• d.An expected course after a concussion

A rising blood pressure with a falling pulse and an irregular breathing pattern is the Cushing triad of rising intracranial pressure, and the declining mental status makes this a load-and-go patient. Hypovolemic shock moves the vital signs the other way — pressure down, pulse up — so scalp bleeding does not explain this picture even though the scalp bleeds freely. A vasovagal reaction lowers both the pressure and the pulse and does not progressively depress consciousness. Drowsiness alone is common after a concussion, but a course that worsens over ten minutes alongside these vital signs is not an expected recovery.

Which set of findings suggests a basilar skull fracture?

• a.Bruising behind the ears and around both eyes with clear fluid draining from the nose✓
• b.A boggy swelling over the parietal area with a laceration through the scalp
• c.Unequal pupils with weakness of the arm and leg on one side of the body
• d.Steady bleeding from a scalp wound that soaks through several trauma dressings in minutes

Battle's sign behind the ears, raccoon eyes around the orbits, and clear or blood-tinged cerebrospinal fluid from the nose or ears together point to a fracture of the skull base, and nothing is packed into the ear or nose to stop that drainage. Unequal pupils with one-sided weakness is the strongest competing answer, because it is also an ominous head-injury finding — but it indicates a mass pressing on the brain rather than locating a fracture of the base. A scalp hematoma or a briskly bleeding laceration indicates local injury only.

A restrained driver in a low-speed collision is alert, has no midline spinal tenderness, no neurological complaint, and is not intoxicated or distracted by another injury. Under many current EMS protocols, what is the appropriate spinal care?

• a.Apply a cervical collar and secure the patient to a long backboard for transport
• b.Restrict motion with a vacuum mattress, since low-speed crashes still transmit force
• c.Apply a cervical collar only
• d.No spinal motion restriction is indicated for this patient✓

Selective spinal motion restriction protocols let an EMT withhold restriction when the patient is alert and sober, has no midline tenderness, no neurological deficit and no distracting injury — this patient meets every criterion. The collar-only answer is the hard call, and many crews reach for it out of habit, but a collar is not risk-free and the criteria for applying one are exactly the assessment that has already been performed. Routine long-board use has largely been abandoned because the board causes pain and pressure injury with no demonstrated benefit, and a vacuum mattress is a gentler device but still restriction this assessment does not call for. These criteria differ between states and services, so the local protocol governs.

A patient has an open abdominal wound with a loop of bowel protruding. How should the EMT dress this evisceration?

• a.Replace the bowel gently into the abdomen and cover the wound with a dry bulky dressing
• b.Cover the organs with a dry sterile gauze and tape it firmly on all four sides
• c.Pack sterile gauze around the loop of bowel to hold it steady during transport
• d.Cover the organs with a moist sterile dressing and then an occlusive outer layer✓

Exposed abdominal contents are covered with a sterile dressing moistened with sterile saline and then an occlusive layer to slow drying and heat loss, and the patient's knees are usually flexed to reduce tension on the wound. The dry sterile dressing is the plausible near-miss, since dry sterile gauze is right for almost every other open wound, but here it lets the bowel dry out and adhere to the dressing. Protruding organs are never pushed back inside, because doing so contaminates the abdominal cavity, and packing gauze around the loop adds pressure without protecting it.

A finger has been completely amputated in a workshop. How should the amputated part be handled for transport?

• a.Wrap the part in sterile gauze, seal it in a dry plastic bag, and keep the bag cool on ice✓
• b.Immerse the part in sterile saline in a sealed jar and keep the jar at room temperature
• c.Leave the part at the scene and transport the patient, since reattachment is rarely possible
• d.Place the part in a container of ice water so the tissue is cooled as fast as possible

The amputated part is wrapped in a sterile dressing, sealed in a plastic bag, and kept cool by resting that bag on ice — never in direct contact with ice or in ice water, which can freeze and destroy the tissue. Saline immersion is the closest wrong answer, and services differ over whether the dressing is left dry or lightly moistened with sterile saline, but no protocol soaks the part, because immersion makes the tissue swell and macerate. The part always travels with the patient, since the surgical team, not the crew, decides whether reattachment is possible.

A patient has a section of ribs broken in two or more places each, and that segment of chest wall moves inward as the patient inhales. What is this finding called and why is it dangerous?

• a.Paradoxical breathing from spinal injury, because the intercostal muscles are paralyzed
• b.Tension pneumothorax, because air trapped under pressure pushes the segment inward
• c.Flail chest, because the segment reduces the volume of air moved with each breath✓
• d.Subcutaneous emphysema, because air trapped in the tissue makes the chest wall move oddly

A free-floating segment of chest wall that moves opposite to the rest of the chest is a flail segment, and it is dangerous because the underlying lung is bruised and the patient cannot generate an effective tidal volume. Spinal injury does cause paradoxical breathing, which makes it the tempting alternative, but there the whole abdomen rises as the chest falls rather than one rib segment moving on its own. A tension pneumothorax pushes structures away from the injured side, and subcutaneous emphysema is felt as crackling under the skin rather than seen as a moving segment.

A construction worker has a metal fragment impaled in the left eye. How should the EMT manage this injury?

• a.Remove the fragment and irrigate the eye continuously with sterile saline en route
• b.Stabilize the object, cover both eyes, and transport✓
• c.Cover the injured eye with a firm pressure patch and leave the other eye uncovered
• d.Apply a moist dressing over the object alone so the cornea does not dry out during transport

The object is stabilized in place, often with a rigid cup, and both eyes are covered, because the eyes move together and any movement of the uninjured eye moves the injured one. Covering only the injured eye is the near-miss: the dressing is right but the uncovered eye keeps tracking whatever it looks at and drags the injured globe with it. An impaled object is not removed in the field, and pressure on a penetrated globe can force its contents out.

A pregnant woman in her third trimester was involved in a crash and must be transported with spinal motion restriction. What positioning change is required?

• a.Tilt the whole immobilization device to the left, or manually displace the uterus✓
• b.Transport her flat and supine, because spinal restriction rules out any tilt of the device
• c.Transport her sitting fully upright so the weight of the uterus is carried by the pelvis
• d.Transport her on her right side so the liver supports the weight of the uterus

Lying flat lets the uterus compress the inferior vena cava and cut venous return, so the entire secured device is tilted toward the patient's left, or the uterus is manually displaced to the left, which preserves spinal alignment while relieving the compression. Keeping her flat and supine is the tempting answer, since tilting a secured patient feels like breaking spinal precautions, but tilting the whole device moves the patient as a unit and does not. Sitting upright does not maintain spinal precautions, and a right-side tilt leaves the uterus over the vena cava, which is the position being avoided.

A 6-year-old fell from a height and has a normal blood pressure with a heart rate of 150 and delayed capillary refill. How should the EMT interpret these findings?

• a.The normal blood pressure shows perfusion is adequate and the child is stable
• b.The heart rate is a normal response to fear and does not indicate any blood loss
• c.The child is in cardiogenic shock, since blunt trauma commonly bruises the heart
• d.The child is in compensated shock and can decompensate very suddenly✓

Children hold their blood pressure up by raising the heart rate and clamping down peripheral vessels, so a normal pressure with tachycardia and delayed capillary refill is compensated shock — and when that compensation fails the pressure falls abruptly. Fear is the reasonable competing explanation for a heart rate of 150 in a frightened child, but fear does not delay capillary refill, so the two findings together cannot be dismissed as distress. Treating the normal pressure as reassurance is the classic pediatric trauma error, and cardiogenic shock is uncommon in children after blunt trauma.

Which mechanism of injury should most strongly raise an EMT's suspicion of severe internal injury even when the patient looks well?

• a.Ejection from a vehicle during a rollover collision✓
• b.A rear-end collision at low speed with no damage to either vehicle
• c.A fall from a standing height onto a carpeted floor indoors
• d.Deployment of the driver's airbag in a frontal collision

Ejection means the occupant absorbed the full energy of the crash and then a second impact on landing, and it remains one of the strongest single predictors of serious injury however well the patient looks. Airbag deployment is the tempting answer: it does show the crash was hard enough to trip the sensor, but the bag absorbed energy rather than delivering it, and deployment by itself is not one of the high-risk mechanism criteria, whereas ejection, compartment intrusion and the death of another occupant are. A low-speed rear-end collision with no vehicle damage and a fall from standing height onto carpet transmit far less energy, although a same-level fall can still be serious in an older adult.

An adult has a large open wound to the side of the neck with dark blood flowing steadily. Besides controlling the bleeding, what specific risk requires an occlusive dressing?

• a.Bacterial contamination of the wound from the surrounding skin and clothing
• b.Swelling of the tissue that compresses the trachea from the outside
• c.Evaporation of fluid from the exposed tissue causing rapid heat loss
• d.Air being drawn into an open vein and forming an air embolism in the heart✓

An open neck vein can draw air in with each breath and send an air embolism to the heart, so the wound is covered with a dressing sealed on all sides and pressure is applied without compressing both carotid arteries. Contamination, heat loss and airway-compressing swelling are all real concerns with neck wounds, which is why they read as plausible, but none of them is a reason the dressing has to be airtight rather than simply absorbent.

A patient's tooth was knocked completely out during an assault and the crew has recovered it. How should the tooth be handled?

• a.Scrub the root clean with sterile gauze and then wrap the tooth in a dry sterile dressing
• b.Place the tooth in tap water so that the root surface is kept from drying out en route
• c.Handle the tooth by the crown and keep it moist, then transport it with the patient✓
• d.Leave the tooth at the scene and have the patient see a dentist within a few days

The tooth is picked up by the crown, kept moist in milk or sterile saline, and sent with the patient, because the living cells on the root surface are what allow reimplantation and they die quickly once dried or scrubbed off. Tap water is the tempting storage medium and it does keep the root wet, but it is hypotonic and bursts those very cells, so it is worse than milk or saline. Delaying dental care by days makes successful reimplantation far less likely.

A patient trapped under a collapsed wall for several hours is about to be freed. Why does the EMT alert the receiving hospital before the weight is lifted?

• a.Because the patient will need pain medication as soon as the pressure is finally released
• b.Because a limb trapped for that long will almost certainly require amputation on arrival
• c.Because releasing the compression can release harmful substances into the circulation✓
• d.Because the injured limb bleeds heavily as soon as circulation is restored to it

Prolonged compression damages muscle, and when the pressure comes off, potassium, myoglobin and acid from that muscle wash into the circulation and can cause cardiac arrest and kidney injury — crush syndrome, which the hospital and advanced providers prepare for in advance. Bleeding on reperfusion is the closest wrong answer, since a crushed limb can indeed bleed once flow returns, but the danger driving the early alert is what enters the bloodstream rather than what leaves the limb. Pain control matters and is not the reason for a pre-arrival notification, and amputation is not a foregone conclusion.

