NREMT Paramedic Exam Prep Document 2026/2027 | National
Registry EMT-P Certification | Advanced Prehospital Care | 150
Verified Questions with Detailed Explanations - 127 Questions
Section 1: Airway Management and Ventilation (Questions 1-10)
1 During a difficult airway situation, a paramedic attempts to place a supraglottic airway device (SAD) but
encounters resistance. The patient has a known history of cervical spine instability. Which of the following
actions is most appropriate to minimize the risk of secondary injury?
A) Apply firm downward pressure on the device to overcome resistance
B) Withdraw the device and attempt a different size or type of SAD
C) Use a laryngoscope to visualize the airway before reattempting SAD insertion
D) Switch to a surgical airway immediately
Answer: B
Rationale: Forcing a supraglottic airway against resistance can cause trauma and is contraindicated in cervical spine
instability. Withdrawing and trying a different size or type is appropriate. Direct laryngoscopy may exacerbate
cervical movement. Surgical airway is not indicated without failed ventilation.
2 A patient with severe metabolic acidosis is receiving bag-valve-mask ventilation at a rate of 20 breaths per
minute with a tidal volume of 600 mL. End-tidal CO2 (ETCO2) is 15 mmHg. What is the most likely
explanation for the low ETCO2?
A) The patient is hyperventilating due to metabolic acidosis
B) The ventilation rate is too high, causing excessive CO2 elimination
C) The tidal volume is too low for adequate alveolar ventilation
D) The patient has a pulmonary embolism reducing cardiac output
Answer: B
Rationale: In metabolic acidosis, compensatory hyperventilation is expected, but the ETCO2 of 15 mmHg is lower
than typical compensation (e.g., expected 20-25 mmHg). The high ventilation rate (20/min) is excessive, washing
out CO2. Tidal volume of 600 mL is adequate. Pulmonary embolism could cause low ETCO2 but is less likely
given the high rate.
3 Which of the following physiological changes associated with pregnancy most significantly impacts the
effectiveness of bag-valve-mask ventilation?
A) Increased functional residual capacity
B) Decreased chest wall compliance
C) Elevated diaphragm due to uterine enlargement
D) Increased oxygen consumption
Answer: C
Rationale: Elevation of the diaphragm reduces functional residual capacity and makes ventilation more difficult.
Decreased chest wall compliance is less pronounced. Increased oxygen consumption increases metabolic demand
but does not directly affect BVM effectiveness. The elevated diaphragm is the primary factor reducing the
effectiveness of positive pressure ventilation.
4 A paramedic is using a quantitative waveform capnograph to confirm endotracheal tube placement. Which
capnography waveform pattern is most indicative of correct tracheal placement?
,A) A gradual upslope with a prolonged phase II
B) A rectangular waveform with a sharp upstroke and downstroke
C) A sinusoidal pattern with varying amplitude
D) A waveform that shows no CO2 after 6 breaths
Answer: B
Rationale: A rectangular waveform (square wave) with sharp upstroke and downstroke indicates normal alveolar gas
exchange and proper tracheal placement. Gradual upslope or prolonged phase II suggests airway obstruction.
Sinusoidal pattern is not typical for tracheal intubation. No CO2 after 6 breaths suggests esophageal intubation.
5 A patient with severe traumatic brain injury (TBI) is being ventilated. The paramedic notes that the patient's
intracranial pressure (ICP) is 25 mmHg and mean arterial pressure (MAP) is 80 mmHg. Which of the following
ventilation strategies is most appropriate?
A) Target PaCO2 of 35-40 mmHg with mild hyperventilation
B) Target PaCO2 of 25-30 mmHg to reduce ICP
C) Target PaCO2 of 45-50 mmHg to avoid cerebral vasoconstriction
D) Use high-frequency oscillatory ventilation to minimize barotrauma
Answer: A
Rationale: In TBI, maintaining PaCO2 at 35-40 mmHg is recommended to balance cerebral perfusion.
Hyperventilation (PaCO2 25-30) can cause vasoconstriction and worsen ischemia. Hypoventilation (PaCO2 45-50)
increases ICP. High-frequency oscillatory ventilation is not standard prehospital management.
