Elite Universal Test
Bank: Montana
EMS/Paramedic State
Protocol
PART 0: THE NAVIGATOR
● Tier 1 (Questions 1–28) - Foundational Syntax & Application: Testing "Hard Deck"
definitions, core pharmacological dosages, explicit scope-of-practice boundaries, and
foundational protocols under the 2026 Montana Board of Medical Examiners framework.
● Tier 2 (Questions 29–58) - Complex Application & Simulation: Scenario-based
physiological variations, triage branch modifications, multi-system trauma logic, and
protocol pivots based on fluctuating hemodynamics.
● Tier 3 (Questions 59–88) - Grandmaster Synthesis: Paragraph-long, high-stakes crises
requiring concurrent trauma/medical triage, interfacility transport contingencies, and
regional destination logic synthesized with legal directives.
PART I: THE PRIMER
Mastering this test bank translates directly to elite prehospital competency, forging the
operational reflex necessary to navigate Montana's austere, high-stakes medical landscape.
This document eliminates protocol hesitation, ensuring your clinical mastery translates directly
to autonomous, high-level paramedicine under the 2026 state standards.
● The "Critical Axioms" Cheat Sheet:
○ Airway Absolute: Drug Assisted Intubation (DAI) and rapid sequence induction
(RSI) are strictly prohibited for field Paramedics in Montana; rely on BLS mastery
and supraglottic airways.
○ Cardiac Analgesia Restriction: Fentanyl is strictly contraindicated for suspected
ischemic chest pain unless a documented Morphine allergy exists.
○ Resuscitation Triage (TOR): Field termination requires 20 minutes of high-quality
CPR, no shocks delivered, un-witnessed arrest, and no ROSC. Mandatory initiation
is required for hypothermia, lightning strikes, and pediatrics.
○ Trauma Triage (RED vs YELLOW): RED criteria (e.g., GCS motor < 6, penetrating
torso trauma) mandate immediate transport to the highest-level trauma center.
YELLOW criteria (e.g., fall > 10 ft, anticoagulant use) allow preferential transport to
any available trauma center.
○ 2026 Administrative Directives: All CARES cardiac arrest data must be submitted
, by the 15th of the following month, and the highest-level medical provider on-scene
MUST take the lead whenever physical restraints are applied.
PART II: THE ELITE TEST BANK
Tier 1 - Foundational Syntax & Application
Q1: You are treating a 55-year-old male complaining of substernal chest pain. His 12-lead ECG
reveals an inferior STEMI. Based on the principles of the Montana STEMI Protocol, which
diagnostic action is REQUIRED? A) Immediately administer 100 mcg of Fentanyl IV B) Perform
a right-sided V4 ECG lead placement C) Administer prophylactic Ketamine for pain
management D) Withhold Nitroglycerin regardless of blood pressure
● The Answer: B (Perform a right-sided V4 ECG lead placement)
● Distractor Analysis:
○ A is incorrect: Fentanyl is explicitly contraindicated for ischemic chest pain in
Montana unless a Morphine allergy is present.
○ C is incorrect: Ketamine is prohibited for cardiac-origin chest pain.
○ D is incorrect: Nitroglycerin is the primary medication and should be given unless
systolic BP drops below 100 mmHg.
The Mentor's Analysis: Inferior STEMIs commonly involve right ventricular infarction, rendering
the patient highly preload-dependent. When facing a suspected inferior wall MI, the immediate
priority is confirming RV involvement via V4R. By utilizing this diagnostic step, you bypass the
common trap of administering vasodilators that induce fatal hypotension. Professional/Academic
Intuition: Always capture a V4R on an inferior STEMI before administering Nitroglycerin.
Q2: A Paramedic is preparing to secure the airway of a combative, hypoxic trauma patient.