An older adult on an anticoagulant fell and struck her head, and she is alert with no complaints. Why does this patient still warrant transport and careful reassessment?

• a.Anticoagulants cause dizziness that will make a second fall happen within hours
• b.Anticoagulation lets a slow intracranial bleed grow for hours before symptoms appear✓
• c.Older patients cannot give reliable histories, so every fall in this age group is transported
• d.The medication itself must be reversed in the emergency department after any fall

An anticoagulated patient can bleed slowly inside the skull and look entirely normal at first, with deterioration appearing hours later, so a reassuring assessment on scene does not rule out serious injury. The reversal answer is the one that traps prepared candidates: reversal agents do exist, but whether any is given is a hospital decision that depends on imaging and on which anticoagulant was taken, so it is not why this patient is transported. Anticoagulants do not themselves cause dizziness, and many older patients give excellent histories.

Which statement about applying a commercial pelvic binder to a patient with a suspected unstable pelvic fracture is correct?

• a.It is centered over the iliac crests
• b.It is centered over the greater trochanters✓
• c.It is applied only after the pelvis is rocked to confirm instability
• d.It is applied loosely enough to slide a hand underneath the strap

A pelvic binder is centered at the level of the greater trochanters, because that is where circumferential compression actually closes the pelvic ring. Placing it higher, over the iliac crests, is the most common application error in practice and feels anatomically sensible, but a binder sitting on the crests squeezes bone that does not move and leaves the ring unreduced. The pelvis is not rocked or sprung to test for instability, since that can disrupt clot that has already formed, and the binder is snug by design because compression is the whole point.

During a mass-casualty incident run under a typical triage protocol, a patient tagged Immediate at initial triage is reassessed twenty minutes later and is now walking and talking normally. What should happen?

• a.The original tag stands until a physician changes it in hospital
• b.The patient is directed to the minor treatment area with the tag unchanged
• c.The patient is retriaged and the tag changed to the current category✓
• d.The patient is transported immediately in the order the first tag set

Triage is repeated as conditions change, and a patient's category is revised in either direction whenever reassessment shows a different status — that is exactly what secondary triage is for. Moving the patient to the minor treatment area while leaving the old tag in place is the closest wrong answer, because the destination is right, but an Immediate tag on a walking patient misinforms everyone downstream who reads it. A tag records a judgement at one moment rather than a permanent classification, and no physician's authorisation is needed to update it on scene. Transporting on an outdated tag sends scarce resources to the wrong patient, which is what triage exists to prevent.

How does a Good Samaritan law generally differ from an EMT's duty to act while on shift?

• a.It removes all liability from any provider who renders aid, on duty or off duty
• b.It offers limited protection to someone who volunteers aid without a duty to act✓
• c.It applies only to physicians and nurses, not to certified EMTs or paramedics
• d.It requires every certified provider to stop and render aid at any emergency scene

Good Samaritan statutes exist to encourage bystanders, including off-duty providers in many states, to help by limiting liability for care given in good faith and without compensation; they do not create an obligation to stop. The blanket-immunity answer is the tempting one, because these laws really are protective, but the protection is limited and none of them shields gross negligence or wilful misconduct. An on-duty EMT dispatched to a call has a duty to act, which is a separate legal concept, and coverage is not restricted to physicians and nurses. The details vary considerably between states.

A crew is asked to set up a landing zone for a medical helicopter at a rural crash. Which requirement is correct?

• a.An area directly beside the wreckage so that the transfer distance to the aircraft is as short as possible
• b.A paved surface only, because the rotor wash lifts dust and gravel from unpaved ground
• c.An area marked with road flares at each corner so the pilot can identify it from the air
• d.A level, firm area clear of wires, poles, and loose debris, sized as the flight crew specifies✓

The landing zone must be level, firm, and free of overhead wires, poles, trees and anything the rotor wash could pick up, and the flight crew specifies the dimensions they need for the aircraft they are flying. Marking the corners is genuinely part of setting up a zone, which is what makes the flare answer plausible, but open flame can be blown into the aircraft or ignite spilled fuel, so cones or secured lights are used instead. Dust and debris are managed by choosing and wetting the surface rather than by demanding pavement that rural scenes rarely offer, and the zone is kept well away from the wreckage.

Under the National EMS Scope of Practice Model, which capability is generally added at the AEMT level that an EMT does not have?

• a.Administering oral glucose to a conscious patient with suspected low blood sugar
• b.Inserting an oropharyngeal airway in an unresponsive patient with no gag reflex
• c.Establishing peripheral intravenous access and administering IV fluids✓
• d.Interpreting a cardiac rhythm and delivering manual defibrillation

Peripheral intravenous access, together with intravenous fluids and a small formulary of intravenous medications, is the capability the Advanced EMT level adds above the EMT. Oral glucose for a conscious patient and insertion of an oropharyngeal airway are both already inside the EMT scope. Interpreting a cardiac rhythm and defibrillating manually sits at the paramedic level; an EMT's defibrillation is done with an AED, which reads the rhythm itself. The national model is a template rather than a law, so the scope any individual provider actually holds is set by that provider's state and, within it, by the service's medical director.National EMS Scope of Practice Model

An EMT assists a patient with the patient's own prescribed nitroglycerin by following a written protocol, without contacting a physician first. What type of medical direction authorized this action?

• a.Offline medical direction, because the physician's authorization was issued in advance as a protocol✓
• b.Delegated practice, which lets an EMT give any medication a patient already has a prescription for
• c.Implied consent, because carrying the prescription shows the patient agreed to the medication
• d.Online medical direction, because the service's medical director personally signed that protocol document

Authorization granted ahead of time in the form of written protocols and standing orders is offline, or indirect, medical direction. Online direction means reaching a physician in real time by radio or phone for that specific patient; a physician's signature on a protocol is what makes the protocol valid, not what makes the direction online. An EMT does practice under delegated physician authority, but that delegation reaches only the medications and procedures the protocol names — a patient's own prescription does not enlarge it. Consent and medical direction are separate requirements that both have to be met: consent comes from the patient, the authority to act comes from the physician.

An ambulance responding with lights and siren reaches a red traffic light at a busy intersection. Under the standard of 'due regard' that state vehicle codes apply to emergency vehicle operators, what should the driver do?

• a.Cross at any speed while the lights and the siren are operating
• b.Proceed at the posted speed limit, holding the right of way
• c.Stop, then cross one lane at a time as each lane yields✓
• d.Cross without stopping, after slowing enough to react to cross traffic

Due regard means the driver stays personally responsible for the safety of everyone else, whatever exemption the traffic code grants. Lights and siren request the right of way, they do not confer it, and a driver who is not seen or not heard has no protection at all. State codes typically permit an emergency vehicle to pass a red signal only after slowing as necessary for safe operation, which makes 'slow, then cross' the tempting answer; emergency vehicle operator training goes further and teaches a full stop with the intersection cleared lane by lane, because a driver who merely slows cannot confirm that the far lanes have yielded, and the near lane stopping is exactly what hides the vehicle still coming in the far one. Intersection collisions are among the most common ways EMS crews and the patients they carry are injured, and the exemption is no defense once the crash has happened.

A helicopter is inbound to a rural crash scene. Which instruction about approaching the aircraft is correct?

• a.Approach from the rear of the aircraft, where the pilot has the clearest view of the ground crew
• b.Approach from the front, in the pilot's view, and only after the crew signals you in✓
• c.Approach as soon as the skids touch down so the transfer is not delayed by the shutdown sequence
• d.Approach from whichever side is uphill so the rotor disc stays well above head height

Ground crews approach a medical helicopter from the front, inside the pilot's field of view, and only after a crew member waves them in. The tail rotor is the lethal hazard and it is close to invisible when turning, so an approach from the rear is never correct. Waiting for the signal matters whether or not the rotors are still turning, because the crew, not the ground unit, decides when the aircraft is ready. Approaching uphill is exactly backwards: on sloping ground the rotor disc sits closest to the ground on the uphill side, so any approach on a slope is made from the downhill side.

EMS is staged at a hazardous materials incident. Where do EMTs without specialized hazmat training normally work, and what is their role?

• a.In the warm zone, where the decontamination corridor is set up and patients can be reached soonest
• b.In the hot zone with the entry team, so treatment begins at the point of exposure
• c.In the cold zone, receiving and treating patients only once they have been decontaminated✓
• d.In the cold zone, but stepping into the warm zone to help move patients who cannot walk out

EMTs without hazmat training and the matching protective equipment work in the cold zone and take patients only after decontamination, because a contaminated patient contaminates the crew, the ambulance and then the emergency department. The warm zone holds the decontamination corridor and is staffed by trained personnel in protective equipment; moving a non-ambulatory patient through that corridor is that team's job, and a good reason for entering is not a substitute for the training and the equipment, which is what makes stepping in 'just to help carry' the most tempting wrong answer here. The hot zone is limited to the entry team. Zone boundaries and the level of protection each requires are set by the hazmat branch under the incident commander.

An EMT arrives first at a single-vehicle crash and sees a diamond-shaped placard with a number on the trailer. What is the correct next step?

• a.Approach the cab closely enough to read the shipping papers, which name the exact material and quantity
• b.Move in immediately to reach the driver, since a short exposure keeps the risk low
• c.Stay well uphill and upwind, and look the placard number up in the Emergency Response Guidebook✓
• d.Read the placard's color and shape, which classify the hazard closely enough to act on

The placard is read from a distance, from uphill and upwind, and the identification number is looked up in the Emergency Response Guidebook, which gives the initial isolation and protective action distance for that material before anyone moves closer. Shipping papers do name the material more precisely, which is what makes that the strongest distractor, but they are carried in the cab within the driver's reach — inside the very area the guidebook exists to keep responders out of until the distance is known. The placard's color and shape give the hazard class only, not the material and not any distance. And an unknown material offers no safe exposure time, so a short exposure is not a low-risk one.

Under the Incident Command System, what does 'span of control' refer to?

• a.The number of people one supervisor can effectively direct, usually three to seven✓
• b.The list of agencies that have authority to assume command at a multi-jurisdiction incident
• c.The geographic area an incident commander is legally responsible for securing and managing
• d.The chain through which orders pass from the incident commander down to the crews

Span of control is a supervision ratio: one supervisor directs roughly three to seven subordinates, with five as the usual working figure, and once the incident grows past that the organization adds another layer of supervisors rather than stretching the ratio. The route orders travel, with each person reporting to exactly one supervisor, is the chain of command and unity of command — a closely related ICS principle and the reason that option is worth a second look, but it describes the direction of reporting rather than how many people report. The ground an incident covers is its perimeter, and which agency holds command at a multi-agency incident is settled through unified command.