6 A patient with status asthmaticus is receiving noninvasive positive pressure ventilation (NIPPV). Which of the
following findings would most strongly indicate the need for immediate intubation?
A) Respiratory rate of 28 breaths per minute
B) PaCO2 of 50 mmHg with pH 7.25
C) SpO2 of 92% on 100% FiO2
D) Use of accessory muscles and paradoxical breathing
Answer: B
Rationale: A rising PaCO2 with acidosis (pH <7.30) indicates ventilatory failure and need for intubation.
Respiratory rate of 28 is high but not absolute. SpO2 92% is acceptable. Accessory muscle use and paradoxical
breathing are signs of severe distress but not definitive criteria for intubation if blood gases are stable.
7 A paramedic is attempting to ventilate a patient with a bag-valve-mask and notes increasing resistance to
ventilation. The patient has no history of lung disease. Which of the following is the most likely cause of
increased resistance?
A) Gastric distention
B) Bronchospasm
C) Pneumothorax
D) Kinked endotracheal tube
Answer: A
Rationale: Gastric distention from air entering the stomach during BVM ventilation increases abdominal pressure,
pushing the diaphragm upward and reducing lung compliance, leading to increased resistance. Bronchospasm and
pneumothorax are possible but less common without history. Kinked tube is unlikely if not intubated.
8 Which of the following statements regarding the use of a laryngeal mask airway (LMA) in cardiac arrest is most
accurate?
A) LMA provides a definitive airway equivalent to endotracheal intubation
,B) LMA insertion is associated with a higher incidence of aspiration compared to endotracheal intubation
C) LMA is contraindicated in patients with a gag reflex
D) LMA allows for effective ventilation even with poor mask seal
Answer: B
Rationale: LMA does not protect the trachea from aspiration, so aspiration risk is higher than with endotracheal
intubation. LMA is not a definitive airway. It can be used in cardiac arrest without a gag reflex. Effective
ventilation with LMA requires proper seal, but it is less affected by facial hair or anatomy than a face mask.
9 A patient with a flail chest and pulmonary contusion is being ventilated. Which of the following ventilation
strategies is most appropriate to minimize further lung injury?
A) Low tidal volume (6 mL/kg) and low plateau pressure
B) High tidal volume (10 mL/kg) to recruit atelectatic areas
C) Permissive hypercapnia with pH target >7.15
D) Pressure-controlled ventilation with peak pressure of 40 cmH2O
Answer: A
Rationale: Low tidal volume ventilation (6 mL/kg) and low plateau pressure are lung-protective strategies to avoid
volutrauma and barotrauma in pulmonary contusion. High tidal volumes can worsen injury. Permissive
hypercapnia may be used but is secondary to lung protection. High peak pressure (40 cmH2O) increases
barotrauma risk.
10 A paramedic is using a portable suction unit to clear a patient's airway. Which of the following techniques is
most effective for suctioning the oropharynx?
A) Insert the catheter to a depth of 15 cm and apply suction while withdrawing
B) Use a rigid tonsil-tip catheter with continuous suction
C) Use a flexible catheter with intermittent suction during insertion
D) Apply suction only after the catheter is fully inserted
Answer: B
Rationale: A rigid tonsil-tip catheter (Yankauer) is designed for oropharyngeal suctioning and allows effective
clearance with continuous suction. Flexible catheters are better for nasopharyngeal or endotracheal suction.
Suctioning during withdrawal (A) is less effective. Intermittent suction (C) is not recommended for oropharynx.
Suctioning only after insertion (D) may not clear secretions.
Section 2: Cardiology and Resuscitation (Questions 11-25)
11 A patient presents with acute chest pain and an ECG showing ST-segment elevation in leads II, III, and aVF
with reciprocal changes in I and aVL. Which of the following coronary arteries is most likely the culprit, and
what is the most appropriate immediate reperfusion strategy if the patient has no contraindications and
symptom onset was 2 hours ago?