Based on the principles of the Montana Airway Protocol, which action is the MOST
ACCURATE? A) Administer Succinylcholine and Etomidate to facilitate Drug Assisted Intubation
(DAI) B) Administer Midazolam 5mg IV to facilitate Drug Assisted Intubation (DAI) C) Utilize
physical restraints and BLS airway adjuncts, as DAI is prohibited D) Perform a surgical
cricothyrotomy prior to attempting non-invasive ventilation
● The Answer: C (Utilize physical restraints and BLS airway adjuncts, as DAI is prohibited)
● Distractor Analysis:
○ A is incorrect: DAI and paralytics are outside the standard Montana Paramedic
scope of practice.
○ B is incorrect: Using sedatives specifically to facilitate intubation violates the DAI
prohibition.
○ D is incorrect: Surgical airways are salvage techniques, never first-line before BLS
measures.
The Mentor's Analysis: Montana explicitly restricts Paramedics from performing Drug Assisted
Intubation. When facing a combative hypoxic patient, the immediate priority is BLS airway
management and oxygenation. By utilizing fundamental airway control, you bypass the common
trap of scope-of-practice violations. Professional/Academic Intuition: In Montana, DAI is a hard
stop; rely on supraglottic airways and BLS mastery.
Q3: You are treating a 22-year-old female in acute adrenal crisis. She is hypotensive and
lethargic. Based on the principles of the Montana Adrenal Insufficiency Protocol, which
pharmacological intervention is the MOST APPROPRIATE? A) Hydrocortisone 100mg IM/IV/IO
B) Epinephrine 1:10,000 1mg IV C) Glucagon 1mg IM D) Diphenhydramine 50mg IV
, ● The Answer: A (Hydrocortisone 100mg IM/IV/IO)
● Distractor Analysis:
○ B is incorrect: Epinephrine is for anaphylaxis or cardiac arrest, not primary adrenal
crisis.
○ C is incorrect: Glucagon addresses hypoglycemia but does not replace missing
cortisol.
○ D is incorrect: Antihistamines play no role in acute adrenal insufficiency.
The Mentor's Analysis: Adrenal crisis is a life-threatening absence of cortisol leading to
refractory shock. When facing an acute adrenal crisis, the immediate priority is exogenous
corticosteroid replacement. By utilizing Hydrocortisone (or
Methylprednisolone/Dexamethasone), you bypass the common trap of treating hypotension
purely with vasopressors. Professional/Academic Intuition: Refractory shock in a patient with
known Addison's requires immediate steroid administration.
Q4: You respond to an unwitnessed cardiac arrest. The patient has been in asystole for 22
minutes despite high-quality CPR and advanced airway management. No shocks have been
advised. Based on the principles of the Montana Resuscitation Triage Protocol, which
action/conclusion is the MOST ACCURATE? A) Initiate transport immediately with CPR in
progress B) Administer Sodium Bicarbonate and continue for 20 more minutes C) Contact
Medical Control to authorize field Termination of Resuscitation (TOR) D) Apply a mechanical
CPR device and transport to a Level 1 Trauma Center
● The Answer: C (Contact Medical Control to authorize field Termination of Resuscitation
(TOR))
● Distractor Analysis:
○ A is incorrect: Transporting non-viable, shock-less asystolic arrests poses severe
risks to the crew without patient benefit.
○ B is incorrect: Prolonging futile CPR is against TOR guidelines.
○ D is incorrect: Medical arrests do not go to Trauma Centers, and mechanical CPR
does not override TOR criteria.
The Mentor's Analysis: The TOR criteria mandate that resuscitative efforts exceeding 20
minutes without a shockable rhythm, ROSC, or EMS witnessing the arrest meet the standard for
medical futility. When facing prolonged asystole, the immediate priority is resource
management. By utilizing the Resuscitation Triage Protocol, you bypass the common trap of
dangerous lights-and-sirens transport of a deceased patient. Professional/Academic Intuition:
20 minutes of asystole with an EtCO2 < 10 mmHg is the definitive physiological marker of
futility.
Q5: A 6-year-old child weighing 20 kg is in severe anaphylactic shock with a blood pressure of
60/40. Based on the principles of the Montana Anaphylaxis Protocol, which action/conclusion is
the MOST ACCURATE? A) Administer Epinephrine 1:1,000 0.2mg IM B) Administer
Epinephrine 1:10,000 0.1 ml/kg IV C) Administer Diphenhydramine 50mg IV push D) Administer
Albuterol 2.5mg nebulized
● The Answer: B (Administer Epinephrine 1:10,000 0.1 ml/kg IV)
● Distractor Analysis:
○ A is incorrect: While IM Epinephrine is correct for stable anaphylaxis, hypotensive
shock (BP < 70) requires IV administration.