During START triage, a patient who did not get up and walk to the collection area when directed is assessed and found to be breathing 24 times per minute, with a radial pulse present, and able to follow simple commands. How is this patient tagged?

• a.Immediate (red)
• b.Minor (green)
• c.Delayed (yellow)✓
• d.Expectant (black)

After the walking wounded have been directed away, START sorts each remaining patient on three checks: respirations, perfusion and mental status. Respirations of 24 are below the 30 per minute that would make this patient Immediate, a radial pulse is present, and the patient follows commands, so nothing triggers an upgrade and the tag is Delayed. Minor is assigned at the very first step to those who get up and walk to the collection area, which this patient did not do; following commands during an assessment is a mental status finding, not the ambulation test, and confusing the two is the usual error here. A respiratory rate that is merely above the normal adult range is not itself a START criterion. Expectant is used for a patient who is still not breathing after the airway has been opened. The four options are the four tag colors themselves, so they are near-identical in length by nature.

Which set of elements must all be present for a claim of negligence against an EMT to succeed?

• a.Breach of the standard of care, damages, and causation, with no separate duty to act required
• b.An error in care, a poor outcome, and a family willing to bring a lawsuit
• c.Duty to act, breach of that duty, damages, and causation linking the breach to the damages✓
• d.Abandonment of the patient, a documented injury, and no signed refusal form

Negligence requires four elements together: a duty to act, a breach of the standard of care, damages the patient actually suffered, and proximate causation tying the breach to those damages. The three-element version that drops the duty is the distractor worth thinking about, because breach, damages and causation are the elements people remember — but in most states an off-duty EMT who drives past a collision, with no relationship to the patient and no statute creating one, has no duty and therefore cannot be negligent for not stopping. The duty is what makes the remaining three actionable. A poor outcome with no breach is not negligence, and a breach that causes no harm is not either. Abandonment and refusal documentation are separate legal problems, not the elements of negligence.

A 15-year-old is injured at a skate park and no parent or guardian can be reached. Under the doctrine generally applied in this situation, how should the EMT proceed?

• a.Have the minor sign the treatment consent form, which makes the consent legally expressed
• b.Withhold all care until a parent arrives, because a minor cannot lawfully consent to treatment
• c.Treat the minor under implied consent, and document the attempts made to reach the guardian✓
• d.Ask an adult bystander to consent on the minor's behalf and record that person's name

When a minor has an emergency condition and a parent or guardian cannot be reached, the law generally presumes a reasonable parent would consent, so the EMT treats under implied consent and documents the attempts made to reach the guardian. Waiting for a parent while an emergency goes untreated is the outcome that doctrine exists to prevent. A bystander, however responsible, has no authority to consent for someone else's child, and a minor's signature does not create valid expressed consent where the minor cannot legally give it. The age of majority, the rules on emancipated and married minors, and the conditions a minor may consent to alone all vary by state, so the local protocol and state law govern the individual case.

A family presents a valid do-not-resuscitate order for a patient in cardiac arrest. What does a DNR order generally direct an EMT to do?

• a.Withhold resuscitation but continue oxygen, suctioning and comfort care✓
• b.Withhold all care, including oxygen, suctioning and any comfort measures
• c.Begin full resuscitation and leave the hospital to honor the order later
• d.Begin chest compressions but withhold ventilations and airway suctioning

A DNR order directs that resuscitation not be started. It is not an order to withhold care, so oxygen, suctioning, positioning, warmth and any pain relief inside the EMT's scope continue as comfort measures, and reading a DNR as 'do nothing' is the most common and most harmful misreading of it. No DNR form asks a crew to compress the chest while withholding ventilation; that combination is not a level any form offers. Deferring the decision to the hospital defeats the point of a prehospital order, which exists precisely so that resuscitation is not begun in the field. Which document a state recognizes out of hospital, and what a crew does when the form cannot be produced or the family objects at the bedside, is set by state law and local protocol, so the service's own policy governs.

An EMT realizes an hour after arriving at the hospital that a vital sign set was recorded on the wrong line of the patient care report. How should the correction be made?

• a.Erase or white out the incorrect entry and write the correct values over it so the record reads cleanly
• b.Leave the report alone and tell the receiving nurse verbally, because an amended report loses its legal weight
• c.Draw a single line through the error so it remains readable, add the correction, then date and initial it✓
• d.Complete a fresh report from memory and discard the original so only one version exists

The record is corrected by striking the error with a single line so the original entry stays readable, writing the correct information beside it, and dating and initialing the change; information remembered later is added the same way as a dated late entry. Erasing, whiting out or destroying the original all look like concealment and can cost the report its credibility if it is ever read in court, which is the opposite of the tidy record those options promise. Telling the nurse verbally is worth doing for the patient's sake, but it does not correct the permanent record. An amended record does not lose its legal weight; a record that appears altered does.

Which entry in a patient care report narrative is objective rather than subjective?

• a.Patient appeared intoxicated and was uncooperative throughout the assessment
• b.Patient was clearly anxious about the crash and seemed to be exaggerating the pain
• c.Skin cool and moist; radial pulse 118 and regular; respirations 22, unlabored✓
• d.The crash was probably caused by speeding, judging from what bystanders said

Measurements and direct observations are objective: skin that is cool and moist to the touch, a pulse counted at 118 and regular, and a respiratory rate counted at 22 without labored effort are findings any other provider at that bedside would record the same way. Intoxicated, uncooperative, exaggerating and probably speeding are all conclusions, and a reader cannot check any of them; they prejudice the care the patient is given next and they read badly if the report is ever produced in court. Record the findings that sit underneath the conclusion instead — the odor of alcohol on the breath, an unsteady gait, the patient's own words in quotation marks, or a bystander's statement attributed to that bystander.

An EMT lifts the head end of a loaded stretcher. Which technique reflects correct body mechanics?

• a.Bend at the waist and use the strong muscles of the lower back to raise the load smoothly
• b.Lift with the legs while twisting toward the ambulance so the load never has to be set down again
• c.Keep the back straight and locked, feet shoulder width apart, and the weight close to the body✓
• d.Extend the arms fully to lift the load away from the body and keep it clear of the shins

A safe lift keeps the back straight and locked in, the feet about shoulder width apart, and the load held as close to the body as possible, because the leverage on the spine grows with every inch the weight moves away from it. Lifting with the legs is right as far as it goes, but twisting while loaded is one of the most common mechanisms of back injury in EMS, so combining the two does not make the lift safe. Bending at the waist transfers the work from the legs to the lumbar spine, and extending the arms to keep the load off the shins buys clearance at the price of exactly the leverage a straight-back lift is trying to avoid.

A patient is found sitting in a car that is burning. Which category of move does this situation call for?

• a.A non-urgent move, because the patient is seated and can be extricated in a controlled way
• b.An emergency move, because the danger to the patient outweighs the risk of moving them✓
• c.An urgent move, because a seated patient is moved with a rapid extrication technique
• d.No move at all until the fire is knocked down, since moving a patient risks worsening any spinal injury

Fire, the threat of explosion, hazardous materials, and an inability to reach other patients are the classic reasons for an emergency move, in which the patient is dragged clear along the long axis of the body before assessment and spinal precautions are completed. The urgent move is the distractor that deserves real thought, because a seated patient often is moved by rapid extrication — but urgent moves are driven by the patient's own condition, such as altered mental status with inadequate breathing, when no external threat is forcing the timing. Here the hazard is the car. Waiting for the fire to be knocked down is only defensible when the scene itself is not what is about to kill the patient.

A combative patient has been physically restrained under local protocol. Which positioning practice is required to reduce the risk of positional asphyxia?

• a.Restrain the patient face down on the stretcher, which limits the patient's ability to strike out
• b.Sit the patient upright with the chest strapped tightly enough to stop the torso moving
• c.Restrain the patient face down with the wrists secured together behind the back for crew safety
• d.Never restrain the patient face down or hog-tied, and monitor the breathing continuously✓

A restrained patient is never left prone or hog-tied, and the breathing is monitored continuously from the moment the restraints go on. Prone positioning, wrists drawn behind the back, and a chest strapped tight enough to stop the torso moving all restrict the chest wall movement the patient needs to breathe — and a patient who has been fighting has just built an oxygen debt, which is what makes any restriction of chest movement so dangerous in exactly this group. Upright positioning is otherwise reasonable; it is the tightness across the chest that makes that option wrong. Restraint is applied only where local protocol and state law permit it, usually with law enforcement present, and the number of restraints, the position and the monitoring interval are all documented.

Which item normally appears in the verbal hand-off report given at the patient's bedside but is kept out of the shorter radio report given while en route?

• a.The patient's age and sex, which the hospital uses to assign a bed and a team
• b.The chief complaint, which tells the hospital what is being brought in
• c.The estimated time of arrival, which sets when the hospital must be ready
• d.The patient's name, which is not put out over an open radio channel✓

The radio report is kept short and identifies the patient only by age and sex, because radio traffic can be picked up by anyone with a scanner; the name is given face to face at the bedside instead. Age, sex, chief complaint, the significant findings, the treatment given and an estimated time of arrival are what the hospital needs in advance so the right team and the right room are ready, so all of those belong on the radio. The bedside hand-off then adds the name, any history obtained during transport, further vital signs, and the patient's response to what was done.

Which statement about releasing a patient's information under privacy rules is correct for an EMT?

• a.It may be given to any nurse or physician who asks for it, at any facility
• b.It may be shared with those involved in this patient's care and treatment✓
• c.It may be released to the patient's spouse or to a parent whenever they ask
• d.It may be discussed in public once the name and the home address are left out

Disclosure for treatment, payment and health care operations is permitted, which is what lets a crew hand a patient off to the receiving nurse without a separate authorization; disclosure beyond that generally needs the patient's written authorization or a specific legal exception such as a subpoena or a mandatory report. Holding a clinical license somewhere is not the same as being involved in this patient's care, which is why 'any nurse or physician' fails. A spouse or parent has no automatic right of access either — for a competent adult patient it is the patient who decides what family is told. And stripping the name does not make the case public property, because the address, the time and the type of crash can identify the patient to anyone who was there. HIPAA reaches EMS agencies that transmit health information electronically for billing, and state confidentiality law can be stricter still.45 CFR 164.506

EMS is called to a scene that turns out to be a homicide, and the patient is obviously deceased. Which action best preserves the scene?