A) Left anterior descending artery; immediate percutaneous coronary intervention (PCI) within 90 minutes
B) Left circumflex artery; fibrinolytic therapy if PCI not available within 120 minutes
C) Right coronary artery; fibrinolytic therapy if PCI not available within 90 minutes
D) Posterior descending artery; emergent coronary artery bypass grafting
Answer: C
Rationale: Inferior STEMI (II, III, aVF) typically involves the right coronary artery (RCA). Current AHA guidelines
recommend PCI within 90 minutes of first medical contact; if PCI cannot be performed within 120 minutes,
fibrinolytic therapy should be given within 30 minutes of arrival. Option C correctly identifies the RCA and the
90-minute fibrinolytic window when PCI is delayed. Option A describes anterior MI (LAD). Option B incorrectly
, associates LCx with inferior MI. Option D is not first-line.
12 During a cardiac arrest resuscitation, the patient has a shockable rhythm. After the third shock and 2 minutes of
CPR, the monitor shows a narrow-complex tachycardia at 150/min with palpable pulses. The patient is
hypotensive with a systolic BP of 70 mmHg. Which of the following is the most appropriate next intervention?
A) Administer adenosine 6 mg rapid IV push
B) Perform synchronized cardioversion at 100 J
C) Start amiodarone 150 mg IV over 10 minutes
D) Initiate a dopamine infusion at 5 mcg/kg/min
Answer: B
Rationale: The patient has post-arrest unstable tachycardia (hypotension with pulses). Synchronized cardioversion is
indicated for unstable tachyarrhythmias. Adenosine (A) is used for stable narrow-complex tachycardia.
Amiodarone (C) is for stable wide-complex tachycardia. Dopamine (D) may be considered after rhythm control but
is not first-line for unstable tachycardia.
13 A patient in pulseless electrical activity (PEA) arrest has a history of end-stage renal disease on hemodialysis.
Which of the following is the most likely reversible cause, and what is the corresponding treatment?
A) Hyperkalemia; administer calcium gluconate and sodium bicarbonate
B) Hypovolemia; rapid fluid bolus of 2 L normal saline
C) Tension pneumothorax; needle decompression
D) Pericardial tamponade; pericardiocentesis
Answer: A
Rationale: ESRD patients are prone to hyperkalemia, a common reversible cause of PEA. Treatment includes
calcium gluconate for cardiac membrane stabilization and sodium bicarbonate for acidosis. Hypovolemia (B) is less
likely in this population. Tension pneumothorax (C) and tamponade (D) are possible but not the most likely given
the history.
14 A 12-lead ECG shows ST-segment depression in leads V1-V3 and tall R waves in V1 with positive T waves.
Which of the following is the most likely diagnosis, and what is the immediate management?
A) Posterior STEMI; activate cath lab and consider fibrinolytic if PCI delayed
B) Anterior NSTEMI; start heparin and monitor troponin
C) Right ventricular hypertrophy; obtain echocardiogram
D) Left bundle branch block; no acute intervention needed
Answer: A
Rationale: ST depression in V1-V3 with tall R waves suggests posterior wall MI (often due to LCx occlusion). This
is a STEMI equivalent and requires emergent reperfusion. Option B is incorrect because it is not NSTEMI. Option
C is not acute. Option D is not supported by the findings.
15 A patient with acute decompensated heart failure presents with pulmonary edema and hypotension (SBP 80
mmHg). Which combination of pharmacological interventions is most appropriate?
A) Dobutamine 5 mcg/kg/min and furosemide 40 mg IV
B) Norepinephrine 0.5 mcg/min and nitroglycerin 10 mcg/min
C) Epinephrine 1 mg IV push and furosemide 80 mg IV
D) Milrinone 0.5 mcg/kg/min and metoprolol 5 mg IV
Answer: A
Rationale: In hypotensive heart failure, inotropic support with dobutamine is preferred to improve cardiac output,
and diuresis with furosemide reduces preload. Norepinephrine (B) increases afterload and is not ideal. Epinephrine
Registry EMT-P Certification | Advanced Prehospital Care | 150
Verified Questions with Detailed Explanations - 127 Questions
Section 1: Airway Management and Ventilation (Questions 1-10)
1 During a difficult airway situation, a paramedic attempts to place a supraglottic airway device (SAD) but
encounters resistance. The patient has a known history of cervical spine instability. Which of the following
actions is most appropriate to minimize the risk of secondary injury?