○ C is incorrect: Diphenhydramine is a secondary adjunct and does not reverse
cardiovascular collapse.
○ D is incorrect: Albuterol treats bronchospasm but will not correct profound
vasodilation.
, The Mentor's Analysis: Profound hypotension in anaphylaxis indicates cardiovascular collapse.
When facing anaphylactic shock, the immediate priority is restoring vascular tone. By utilizing IV
Epinephrine 1:10,000, you bypass the common trap of relying on IM absorption in a poorly
perfused patient. Professional/Academic Intuition: If the blood pressure crashes below 70
systolic in anaphylaxis, switch from the IM route to the IV route immediately.
Q6: An EMS crew assesses a 70-year-old male with acute facial droop and right-sided
hemiparesis. The RACE stroke scale score is 6. Based on the principles of the Montana Stroke
System of Care, which destination decision is the MOST ACCURATE? A) Transport to the
closest Primary Stroke Center regardless of other hospital capabilities B) Bypass the Primary
Stroke Center and transport to an Endovascular/Thrombectomy-Capable Stroke Center C)
Transport to the closest Level 1 Trauma Center D) Remain on scene to administer Nitroglycerin
to lower his blood pressure
● The Answer: B (Bypass the Primary Stroke Center and transport to an
Endovascular/Thrombectomy-Capable Stroke Center)
● Distractor Analysis:
○ A is incorrect: A RACE score of 6 indicates a high probability of a Large Vessel
Occlusion (LVO), which requires mechanical thrombectomy.
○ C is incorrect: Trauma centers manage kinetic injury, not acute ischemic stroke.
○ D is incorrect: Prehospital lowering of blood pressure in acute stroke is
contraindicated.
The Mentor's Analysis: A high RACE or VAN score signifies a massive clot in a major cerebral
artery (LVO). When facing an LVO, the immediate priority is mechanical clot extraction. By
utilizing LVO-specific destination protocols, you bypass the common trap of transporting to a
facility that cannot provide definitive surgical care. Professional/Academic Intuition: Time is
brain; bypass primary centers for thrombectomy-capable centers if an LVO is suspected.
Q7: You are treating a patient with a suspected narcotic overdose who is apneic. Based on the
principles of the Montana Overdose Protocol, which action/conclusion is the FIRST step? A)
Administer Naloxone 4mg IV immediately B) Secure the airway and begin bag-valve-mask
ventilations C) Insert an intraosseous line and administer Epinephrine D) Administer Naloxone
2mg IN and wait 5 minutes
● The Answer: B (Secure the airway and begin bag-valve-mask ventilations)
● Distractor Analysis:
○ A is incorrect: While Naloxone is the antidote, restoring oxygenation precedes
medication administration to prevent anoxic brain injury.
○ C is incorrect: Epinephrine is not indicated for respiratory arrest secondary to opiate
overdose.
○ D is incorrect: Waiting 5 minutes while the patient remains apneic will result in
cardiac arrest.
The Mentor's Analysis: Opiates kill by inducing profound respiratory depression, leading to
hypoxia and secondary cardiac arrest. When facing an apneic overdose, the immediate priority
is mechanical ventilation. By utilizing prompt BVM ventilations, you bypass the common trap of
allowing the patient to suffer anoxic brain damage while waiting for Naloxone.
Professional/Academic Intuition: Oxygenate before you medicate; the brain dies from lack
of oxygen, not lack of Naloxone.