• a.Cover the body with a sheet from the ambulance and turn off any lights left burning in the room
• b.Move the body to the ambulance so the family is not left looking at the deceased any longer
• c.Search the pockets and wallet for identification and a medical history to complete the report
• d.Use a single path in and out, disturb as little as possible, and document whatever you moved✓

Once a patient is obviously dead and law enforcement holds the scene, the crew limits itself to one route in and out, touches as little as possible, and writes down anything that was moved or changed while the patient was being assessed. Moving the body, searching belongings for identification, laying a sheet over the body and switching lights off all alter evidence, and the sheet in particular can transfer fibers onto the body. Sparing the family the sight of the deceased is a real motive, which is what makes that option tempting, but it is the investigator's decision, not the crew's. Nothing about scene preservation delays care where there is any chance the patient is still viable.

A crew member has been irritable, sleeping badly and withdrawing from colleagues since a pediatric call two weeks ago. What is the most appropriate response?

• a.Encourage the colleague to use the service's peer support or employee assistance program✓
• b.Reassure the colleague that the reaction will pass and that talking about the call would make it worse
• c.Report the colleague to the medical director so that fitness for duty is formally reviewed
• d.Move the colleague permanently onto administrative duties, away from any further pediatric calls

Sleep disturbance, irritability and withdrawal that persist for weeks after a difficult call are recognized stress reactions, and the appropriate step is to encourage the confidential help the service already provides — peer support, an employee assistance program, or a mental health professional. Telling a colleague that talking about it would make things worse discourages exactly the help-seeking that resolves most of these reactions. A fitness-for-duty referral is the strongest competing answer and may well be right later if the colleague's ability to work safely is genuinely in question, but as the opening move it turns a colleague's distress into a formal proceeding and teaches the rest of the crew not to disclose. A permanent reassignment does the same and pre-empts a decision the colleague has not been offered.

Which task is part of the post-run phase of an ambulance call rather than the en-route or at-scene phase?

• a.Cleaning and disinfecting the patient compartment, restocking supplies, and completing the report✓
• b.Fastening seat belts and reviewing which crew member will take the lead on patient care
• c.Confirming the dispatch address and the nature of the call with the communications center
• d.Notifying the receiving facility of the patient's condition and the estimated time of arrival en route

Cleaning and disinfecting the patient compartment, restocking what was used and completing the patient care report are post-run tasks, and the unit is not genuinely available again until they are done. Confirming the address with dispatch, fastening belts and settling who leads patient care all belong to the en-route phase, and notifying the receiving facility happens during transport. The post-run phase is the one crews cut short when calls are stacking up, which is how the next patient meets equipment the last patient used.

During the daily vehicle check an EMT finds the portable suction unit will not hold a vacuum. What is the correct action?

• a.Note the fault on the checklist and stay available, relying on the mounted onboard unit
• b.Retest the unit on the way to the first call, once the pump has warmed up
• c.Carry a spare set of rigid catheters as a workaround until the maintenance shop reopens
• d.Remove the unit from service, replace it, and document the fault before taking a call✓

A portable suction unit that will not hold a vacuum is taken out of service, replaced from stock, and the fault documented before the ambulance goes back on the queue. Leaning on the mounted onboard unit is the answer worth arguing about, and it is wrong for a practical reason: the portable is the one that goes to the patient — down the stairs, into the wreck, out to the curb — and state ambulance equipment lists generally require a working portable unit in addition to the mounted one, so a unit missing it is not properly equipped. Catheters generate no suction on their own. Retesting later means the failure is discovered beside a vomiting patient, and the daily check exists precisely so it is found in the bay instead.

An EMT is preparing to suction an unresponsive patient who is vomiting copiously. Which personal protective equipment is indicated?

• a.Gloves, eye protection, and a mask, because a splash of vomit is likely during suctioning✓
• b.Gloves alone, which are sufficient because vomit is not classed as a bloodborne hazard
• c.Gloves and a gown, with eye protection reserved for calls involving arterial bleeding
• d.A fit-tested respirator and gloves, because the airborne route is the concern when suctioning

Any task likely to generate a splash calls for gloves, eye protection and a mask, and suctioning an actively vomiting patient is the standard example; a gown is added when clothing is likely to be soaked through. It is true that vomit without visible blood falls outside the bloodborne pathogens rule, but standard precautions go further and treat all body fluids as potentially infectious rather than sorting them by type, so that reasoning does not get an EMT down to gloves alone. Eye protection is not reserved for arterial bleeding — the eye is a mucous membrane and any splash reaches it. A fit-tested respirator is selected for suspected airborne disease such as tuberculosis, which is a different route of exposure from a splash.

An EMS system reviews a sample of patient care reports each month against its own protocols and feeds the findings back to crews as training. What is this process called?

• a.Medical direction, the physician authority a service operates under
• b.Continuous quality improvement, often shortened to CQI✓
• c.Peer review privilege, a legal protection for the findings of a review
• d.Mandatory reporting, a statutory duty to notify a state agency

Measuring performance against the service's own standard and feeding the result back as education is continuous quality improvement, and the patient care report is the raw material it runs on. Medical direction is the physician authority the service operates under; the medical director usually sponsors and signs off the improvement program, which is why that answer attracts people, but the authority and the review process are two different things. Mandatory reporting is a narrow statutory duty to notify an agency of specific things such as suspected abuse or certain communicable diseases. Peer review privilege is a legal doctrine that in many states shields the findings of such a review from discovery in litigation — it describes protection given to the output, not the name of the activity.

An EMT arrives at a two-car crash on a divided highway at night. Which element of scene size-up is assessed first?

• a.Scene safety, including oncoming traffic, downed power lines, and the vehicle stability✓
• b.The mechanism of injury, which determines whether spinal motion restriction will be needed
• c.The nature of the illness reported by dispatch, which frames the assessment before arrival
• d.The number of patients, so that additional ambulances can be requested without delay

Standard precautions and scene safety come first in the size-up, because an EMT struck by traffic or contacting an energized conductor becomes a second patient and subtracts a rescuer at the same time. Counting patients and calling for resources is the next step and matters greatly at a two-car crash, but it is done from a position that is already safe. Mechanism of injury and nature of illness shape the assessment that follows once the scene can be entered. On a divided highway at night, scene safety means positioning the apparatus to shield the work area and putting on high-visibility outerwear before anyone steps out of the cab.

A 58-year-old had chest pressure while shoveling snow that eased within about four minutes once he stopped and rested. He is now pain-free with normal vital signs. Which interpretation is most accurate?

• a.Chest pressure that stops with rest rules out myocardial infarction, so he can be told to see his own doctor this week.
• b.Being pain-free means no heart muscle was injured.
• c.Exertional chest pressure in a man of this age is diagnostic of an evolving myocardial infarction.
• d.This fits stable angina, but only hospital evaluation can exclude a heart attack.✓

Stable angina is brief, predictable, provoked by exertion and relieved by rest, which is exactly what he describes, but unstable angina and an early infarction can also ease temporarily and no field finding distinguishes them. The tempting claim that relief with rest rules out infarction is wrong for that reason: patients whose pain settles still turn out to have infarcted, which is why evaluation is needed rather than a clinic appointment days later. Nothing about the episode makes the diagnosis certain in either direction.

A 62-year-old man has 40 minutes of burning epigastric discomfort that he blames on a heavy meal. He is pale and sweating heavily and feels short of breath. He denies any chest pain at all. The EMT should:

• a.Withhold aspirin until a hospital electrocardiogram has confirmed that the problem is cardiac in origin.
• b.Treat the complaint as indigestion, since he denies any chest pain at all.
• c.Manage him as a possible acute coronary syndrome and assist with aspirin if not contraindicated.✓
• d.Offer an antacid and reassess in ten minutes.

Epigastric burning with diaphoresis and shortness of breath is a classic anginal equivalent, and older adults, women and people with diabetes often infarct without ever reporting chest pain, so the crew must work the case as an acute coronary syndrome. Waiting for the hospital electrocardiogram is the strongest competing choice and sounds cautious, but aspirin's benefit depends on being given early, the field cannot exclude infarction, and a single chewed dose carries little risk in a patient with no bleeding history or allergy. An antacid neither treats nor excludes an infarction and only delays transport.

Before assisting a patient with suspected acute coronary syndrome with aspirin, which finding under most EMS protocols would lead the EMT to withhold it?

• a.A blood pressure of 96/60, because aspirin lowers the pressure further in a patient who is already hypotensive.
• b.A previous heart attack treated with a coronary stent and daily clopidogrel.
• c.Active gastrointestinal bleeding or a known aspirin allergy.✓
• d.A heart rate of 52 beats per minute.

Aspirin is withheld for hypersensitivity to it and for active or recent bleeding, because its only meaningful hazards are allergic reaction and bleeding. The patient already taking clopidogrel is the tempting exclusion, since it feels like doubling up on blood thinners, but existing antiplatelet therapy is not a contraindication and protocols still direct the aspirin dose for a new suspected infarction. Aspirin has no effect on blood pressure or heart rate, so neither vital sign has any bearing on the decision.

Under a typical EMS protocol, aspirin for a patient with suspected acute coronary syndrome is given as:

• a.Two 325 mg enteric-coated tablets swallowed whole with water to protect the stomach.
• b.One 81 mg tablet swallowed whole, with the rest given later at the hospital.
• c.160 to 325 mg of chewable aspirin, chewed.✓
• d.A single 650 mg dose, repeated once after fifteen minutes.

Protocols call for roughly 160 to 325 mg, and the tablets are chewed rather than swallowed because chewing speeds absorption and platelet inhibition when minutes of clot growth matter. An enteric coating is designed to delay dissolution in the stomach, which is the opposite of what is wanted here, and swallowing whole tablets has the same drawback. Splitting the dose or repeating it in fifteen minutes is not part of the prehospital regimen.

A man with chest pain has his own prescribed nitroglycerin and a systolic blood pressure of 132 mmHg. He mentions he took tadalafil (Cialis) last night. Under most EMS protocols the EMT should:

• a.Assist with the nitroglycerin, since the blood pressure is well within the range the protocol requires.
• b.Withhold the nitroglycerin because of the risk of severe, prolonged hypotension.✓
• c.Assist with half of the usual dose to blunt the drop in blood pressure.
• d.Have him lie flat and take the nitroglycerin.