Q8: An agency submits its cardiac arrest data to the state. Based on the principles of the 2026
Montana CARES requirements, which action/conclusion is the MOST ACCURATE? A) Data
must be submitted annually by December 31st B) Data must be entered into the CARES registry
by the 15th of the following month C) Data submission is voluntary for Paramedic-level transport
Bank: Montana
EMS/Paramedic State
Protocol
PART 0: THE NAVIGATOR
● Tier 1 (Questions 1–28) - Foundational Syntax & Application: Testing "Hard Deck"
definitions, core pharmacological dosages, explicit scope-of-practice boundaries, and
foundational protocols under the 2026 Montana Board of Medical Examiners framework.
● Tier 2 (Questions 29–58) - Complex Application & Simulation: Scenario-based
physiological variations, triage branch modifications, multi-system trauma logic, and
protocol pivots based on fluctuating hemodynamics.
● Tier 3 (Questions 59–88) - Grandmaster Synthesis: Paragraph-long, high-stakes crises
requiring concurrent trauma/medical triage, interfacility transport contingencies, and
regional destination logic synthesized with legal directives.
PART I: THE PRIMER
Mastering this test bank translates directly to elite prehospital competency, forging the
operational reflex necessary to navigate Montana's austere, high-stakes medical landscape.
This document eliminates protocol hesitation, ensuring your clinical mastery translates directly
to autonomous, high-level paramedicine under the 2026 state standards.
● The "Critical Axioms" Cheat Sheet:
○ Airway Absolute: Drug Assisted Intubation (DAI) and rapid sequence induction
(RSI) are strictly prohibited for field Paramedics in Montana; rely on BLS mastery
and supraglottic airways.
○ Cardiac Analgesia Restriction: Fentanyl is strictly contraindicated for suspected
ischemic chest pain unless a documented Morphine allergy exists.
○ Resuscitation Triage (TOR): Field termination requires 20 minutes of high-quality
CPR, no shocks delivered, un-witnessed arrest, and no ROSC. Mandatory initiation
is required for hypothermia, lightning strikes, and pediatrics.
○ Trauma Triage (RED vs YELLOW): RED criteria (e.g., GCS motor < 6, penetrating
torso trauma) mandate immediate transport to the highest-level trauma center.
YELLOW criteria (e.g., fall > 10 ft, anticoagulant use) allow preferential transport to
any available trauma center.
○ 2026 Administrative Directives: All CARES cardiac arrest data must be submitted
, by the 15th of the following month, and the highest-level medical provider on-scene
MUST take the lead whenever physical restraints are applied.
PART II: THE ELITE TEST BANK
Tier 1 - Foundational Syntax & Application
Q1: You are treating a 55-year-old male complaining of substernal chest pain. His 12-lead ECG
reveals an inferior STEMI. Based on the principles of the Montana STEMI Protocol, which
diagnostic action is REQUIRED? A) Immediately administer 100 mcg of Fentanyl IV B) Perform
a right-sided V4 ECG lead placement C) Administer prophylactic Ketamine for pain
management D) Withhold Nitroglycerin regardless of blood pressure
● The Answer: B (Perform a right-sided V4 ECG lead placement)
● Distractor Analysis:
○ A is incorrect: Fentanyl is explicitly contraindicated for ischemic chest pain in
Montana unless a Morphine allergy is present.
○ C is incorrect: Ketamine is prohibited for cardiac-origin chest pain.
○ D is incorrect: Nitroglycerin is the primary medication and should be given unless
systolic BP drops below 100 mmHg.
The Mentor's Analysis: Inferior STEMIs commonly involve right ventricular infarction, rendering
the patient highly preload-dependent. When facing a suspected inferior wall MI, the immediate
priority is confirming RV involvement via V4R. By utilizing this diagnostic step, you bypass the
common trap of administering vasodilators that induce fatal hypotension. Professional/Academic
Intuition: Always capture a V4R on an inferior STEMI before administering Nitroglycerin.
Q2: A Paramedic is preparing to secure the airway of a combative, hypoxic trauma patient.
Based on the principles of the Montana Airway Protocol, which action is the MOST
ACCURATE? A) Administer Succinylcholine and Etomidate to facilitate Drug Assisted Intubation
(DAI) B) Administer Midazolam 5mg IV to facilitate Drug Assisted Intubation (DAI) C) Utilize
physical restraints and BLS airway adjuncts, as DAI is prohibited D) Perform a surgical
cricothyrotomy prior to attempting non-invasive ventilation
● The Answer: C (Utilize physical restraints and BLS airway adjuncts, as DAI is prohibited)
● Distractor Analysis:
○ A is incorrect: DAI and paralytics are outside the standard Montana Paramedic
scope of practice.