Nitrates combined with an erectile-dysfunction drug of this class can cause profound hypotension that does not respond well to treatment; protocols exclude nitroglycerin within roughly 24 hours of sildenafil or vardenafil and roughly 48 hours of the longer-acting tadalafil. An adequate starting blood pressure is the tempting reason to proceed, but the pressure being acceptable now is exactly the situation in which the combined vasodilation causes the crash. There is no half-dose provision for this interaction, and lying the patient flat does not prevent it.

Under a typical EMS protocol that lets an EMT assist a patient with his own nitroglycerin for chest pain, what must happen before each additional dose?

• a.Nothing further is needed, because the pressure was checked before the first dose and the doses are five minutes apart.
• b.The blood pressure is rechecked and must still meet the protocol's minimum.✓
• c.The patient must be given oxygen by nonrebreather mask before each further dose.
• d.The patient must stand up to show he tolerates the drug.

Every dose dilates veins and can drop the blood pressure, so the pressure is measured again before each dose and the dose is withheld if it has fallen below the protocol's threshold; typical protocols allow up to three doses about five minutes apart on that condition. Relying on the pre-first-dose reading is the tempting shortcut, but it tells the crew nothing about what the drug has already done. Oxygen is given for hypoxia rather than as a prerequisite, and standing a patient up after a nitrate invites syncope.

A patient's chest pain eases substantially a few minutes after one dose of his own prescribed nitroglycerin. What does this response tell the EMT about the cause of the pain?

• a.It confirms the pain is cardiac, since nitroglycerin relieves only pain from narrowed coronary arteries.
• b.It shows the artery has reopened, so he can be transported without further reassessment.
• c.It rules out a heart attack and points to stable angina.
• d.Very little about the cause of the pain.✓

Nitroglycerin relaxes smooth muscle generally, so it can ease esophageal spasm and other noncardiac pain, while a genuine infarction may improve for a while and then return; response to the drug is not a diagnostic test in either direction. The claim that it confirms a cardiac cause is the most tempting because that is how the drug is described to patients, but it is a vasodilator rather than a coronary-specific one. Whatever the response, the patient needs continued monitoring and transport.

A patient with long-standing heart failure has marked swelling of both ankles and distended neck veins, but his lungs are clear on both sides and he speaks in full sentences. This pattern points to:

• a.Left-sided heart failure, because the left ventricle is the chamber that fails first in most patients.
• b.Right-sided heart failure with systemic venous congestion.✓
• c.Early acute pulmonary edema, before crackles become audible.
• d.Cardiac tamponade from a pericardial effusion.

When the right side of the heart fails, blood backs up into the systemic veins, producing jugular distention, dependent swelling of the ankles and an enlarged, tender liver, with the lungs staying clear. Left-sided failure is the tempting choice because it is more common, but it backs blood up into the lungs and would produce crackles and breathlessness, which this patient does not have. Tamponade also distends the neck veins, but it develops acutely with hypotension and muffled heart sounds rather than over years of ankle swelling.

A 74-year-old fainted while sitting at dinner with no warning symptoms at all. She is alert again and says she feels fine; her pulse is 38 and regular and her blood pressure is 104/62. The EMT should recognize that:

• a.Because she has recovered fully and her blood pressure is adequate, she can safely refuse transport.
• b.Sudden syncope with a very slow pulse suggests a cardiac cause and needs monitored transport.✓
• c.The slow pulse is a normal vagal after-effect of fainting and will settle on its own.
• d.Fainting while seated is typical of a simple vasovagal episode.

A vasovagal faint usually happens while standing and gives warning, such as nausea, sweating, tunnel vision or lightheadedness; collapse with no warning while seated, together with a heart rate that is still profoundly slow afterward, suggests a dysrhythmia such as heart block. The vagal after-effect explanation is the strongest competing answer, because vagal tone genuinely does slow the heart during a faint, but that slowing is transient and resolves once the patient is supine and awake, not a persistent rate of 38. Feeling well proves nothing when the underlying rhythm can stop again.

While assessing a patient who called for an ankle injury, an EMT records a blood pressure of 192/108. She feels well, with no headache, visual change, chest pain or neurologic deficit. The EMT should understand that:

• a.A high reading without end-organ symptoms is not an emergency.✓
• b.The reading is almost certainly an artifact of a cuff that is too small and can be disregarded.
• c.Nitroglycerin should be offered to bring the pressure down before transport.
• d.This is a hypertensive emergency, and the crew should arrange an intercept to have the pressure lowered en route.

A hypertensive emergency is defined by acute end-organ dysfunction accompanying the high pressure, such as chest pain, neurologic change, severe headache with visual disturbance or pulmonary edema, not by the number alone; this reading is documented, reported and rechecked. A cuff that is too small does inflate readings, which is why the crew should confirm with a correctly sized cuff, but that is a reason to remeasure rather than to dismiss the value. Lowering blood pressure is not an EMT intervention, and nitroglycerin is neither carried for this nor prescribed to her.

A crew finds a man unresponsive and cold in an unheated garage. His jaw is rigid and there is dependent purple discoloration along his back where he lies. Under a typical EMS protocol, the crew should:

• a.Begin CPR and apply the AED, because lividity and rigor are unreliable in a cold environment.
• b.Begin CPR while a supervisor is asked to confirm the findings before it is stopped.
• c.Move him to the ambulance and transport with compressions.
• d.Withhold resuscitation and follow the protocol for a death scene.✓

Rigor mortis together with dependent lividity is one of the definitive signs of death that protocols list as grounds for withholding resuscitation, alongside decapitation, decomposition and injury incompatible with life. The cold-environment objection is the strongest competing answer, and it is true that a severely hypothermic patient can feel stiff and look dead, but that stiffness is generalized cold rigidity without settled pooling of blood in the dependent tissues, which takes a prolonged period of no circulation to appear. Starting compressions and then hunting for permission to stop only exposes the crew and the scene to unnecessary disruption.

An adult is found in cardiac arrest lying in the middle of a soft bed. As compressions are started, the EMT should:

• a.Begin compressions on the mattress and accept a shallower depth, since any delay is more harmful.
• b.Move him to the floor or slide a backboard under him.✓
• c.Raise the bed to waist height and compress while kneeling on the mattress.
• d.Deflate the mattress and compress with the arms bent to add force.

A soft mattress absorbs part of every compression, so the chest is squeezed far less than the rescuer's hand travel suggests and cardiac output falls; a firm surface, gained by moving the patient down or sliding a board underneath, takes only seconds. Accepting a shallower depth is the tempting trade, but shallow compressions generate little forward flow, so the few seconds spent are repaid immediately. Kneeling on the mattress makes the sinking worse, and bent arms tire the rescuer and reduce depth rather than adding force.

An EMT is alone with a 7-year-old in cardiac arrest until the rest of the crew reaches her. What compression-to-ventilation ratio should she use?

• a.15 compressions to 2 breaths, the pediatric ratio at every stage of a child resuscitation.
• b.30 compressions to 2 breaths, changing to 15:2 when a second rescuer arrives.✓
• c.Continuous compressions with no pauses for breaths.
• d.5 compressions to 1 breath.

A single rescuer uses 30:2 for a child or infant, the same ratio as for an adult, because one person cannot switch between the chest and the airway often enough to sustain 15:2; the ratio drops to 15 compressions to 2 breaths only once a second trained rescuer is working. The 15:2 answer is the strongest distractor because that ratio is genuinely pediatric, but it is defined for two rescuers. Compressions without breaths are not the recommendation in children, whose arrests are usually caused by a breathing problem.

Two EMTs are resuscitating a 3-month-old in cardiac arrest. Which compression technique should be used?

• a.Two thumbs with the hands encircling the chest.✓
• b.The heel of one hand on the lower half of the sternum, as for a small child.
• c.Both thumbs side by side over the upper sternum, above the nipple line.
• d.Two fingers on the sternum, the infant technique whatever the number of rescuers.

With two rescuers the two-thumb encircling-hands technique is preferred for an infant: it produces more consistent depth and force and lets the compressor stay in position while the partner ventilates. The two-finger technique is the correct choice for a lone rescuer, which is why it is tempting, but it delivers less consistent depth when a second pair of hands is available. Whichever technique is used, the compression site is the lower half of the sternum, just below the nipple line, not the upper sternum.

A 79-year-old woke gasping for breath and has crackles throughout both lungs and pink-tinged frothy sputum. Her blood pressure is 168/96 and she is alert and anxious. Under most EMS protocols, initial EMT care includes:

• a.Laying her flat with the legs raised to improve blood return to the heart and support the pressure.
• b.Assisting her with a friend's furosemide tablet to draw fluid off the lungs.
• c.Encouraging her to cough forcefully.
• d.Sitting her upright with the legs dependent, plus oxygen.✓

This is acute pulmonary edema from left-sided heart failure; sitting the patient upright with the legs hanging down lets fluid settle away from the upper lungs and reduces the volume of blood returning to an overloaded heart, while oxygen treats the hypoxia. Laying her flat with the legs raised is the reflex for a shock patient and is the most tempting wrong answer, but here it pushes still more blood into a heart that cannot move it and worsens the flooding of the lungs. An EMT may never give a medication prescribed to someone else, and coughing does not clear fluid out of the alveoli.

Where the EMT's scope permits placing a supraglottic airway, how does adult CPR change once that airway is in place?

• a.Compressions still pause every 30 compressions for two breaths, since pausing keeps the ventilations effective.
• b.Ventilation stops once the airway is in place.
• c.Continuous compressions with a breath every 2 seconds.
• d.Compressions become continuous, with one breath every 6 seconds.✓

Once an advanced airway seals the airway, breaths no longer have to be synchronized with compressions, so the compressor works continuously while the other rescuer delivers about 10 breaths per minute, one every 6 seconds. Continuing to pause after every 30 compressions is the tempting habit carried over from bag-mask CPR, but those pauses drop coronary perfusion pressure that then takes several compressions to rebuild. A breath every 2 seconds is 30 per minute, which raises pressure inside the chest, impedes venous return and reduces the output the compressions generate.

A bystander asks why hands-only CPR, which is encouraged for adults, is not what is recommended for a child. The best explanation is:

• a.Hands-only CPR is only approved for rescuers with formal training.
• b.A child's chest is too flexible for compressions alone to move blood, so breaths replace the missing circulation.
• c.Compressions may fracture a child's ribs, so ventilations reduce the number of compressions needed.
• d.Most pediatric arrests begin with a breathing problem, so ventilations matter more.✓

Adults usually arrest from a sudden rhythm problem with oxygenated blood still in the chest, whereas children usually arrest at the end of a respiratory or shock process, so their blood is already oxygen-depleted and rescue breaths are a necessary part of the resuscitation. Breaths do not create circulation, however, so describing them as replacing compressions is wrong, and a flexible chest makes compressions more effective rather than less. A bystander who is unwilling or unable to ventilate should still do compressions rather than nothing.

An adult in cardiac arrest has a hard lump under the skin below the left collarbone with a small surgical scar over it, consistent with an implanted pacemaker or defibrillator. The EMT should:

• a.Withhold the AED, because the implanted device will deliver its own shocks and an external shock could destroy it.
• b.Place the pad directly over the device so the shock reaches the heart.
• c.Place the pad about an inch clear of the device and use the AED normally.✓
• d.Turn the implanted device off first.

The pad is positioned about an inch, or 2.5 cm, away from the generator so that current is not shunted around the device or the heart, and the AED is then used exactly as usual. Withholding the shock is the dangerous temptation, since the patient is pulseless and the implanted device has plainly failed to restore a rhythm; an external shock may damage it, but that is a repairable problem in a survivor. An EMT has no means of switching the implant off, and a pad directly over it wastes energy on the metal can.

A man is pulled from a swimming pool in cardiac arrest onto a wet pool deck. Regarding AED use, the EMT should:

• a.Wait until he is completely dry from head to toe before attaching the pads, since surface water conducts the shock.
• b.Move him clear of standing water and dry the chest.✓
• c.Attach the pads at once without drying, because a little water does not affect the shock.
• d.Move him onto a rubber mat and shock without wiping the chest.

Standing water can carry current to rescuers, and a film of water on the chest lets the shock track across the skin between the pads instead of through the heart, so the patient is moved clear of pooled water and the chest is wiped dry before the pads go on. Drying him from head to toe is the tempting overcorrection, but it costs minutes of defibrillation delay for no added safety once he is off the wet surface and the pad sites are dry. A mat does not solve the problem of a wet chest between the pads.

A patient re-arrests in the back of an ambulance that is moving at highway speed, and the AED needs to analyze the rhythm. The crew should:

• a.Keep driving and let the AED analyze, because the device filters out vehicle vibration automatically.
• b.Keep driving and rely on chest compressions alone until arrival at the hospital.
• c.Disconnect the pads while the ambulance is moving.
• d.Stop the vehicle so the AED can analyze without motion artifact.✓

Road vibration and compressions both create artifact that an AED can misread as an organized rhythm or as a shockable one, so the standard practice is to bring the ambulance to a stop for the few seconds of analysis and, if advised, the shock. Trusting the device to filter the motion out is the tempting answer, but AED filtering is designed for a stationary patient, which is why every operating instruction says to stop movement during analysis. Giving up on defibrillation entirely abandons the only definitive treatment for ventricular fibrillation.

After a shock, a patient in cardiac arrest regains a strong palpable carotid pulse but remains unresponsive and is breathing about 6 shallow breaths per minute. The EMT should:

• a.Give high-flow oxygen by nonrebreather mask.
• b.Remove the AED pads and place him in the recovery position, then transport and check the pulse every five minutes.
• c.Resume chest compressions, because his breathing is inadequate.
• d.Leave the pads attached, ventilate with a bag-valve mask, and reassess frequently.✓

Return of circulation is fragile and re-arrest is common, so the pads stay on and the pulse and breathing are rechecked often, while breathing this slow and shallow is inadequate and must be assisted with positive pressure. A nonrebreather mask is the closest competing answer, but it only enriches the air a patient draws in himself, and 6 shallow breaths a minute do not move enough volume for that to matter. Compressions are not restarted while a pulse is present, and removing the pads throws away the ability to shock immediately if the rhythm deteriorates again.

What is the practical implication of the chain of survival for an EMS system responding to out-of-hospital cardiac arrest?

• a.Defibrillation is the only link that changes outcome, so the other links matter mainly for documentation.
• b.The links are carried out by hospital staff, so out-of-hospital care is only a transport function.
• c.Each link can make up for a weak link earlier in the chain.
• d.Survival depends on every link, so a delay at any one step lowers survival even when the other steps are done well.✓

The metaphor's whole point is dependency: recognition and activation, immediate CPR, rapid defibrillation, advanced resuscitation, post-arrest care and recovery each depend on the ones before, so excellent defibrillation cannot rescue an arrest that went ten minutes without compressions. That is also why later links cannot compensate for earlier failures. The first links belong to bystanders and dispatchers rather than to the hospital, which is why systems invest in bystander CPR training and public access defibrillators.

A patient with an hour of crushing chest pain is gray and clammy, with crackles at both lung bases, a blood pressure of 76/50 and a pulse of 120. He has nitroglycerin prescribed to him and asks for it. Under most EMS protocols the EMT should:

• a.Assist with the nitroglycerin, because relieving the pain will reduce the strain on the failing heart.
• b.Withhold the nitroglycerin, support oxygenation and transport rapidly.✓
• c.Lay him completely flat and raise both legs to bring the blood pressure up first.
• d.Have him chew a second aspirin.

This is cardiogenic shock: the infarcting heart cannot maintain output, which is why the pressure is low and fluid is backing into the lungs. Nitroglycerin protocols set a minimum systolic pressure, commonly around 100 to 110 mmHg, and a pressure of 76 is far below any of them, so the drug is withheld however severe the pain. Raising the legs is the strongest competing answer because it is right for hypovolemic shock, but the problem here is a pump that has already failed to move the blood it has, and adding preload worsens the pulmonary edema.

A 66-year-old has sudden severe chest pain that he describes as tearing and that radiates through to between his shoulder blades. Which additional finding would most suggest an acute aortic dissection rather than a myocardial infarction?

• a.Pain that worsens when he leans forward and eases when he sits still and breathes shallowly.
• b.Nausea, vomiting and heavy sweating with the pain.
• c.Pain radiating into the left jaw.
• d.A large difference in blood pressure between the two arms.✓

A dissection can extend into the origin of a subclavian artery, so the pulse and pressure on one side fall and the arms read very differently, which is why blood pressure is checked in both arms when the description is tearing pain radiating to the back. Nausea and diaphoresis accompany both conditions and cannot separate them, and jaw radiation is the classic pattern of an infarction rather than a dissection. Pain that changes with position and breathing points instead toward pericarditis or a musculoskeletal cause.

During a resuscitation the team leader says, 'Ken, take over compressions at the next rhythm check.' Which response reflects closed-loop communication?

• a.The leader repeats the instruction until someone starts compressions.
• b.Ken nods and moves into position without speaking, so the noise level stays down.
• c.Whoever is closest to the patient calls out 'I've got it' and takes over.
• d.Ken answers, 'Taking compressions at the next check.'✓

Closed-loop communication means the person named repeats the assignment back out loud so the leader knows it was heard, understood and accepted by that specific person. A silent nod is the most tempting alternative because the task does get done, but a leader who is watching the monitor or timing the rhythm check never sees it and cannot confirm the loop is closed. An anonymous volunteer leaves the leader unsure who holds which role, and repeating an order into the noise is an open loop rather than a closed one.

Several sites in the heart can generate their own electrical impulses, yet in a healthy adult the sinoatrial node sets the heart rate. What explains that?

• a.The sinoatrial node is the only cardiac tissue that can generate an impulse without a nerve signal reaching it first
• b.The sinoatrial node lies in the left atrium, where each cardiac cycle begins before spreading to the right side
• c.The sinoatrial node alone receives a sympathetic nerve supply, so only its rate can be driven upward
• d.The sinoatrial node depolarizes at a faster intrinsic rate than the other pacemaker sites, so it reaches threshold and fires before they do✓

Every pacemaker site has its own intrinsic rate — the sinoatrial node fastest, the atrioventricular junction slower, the ventricles slowest — and the fastest site drives the heart because it resets the others before they can fire on their own. The idea that the sinoatrial node is the only tissue with automaticity is the common misconception: the junction and the ventricles both take over when the node fails, just at a slower escape rate. The node sits in the right atrium, not the left, and both sympathetic and parasympathetic fibers reach far more of the heart than the node alone.

Impulses arriving from the atria are briefly held up at the atrioventricular node before passing on to the ventricles. What does that delay accomplish in a normal beat?

• a.It lets the atria finish emptying into the ventricles before the ventricles contract✓
• b.It gives the ventricular muscle time to repolarize fully so that the next impulse is not blocked
• c.It slows conduction enough for the coronary arteries to fill with blood while the atria are contracting
• d.It blocks impulses that arrive from the atria too quickly

The pause at the atrioventricular node lasts only a fraction of a second, and in that time the atria squeeze their remaining volume into the ventricles, adding to the stroke volume before ventricular contraction begins. The node does limit how many impulses reach the ventricles when the atria fire very fast, which makes the blocking answer tempting, but that protection is a consequence of the same slow conduction rather than the purpose of the normal beat-to-beat delay. Coronary filling occurs during ventricular relaxation and is not produced by the nodal delay, and ventricular repolarization is governed by the muscle's own refractory period.

An adult trauma patient has a strong carotid pulse but no palpable radial pulse at either wrist. Which conclusion is best supported by that finding alone?

• a.The systolic pressure is between 60 and 80 mmHg, the range in which the radial pulse disappears
• b.Perfusion at the periphery is poor and a blood pressure must actually be measured✓
• c.The arm is injured; the blood pressure is normal
• d.This finding by itself establishes decompensated shock

A carotid pulse with no radial pulse tells the EMT that blood is being shunted centrally, which is a real warning of poor peripheral perfusion — but it is a sign, not a number, and the pressure still has to be measured with a cuff. The old teaching that carotid, femoral and radial pulses correspond to systolic pressures of roughly 60, 70 and 80 mmHg has been tested against measured pressures and was found to overestimate them, so it should not be used to assign a value. Shock is staged from the whole picture, including mental status and an actual blood pressure, rather than from one missing pulse, and an isolated arm injury would not explain central shunting in both arms.

A crew checks capillary refill on the fingernail of an adult found outdoors on a cold night. Which statement about that finding is correct?

• a.Cold surroundings slow refill on their own, so it must be read alongside the rest of the perfusion picture✓
• b.Refill time is the single most reliable indicator of perfusion in adults, so a delayed result confirms shock whatever the conditions
• c.A refill time over two seconds in an adult establishes that the patient is hypovolemic
• d.Refill is more useful in adults than in young children

Capillary refill is slowed by cold ambient temperature, by age and by peripheral vascular disease, so on a cold night a delayed result may say more about the environment than about cardiac output; it belongs in the perfusion picture beside skin color and temperature, mental status, pulse quality and blood pressure. Treating it as the single most reliable adult indicator is the tempting error — it is one of the better bedside signs in young children and least reliable in exactly the setting described here. The two-second figure is a rough guide rather than a threshold that establishes hypovolaemia on its own.