○ B is incorrect: Using sedatives specifically to facilitate intubation violates the DAI
prohibition.
○ D is incorrect: Surgical airways are salvage techniques, never first-line before BLS
measures.
The Mentor's Analysis: Montana explicitly restricts Paramedics from performing Drug Assisted
Intubation. When facing a combative hypoxic patient, the immediate priority is BLS airway
management and oxygenation. By utilizing fundamental airway control, you bypass the common
trap of scope-of-practice violations. Professional/Academic Intuition: In Montana, DAI is a hard
stop; rely on supraglottic airways and BLS mastery.
Q3: You are treating a 22-year-old female in acute adrenal crisis. She is hypotensive and
lethargic. Based on the principles of the Montana Adrenal Insufficiency Protocol, which
pharmacological intervention is the MOST APPROPRIATE? A) Hydrocortisone 100mg IM/IV/IO
B) Epinephrine 1:10,000 1mg IV C) Glucagon 1mg IM D) Diphenhydramine 50mg IV
, ● The Answer: A (Hydrocortisone 100mg IM/IV/IO)
● Distractor Analysis:
○ B is incorrect: Epinephrine is for anaphylaxis or cardiac arrest, not primary adrenal
crisis.
○ C is incorrect: Glucagon addresses hypoglycemia but does not replace missing
cortisol.
○ D is incorrect: Antihistamines play no role in acute adrenal insufficiency.
The Mentor's Analysis: Adrenal crisis is a life-threatening absence of cortisol leading to
refractory shock. When facing an acute adrenal crisis, the immediate priority is exogenous
corticosteroid replacement. By utilizing Hydrocortisone (or
Methylprednisolone/Dexamethasone), you bypass the common trap of treating hypotension
purely with vasopressors. Professional/Academic Intuition: Refractory shock in a patient with
known Addison's requires immediate steroid administration.
Q4: You respond to an unwitnessed cardiac arrest. The patient has been in asystole for 22
minutes despite high-quality CPR and advanced airway management. No shocks have been
advised. Based on the principles of the Montana Resuscitation Triage Protocol, which
action/conclusion is the MOST ACCURATE? A) Initiate transport immediately with CPR in
progress B) Administer Sodium Bicarbonate and continue for 20 more minutes C) Contact
Medical Control to authorize field Termination of Resuscitation (TOR) D) Apply a mechanical
CPR device and transport to a Level 1 Trauma Center
● The Answer: C (Contact Medical Control to authorize field Termination of Resuscitation
(TOR))
● Distractor Analysis:
○ A is incorrect: Transporting non-viable, shock-less asystolic arrests poses severe
risks to the crew without patient benefit.
○ B is incorrect: Prolonging futile CPR is against TOR guidelines.
○ D is incorrect: Medical arrests do not go to Trauma Centers, and mechanical CPR
does not override TOR criteria.
The Mentor's Analysis: The TOR criteria mandate that resuscitative efforts exceeding 20
minutes without a shockable rhythm, ROSC, or EMS witnessing the arrest meet the standard for
medical futility. When facing prolonged asystole, the immediate priority is resource
management. By utilizing the Resuscitation Triage Protocol, you bypass the common trap of
dangerous lights-and-sirens transport of a deceased patient. Professional/Academic Intuition:
20 minutes of asystole with an EtCO2 < 10 mmHg is the definitive physiological marker of
futility.
Q5: A 6-year-old child weighing 20 kg is in severe anaphylactic shock with a blood pressure of
60/40. Based on the principles of the Montana Anaphylaxis Protocol, which action/conclusion is
the MOST ACCURATE? A) Administer Epinephrine 1:1,000 0.2mg IM B) Administer
Epinephrine 1:10,000 0.1 ml/kg IV C) Administer Diphenhydramine 50mg IV push D) Administer
Albuterol 2.5mg nebulized
● The Answer: B (Administer Epinephrine 1:10,000 0.1 ml/kg IV)
● Distractor Analysis:
○ A is incorrect: While IM Epinephrine is correct for stable anaphylaxis, hypotensive
shock (BP < 70) requires IV administration.