A patient with a very large upper arm is assessed with the standard adult cuff, the only size carried on the ambulance. The reading is 168/96, although she feels well and has never been told she has high blood pressure. What is the most likely explanation?

• a.The reading is accurate and simply reflects the extra work of perfusing a larger body
• b.A cuff that is too small leaks pressure as it deflates, so the true pressure is higher than the reading shown
• c.Arm circumference does not affect the reading as long as the bladder is centered over the brachial artery
• d.The cuff is too small for her arm, which pushes the reading up✓

A cuff whose bladder is too narrow for the arm has to be inflated to a higher pressure before it compresses the brachial artery, so it reads falsely high; a cuff that is too large for the arm reads falsely low. The reading should be repeated with a large adult cuff before hypertension is reported or acted on. Centring the bladder over the artery does matter, but it does not cancel out the wrong cuff size, and body size by itself does not produce a genuinely elevated pressure in a well patient.

In some patients the Korotkoff sounds fade out just below the true systolic pressure and reappear again lower down — an auscultatory gap. If the cuff is not inflated above that silent interval, what happens to the reading, and what prevents the error?

• a.The diastolic pressure is underestimated; deflating the cuff more slowly through the lower range prevents it
• b.The pulse pressure is exaggerated; switching to a wider cuff and repeating the measurement prevents it
• c.The systolic reading comes out too low; palpating the systolic first prevents it✓
• d.Neither number is affected; the gap only delays the reading

If the cuff is inflated only into the silent interval, the first sound heard on deflation is the return of sounds below the gap, so the systolic pressure is recorded lower than it truly is. Palpating the radial pulse, noting the pressure at which it disappears and then inflating roughly 30 mmHg above that point puts the cuff safely above the gap before deflation begins. An auscultatory gap tends to make the diastolic value read high rather than low, and cuff width is a separate source of error that does not create the silent interval.

A 30-year-old struck in the abdomen has a heart rate of 124, a blood pressure of 116/94, cool moist skin, and is anxious and repeatedly asking what happened. How should the EMT read this set of numbers?

• a.Adequate perfusion, since the systolic pressure is within the normal adult range and he is awake and talking
• b.Compensated shock, with the narrow pulse pressure showing that vasoconstriction is holding the systolic up✓
• c.Decompensated shock, since a diastolic above 90 marks the point where compensation has failed
• d.Anxiety alone, which raises both the pulse and the diastolic pressure

Vasoconstriction raises the diastolic pressure while the systolic is defended, so the pulse pressure narrows — here 116 minus 94 leaves 22 mmHg — and that narrowing, together with tachycardia, cool moist skin and anxiety, is the picture of compensated shock. A systolic of 116 looks reassuring, which is precisely the trap: in decompensated shock the systolic falls, and waiting for that means waiting until compensation has already failed. No diastolic number defines decompensation, and anxiety alone does not produce cool, moist skin after abdominal trauma.

A 74-year-old, two days after a heart attack, is confused, with a blood pressure of 78/56, a heart rate of 118, cold grey skin, and crackles heard part way up both lung fields. Under a typical EMS protocol, what does this patient need from the EMT?

• a.Supine with the legs raised, the standard response to any patient whose systolic pressure is below 90
• b.Assisting him with his own nitroglycerin, since reducing the heart's workload is the priority in cardiogenic shock
• c.Oxygen titrated to his saturation, a position that eases his breathing, and rapid transport✓
• d.Warm blankets and a flat position while ALS is awaited

This is cardiogenic shock: the damaged pump cannot maintain output, so pressure falls while blood backs up into the lungs. EMT care is supportive — oxygen guided by the saturation, a position the patient can breathe in, warmth, and fast transport to a facility that can treat the pump, with an ALS intercept where one is available. Raising the legs is the tempting move because the pressure is low, but in a patient whose lungs are already wet it pushes more volume back toward a failing left ventricle, and nitroglycerin lowers the pressure further and is contraindicated at this blood pressure.

A patient thrown from a motorcycle cannot move his legs. His blood pressure is 84/60, his heart rate is 58, and his skin is warm and dry below the nipple line. Which explanation fits the findings best?

• a.A faint brought on by pain, which lifts once he is lying flat
• b.Hypovolemic shock from an unrecognised abdominal bleed, since hemorrhage is by far the commonest cause of hypotension after trauma
• c.Spinal shock, the temporary loss of reflexes and movement below the level of injury
• d.Neurogenic shock, in which lost sympathetic tone leaves the vessels dilated and prevents the usual rise in heart rate✓

Warm, dry skin below the injury, hypotension without tachycardia, and a motor deficit point to neurogenic shock, where the injury has interrupted sympathetic outflow so the vessels dilate and the heart cannot speed up to compensate. Occult hemorrhage is the strong competing answer and must still be assumed and treated in any thrown rider — but bleeding produces cool, pale, sweaty skin and a fast pulse, and the picture here is the opposite. Spinal shock names the loss of reflex activity below a cord injury and is not a circulatory diagnosis, and a simple faint does not leave a patient hypotensive and paralysed.

Which pairing of a type of shock with the skin findings usually seen early in it is correct?

• a.Cardiogenic shock — warm, dry, flushed skin produced by blood backing up behind the failing heart
• b.Hypovolemic shock — flushed skin produced by stored red cells released from the spleen
• c.Septic shock — skin that is warm and flushed early, turning cool and mottled later✓
• d.Anaphylactic shock — cold, pale, dry skin from the histamine release

Septic shock, like the other distributive shocks, begins with widespread vasodilation, so the skin is often warm, flushed and dry early on and only becomes cool and mottled as the patient deteriorates — which is why a warm patient can still be in profound shock. Cardiogenic and hypovolemic shock both drive intense vasoconstriction and give the cold, pale, sweaty skin that most candidates associate with shock in general. Anaphylaxis is also distributive, so it typically flushes the skin and adds hives rather than making it cold and dry.

An 80-year-old is dizzy and nearly fainting when she sits up. Her pulse is regular at 38 and her blood pressure is 82/50. No cardiac monitor is available. Under a typical EMS protocol, what should the EMT do?

• a.Keep her supine, give oxygen if she is hypoxic, and request ALS✓
• b.Walk her to the ambulance, since activity raises the heart rate through the sympathetic response
• c.Apply the AED, which will pace the heart once the pads are attached
• d.Withhold treatment unless the rate falls below 30, the point at which bradycardia becomes symptomatic

A regular rate of 38 with hypotension and near-syncope is symptomatic bradycardia, and the EMT's part is supportive — supine positioning, oxygen if the saturation is low, close reassessment — plus getting her to definitive care or to a paramedic crew, since the drugs and pacing that treat the rhythm sit above the EMT scope in essentially every system. Applying the AED is the tempting action because it is the cardiac device on the truck, but an automated external defibrillator analyzes for shockable rhythms and has no pacing function. Bradycardia is called symptomatic because of the symptoms rather than because the rate crosses a set figure, and making a hypotensive patient stand invites a syncopal fall.

A 40-year-old says her heart suddenly started racing while she sat watching television. The radial pulse is regular and too fast to count reliably; a carotid count gives about 190. She is alert, with a blood pressure of 108/70, no fever, no pain, no blood loss and no exertion. Without a monitor, what should the EMT suspect?

• a.Sinus tachycardia from anxiety, which commonly drives an adult resting heart rate to around 190
• b.Atrial fibrillation, which characteristically produces a rapid but perfectly regular pulse at the wrist
• c.A normal finding, since she is alert with an acceptable blood pressure
• d.A supraventricular tachycardia, given the abrupt onset at rest and the very high rate✓

An abrupt onset at rest and a regular rate near 190 in an adult with no fever, pain, bleeding or exertion fit a supraventricular tachycardia; sinus tachycardia has an identifiable cause, comes on gradually and rarely reaches that rate at rest in an adult of this age. Anxiety is the strong competing answer and certainly produces a fast pulse, but the switch-on-while-sitting-quietly history and the rate itself argue against it. Atrial fibrillation gives an irregularly irregular pulse, and a rate near 190 is not a normal finding even in a patient who currently looks well; EMT care here is oxygen if indicated, a position of comfort and transport with ALS where available.

A hiker is dug out of a snowdrift, unresponsive, with no breathing and no pulse detected over a careful 45-second check. He is profoundly cold and stiff, with no rigor mortis, no lividity and no obviously lethal injury. Under most EMS protocols, how does the crew's approach differ from an ordinary cardiac arrest?

• a.Move him quickly and vigorously into the warm ambulance so that rewarming can begin at once
• b.Withhold resuscitation, since a cold and pulseless patient recovered from snow meets the usual criteria for obvious death
• c.Start compressions and ventilations, handle him gently, and continue while he is rewarmed during transport✓
• d.Compress at half the usual rate to match his slowed metabolism

Severe hypothermia slows metabolism enough that a pulse and respirations can be undetectable in a patient who is still salvageable, so resuscitation is started and continued with active rewarming, and the decision to stop is generally deferred to the hospital. Withholding care is tempting because the patient is cold and stiff, but stiffness from cold is not rigor mortis and none of the usual signs of irreversible death are present here. A profoundly cold heart is irritable and rough handling can precipitate ventricular fibrillation, and compressions are still delivered at the standard rate and depth.

A child is pulled from a lake unresponsive, not breathing and pulseless. Compared with a witnessed adult collapse from a suspected cardiac cause, what does the drowning change about the resuscitation?

• a.Nothing changes; compression-only CPR is preferred after drowning just as it is for a witnessed adult collapse
• b.Ventilations matter more, because the arrest follows a period of hypoxia✓
• c.The AED is left off because the chest is wet
• d.Abdominal thrusts are given first to clear water from the lungs before compressions begin

Drowning kills by hypoxia, so the blood is already desaturated by the time the heart stops and rescue breaths are an essential part of the resuscitation rather than an optional extra — compressions combined with ventilations, not compression-only CPR, are what this child needs. Trying to expel water first is the classic error: water in the lungs cannot be drained out, and abdominal thrusts delay compressions and invite vomiting and aspiration. The AED is still applied; the chest is simply dried before the pads go on.

A woman who appears to be near term collapses in cardiac arrest in a shop. Two rescuers are present. Besides high-quality CPR and rapid transport, what does the pregnancy add?