○ C is incorrect: Diphenhydramine is a secondary adjunct and does not reverse
cardiovascular collapse.
○ D is incorrect: Albuterol treats bronchospasm but will not correct profound
vasodilation.
, The Mentor's Analysis: Profound hypotension in anaphylaxis indicates cardiovascular collapse.
When facing anaphylactic shock, the immediate priority is restoring vascular tone. By utilizing IV
Epinephrine 1:10,000, you bypass the common trap of relying on IM absorption in a poorly
perfused patient. Professional/Academic Intuition: If the blood pressure crashes below 70
systolic in anaphylaxis, switch from the IM route to the IV route immediately.
Q6: An EMS crew assesses a 70-year-old male with acute facial droop and right-sided
hemiparesis. The RACE stroke scale score is 6. Based on the principles of the Montana Stroke
System of Care, which destination decision is the MOST ACCURATE? A) Transport to the
closest Primary Stroke Center regardless of other hospital capabilities B) Bypass the Primary
Stroke Center and transport to an Endovascular/Thrombectomy-Capable Stroke Center C)
Transport to the closest Level 1 Trauma Center D) Remain on scene to administer Nitroglycerin
to lower his blood pressure
● The Answer: B (Bypass the Primary Stroke Center and transport to an
Endovascular/Thrombectomy-Capable Stroke Center)
● Distractor Analysis:
○ A is incorrect: A RACE score of 6 indicates a high probability of a Large Vessel
Occlusion (LVO), which requires mechanical thrombectomy.
○ C is incorrect: Trauma centers manage kinetic injury, not acute ischemic stroke.
○ D is incorrect: Prehospital lowering of blood pressure in acute stroke is
contraindicated.
The Mentor's Analysis: A high RACE or VAN score signifies a massive clot in a major cerebral
artery (LVO). When facing an LVO, the immediate priority is mechanical clot extraction. By
utilizing LVO-specific destination protocols, you bypass the common trap of transporting to a
facility that cannot provide definitive surgical care. Professional/Academic Intuition: Time is
brain; bypass primary centers for thrombectomy-capable centers if an LVO is suspected.
Q7: You are treating a patient with a suspected narcotic overdose who is apneic. Based on the
principles of the Montana Overdose Protocol, which action/conclusion is the FIRST step? A)
Administer Naloxone 4mg IV immediately B) Secure the airway and begin bag-valve-mask
ventilations C) Insert an intraosseous line and administer Epinephrine D) Administer Naloxone
2mg IN and wait 5 minutes
● The Answer: B (Secure the airway and begin bag-valve-mask ventilations)
● Distractor Analysis:
○ A is incorrect: While Naloxone is the antidote, restoring oxygenation precedes
medication administration to prevent anoxic brain injury.
○ C is incorrect: Epinephrine is not indicated for respiratory arrest secondary to opiate
overdose.
○ D is incorrect: Waiting 5 minutes while the patient remains apneic will result in
cardiac arrest.
The Mentor's Analysis: Opiates kill by inducing profound respiratory depression, leading to
hypoxia and secondary cardiac arrest. When facing an apneic overdose, the immediate priority
is mechanical ventilation. By utilizing prompt BVM ventilations, you bypass the common trap of
allowing the patient to suffer anoxic brain damage while waiting for Naloxone.
Professional/Academic Intuition: Oxygenate before you medicate; the brain dies from lack
of oxygen, not lack of Naloxone.
Q8: An agency submits its cardiac arrest data to the state. Based on the principles of the 2026
Montana CARES requirements, which action/conclusion is the MOST ACCURATE? A) Data
must be submitted annually by December 31st B) Data must be entered into the CARES registry
by the 15th of the following month C) Data submission is voluntary for Paramedic-level transport