• a.Tilt the whole backboard about 30 degrees to the left, which is preferred to manual displacement because it frees a rescuer
• b.Have one rescuer manually displace the uterus to her left while compressions continue✓
• c.Hold defibrillation until after delivery, because the shock can reach the fetus
• d.Compress over the xiphoid to reach the displaced heart

Near term the uterus compresses the inferior vena cava when the patient is supine, cutting off the venous return that chest compressions depend on, so a dedicated rescuer holds the uterus displaced to the patient's left throughout. Tilting the board is the older technique and is the tempting answer, but a tilted torso makes effective compressions much harder, so continuous manual displacement on a flat, firm surface is now preferred. Defibrillation is delivered in the usual way, and compressions are given on the lower half of the sternum rather than over the xiphoid process.

A service equips some of its ambulances with a mechanical chest-compression device. Which statement reflects current guidance on how such a device should be used?

• a.Applying it takes priority over starting manual compressions, since it delivers a consistent depth and rate from the first minute
• b.It has been shown to improve survival with good neurological recovery compared with high-quality manual compressions
• c.Once it is running, ventilations are no longer needed because it moves enough air on its own
• d.It is a reasonable alternative to manual compressions in particular situations✓

Trials comparing mechanical compression devices with high-quality manual CPR have not shown better survival or better neurological outcome, so guidelines treat them as a reasonable alternative in specific circumstances — a moving ambulance, a prolonged resuscitation, too few rescuers, or a place where a rescuer cannot kneel safely — rather than as a routine upgrade. Because of that, manual compressions begin at once and the device is fitted with only a brief planned pause. The device compresses the chest; it does not ventilate the patient, so ventilations continue as the protocol directs.

Cardiac arrest in children usually develops differently from arrest in adults. What follows from that for an EMT at the side of an unresponsive, pulseless 5-year-old?

• a.Compressions must be paired with effective ventilations, because the arrest usually began with hypoxia✓
• b.Compression-only CPR is preferred for children too, since pausing to ventilate lowers the perfusion pressure
• c.The AED should go on before compressions, because a shockable rhythm is the commonest cause of arrest at this age
• d.Ventilations alone are given until a pulse returns

Most pediatric arrests are the end point of respiratory failure or shock rather than a sudden rhythm problem, so the child is profoundly hypoxic by the time the pulse is lost and oxygen has to be put back in: compressions together with ventilations, at the ratio local guidelines set for one or two rescuers. That is why compression-only CPR, a reasonable option for an untrained bystander at an adult collapse, is not the preferred approach here. A shockable rhythm is uncommon at this age, so the defibrillator does not come ahead of compressions, and ventilations alone cannot circulate the oxygen once the pulse is gone.

A crew is shown a signed POLST form for a nursing-home resident who is in cardiac arrest. In most states, how does a POLST form differ from a traditional do-not-resuscitate order?

• a.It is a statement of the patient's wishes written by the patient or family, which the crew may honour only after medical direction agrees
• b.It applies only inside the facility that issued it
• c.It is a portable medical order covering several treatment decisions, not only resuscitation✓
• d.It authorises the crew to withhold comfort measures as well as resuscitation

In most states a POLST — also called a MOLST or POST — is a portable medical order signed by a physician or other authorised clinician that travels with the patient and addresses more than code status, recording decisions about intubation, other interventions and sometimes transport, whereas a traditional do-not-resuscitate order addresses resuscitation alone. Which forms are valid, whose signature is required and whether the original must be produced are set by state law and local protocol, so crews follow their own state's rules. The form is a clinician's order rather than a family's statement of wishes, it follows the patient between settings, and comfort care is given whatever the form says.

A crew finds an unresponsive man with no pulse and no breathing, cool skin, a stiff jaw and stiff limbs, and dark purple discolouration along the back where he lies. Under the resuscitation policies used in most states, what is appropriate?

• a.Begin CPR and continue until a physician orders it stopped, since only a physician may declare a patient dead
• b.Begin CPR, since rigor and lividity are unreliable in a cool room and the arrest may be recent
• c.Withhold resuscitation and follow local policy for a death on scene✓
• d.Begin CPR and stop only after the AED has advised no shock on three consecutive analyzes

Rigor mortis together with dependent lividity are among the signs of irreversible death that EMS protocols in most states allow a crew to recognize without starting resuscitation; the crew then preserves the scene, makes the notifications its policy requires and supports the family. Beginning CPR is the safe default and is the right choice whenever the findings are equivocal, which is what makes that answer tempting — but here two independent signs of prolonged death are present together. Who may pronounce death, and who may authorise stopping a resuscitation once it has begun, are matters of state law and local protocol, and neither is settled by counting AED analyzes.

A 79-year-old with type 2 diabetes has become gradually more confused over three days. His mouth and skin are very dry, his heart rate is 116 and his blood pressure is 96/58. His breathing is of normal depth with no unusual odor, and his home meter reads 'HI'. What should the EMT most suspect?

• a.A hyperosmolar hyperglycemic state, in which extreme dehydration develops without significant ketosis✓
• b.Diabetic ketoacidosis, since a sugar too high for the home meter to read must be producing ketones and deep rapid breathing
• c.Hypoglycemia, because confusion with a fast pulse and a low blood pressure is the classic picture of a low sugar
• d.Dehydration from poor intake alone, with the meter reading an error

Type 2 diabetics can drift over days into a hyperosmolar hyperglycemic state: the glucose climbs very high, the osmotic diuresis strips out water, and the patient becomes profoundly dehydrated and confused, yet enough insulin remains to prevent significant ketone production, so there is no acetone odor and no deep, rapid Kussmaul breathing. Ketoacidosis is the tempting answer whenever a meter reads too high to display, which is exactly why the breathing pattern and the absent odor matter here. A hypoglycemic patient does not produce an unreadably high meter result, and simple poor intake would not explain it either. EMT care is airway, oxygen if indicated, positioning and prompt transport, because these patients need intravenous fluid.

A teenager swallowed a large number of acetaminophen (paracetamol) tablets about two hours ago. She is alert, her vital signs are normal, and she says she feels fine and does not want to go to hospital. What is the most important point for the EMT to make?

• a.Severe liver injury can develop over the days that follow even though she feels well now✓
• b.She is out of danger, because acetaminophen becomes toxic only when it is taken with alcohol or another drug
• c.Feeling well two hours after the overdose shows the amount taken was below the toxic dose for her weight
• d.She should be made to vomit at home and then watched by her family for the next several hours

Acetaminophen poisoning is dangerous precisely because the first hours are quiet — nausea at most, then an apparently well patient — while a toxic metabolite injures the liver over the days that follow. The antidote works best when it is started early, so assessment, blood testing and the transport decision cannot wait for symptoms to appear. Alcohol and poor nutrition increase the risk but are not required for toxicity, and inducing vomiting at home is not recommended, since it delays definitive care and risks aspiration.

An EMT is called for a 22-year-old who told a friend he wanted to end his life. He is calm and cooperative, has no injuries and answers questions politely. What is the most appropriate way to assess his risk?

• a.Avoid raising the subject of suicide, since asking can plant the idea in a vulnerable patient's mind
• b.Ask him directly whether he has a plan and the means to carry it out✓
• c.Rely on the friend's account rather than questioning him, so that he is not made defensive
• d.Treat his calm manner as reassuring, since a patient at genuine risk is agitated and visibly distressed

Asking plainly about suicidal thoughts, a specific plan and access to the means does not increase risk — it is how risk is assessed, and a definite plan with the means at hand marks high risk. The calm, cooperative manner is the trap in this scenario: composure can follow a decision to act, so it is not evidence of safety. A friend's account is useful but does not replace speaking with the patient himself, and the crew still keeps the scene safe and removes obvious means where it can do so safely.

During an unavoidable field delivery the baby's buttocks present first and the body delivers as far as the shoulders, but the head does not follow. Under most EMS protocols, what should the EMT do?

• a.Support the body and slip a gloved hand in to make an airway space at the baby's face, then transport at once✓
• b.Pull steadily on the baby's body with each contraction until the head delivers, keeping the traction in line with the spine
• c.Push the baby back into the birth canal and hold it there until arrival at the hospital
• d.Wait without touching the baby for the mother to deliver the head herself

Once a breech body has delivered and the head has not followed, the cord is compressed between the head and the pelvis and the baby's face is pressed against the vaginal wall, so most protocols have the EMT support the body, insert a gloved hand palm-toward-the-face to push the tissue away from the nose and mouth, and transport immediately while maintaining that space. Traction on the body is the intuitive response and is the one thing that must not be done, because it can trap the head further and injure the neck and spinal cord. Pushing the baby back is not an EMT procedure, and waiting passively leaves both the airway and the cord obstructed.

An 84-year-old who takes a beta blocker fell at home and has a painful, swollen thigh. He is pale and sweaty, his skin is cool, his heart rate is 74 and his blood pressure is 104/86. How should the EMT interpret that heart rate?

• a.It rules out serious blood loss, since an injury bad enough to cause shock always drives the pulse up
• b.It shows he is compensating well, since a normal rate in an older adult means cardiac output is being maintained
• c.It may be blunted by his medication, so the other signs of poor perfusion carry more weight✓
• d.It points to neurogenic shock from a spine injury in the fall

Beta blockers prevent the heart-rate response that normally signals blood loss, so an older patient can be bleeding significantly with a pulse in the seventies; the pale, cool, sweaty skin and the narrow pulse pressure of 104/86 are the findings that carry the weight here. Reading the normal rate as evidence of good compensation is the tempting error, and it is the one most likely to slow the transport decision. A closed femur injury can hold a large volume of blood, and nothing here suggests a cord injury, which would give warm, dry skin rather than cool and sweaty.

A 55-year-old who has taken prednisone every day for years for an autoimmune illness has had two days of vomiting and has not kept her tablets down. She is weak, with a blood pressure of 82/54, a heart rate of 122 and warm skin. What should the EMT most suspect?

• a.An adrenal crisis brought on by stopping the steroid✓
• b.Simple dehydration from the vomiting, which will settle once she can drink again at home
• c.A vasovagal episode caused by the repeated vomiting, needing only supine positioning
• d.A late allergic reaction to the medication she has taken for years

Long-term steroid therapy suppresses the body's own cortisol production, so a patient who cannot keep the tablets down during an illness can lose the hormone that helps maintain blood pressure and blood sugar, producing weakness, vomiting and hypotension out of proportion to the fluid loss. Dehydration is the strong competing answer and is genuinely part of the picture, but the degree of hypotension in a steroid-dependent patient who has missed doses points beyond simple fluid loss, and these patients need hospital steroid replacement rather than fluids at home. EMT care is supportive: position, oxygen if indicated, warmth, a glucose check where a meter is carried, and prompt transport.

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.