A) Apply firm downward pressure on the device to overcome resistance
B) Withdraw the device and attempt a different size or type of SAD
C) Use a laryngoscope to visualize the airway before reattempting SAD insertion
D) Switch to a surgical airway immediately
Answer: B
Rationale: Forcing a supraglottic airway against resistance can cause trauma and is contraindicated in cervical spine
instability. Withdrawing and trying a different size or type is appropriate. Direct laryngoscopy may exacerbate
cervical movement. Surgical airway is not indicated without failed ventilation.
2 A patient with severe metabolic acidosis is receiving bag-valve-mask ventilation at a rate of 20 breaths per
minute with a tidal volume of 600 mL. End-tidal CO2 (ETCO2) is 15 mmHg. What is the most likely
explanation for the low ETCO2?
A) The patient is hyperventilating due to metabolic acidosis
B) The ventilation rate is too high, causing excessive CO2 elimination
C) The tidal volume is too low for adequate alveolar ventilation
D) The patient has a pulmonary embolism reducing cardiac output
Answer: B
Rationale: In metabolic acidosis, compensatory hyperventilation is expected, but the ETCO2 of 15 mmHg is lower
than typical compensation (e.g., expected 20-25 mmHg). The high ventilation rate (20/min) is excessive, washing
out CO2. Tidal volume of 600 mL is adequate. Pulmonary embolism could cause low ETCO2 but is less likely
given the high rate.
3 Which of the following physiological changes associated with pregnancy most significantly impacts the
effectiveness of bag-valve-mask ventilation?
A) Increased functional residual capacity
B) Decreased chest wall compliance
C) Elevated diaphragm due to uterine enlargement
D) Increased oxygen consumption
Answer: C
Rationale: Elevation of the diaphragm reduces functional residual capacity and makes ventilation more difficult.
Decreased chest wall compliance is less pronounced. Increased oxygen consumption increases metabolic demand
but does not directly affect BVM effectiveness. The elevated diaphragm is the primary factor reducing the
effectiveness of positive pressure ventilation.
4 A paramedic is using a quantitative waveform capnograph to confirm endotracheal tube placement. Which
capnography waveform pattern is most indicative of correct tracheal placement?
,A) A gradual upslope with a prolonged phase II
B) A rectangular waveform with a sharp upstroke and downstroke
C) A sinusoidal pattern with varying amplitude
D) A waveform that shows no CO2 after 6 breaths
Answer: B
Rationale: A rectangular waveform (square wave) with sharp upstroke and downstroke indicates normal alveolar gas
exchange and proper tracheal placement. Gradual upslope or prolonged phase II suggests airway obstruction.
Sinusoidal pattern is not typical for tracheal intubation. No CO2 after 6 breaths suggests esophageal intubation.
5 A patient with severe traumatic brain injury (TBI) is being ventilated. The paramedic notes that the patient's
intracranial pressure (ICP) is 25 mmHg and mean arterial pressure (MAP) is 80 mmHg. Which of the following
ventilation strategies is most appropriate?
A) Target PaCO2 of 35-40 mmHg with mild hyperventilation
B) Target PaCO2 of 25-30 mmHg to reduce ICP
C) Target PaCO2 of 45-50 mmHg to avoid cerebral vasoconstriction
D) Use high-frequency oscillatory ventilation to minimize barotrauma
Answer: A
Rationale: In TBI, maintaining PaCO2 at 35-40 mmHg is recommended to balance cerebral perfusion.
Hyperventilation (PaCO2 25-30) can cause vasoconstriction and worsen ischemia. Hypoventilation (PaCO2 45-50)
increases ICP. High-frequency oscillatory ventilation is not standard prehospital management.
6 A patient with status asthmaticus is receiving noninvasive positive pressure ventilation (NIPPV). Which of the
following findings would most strongly indicate the need for immediate intubation?
A) Respiratory rate of 28 breaths per minute
B) PaCO2 of 50 mmHg with pH 7.25
C) SpO2 of 92% on 100% FiO2
D) Use of accessory muscles and paradoxical breathing
Answer: B
Rationale: A rising PaCO2 with acidosis (pH <7.30) indicates ventilatory failure and need for intubation.
Respiratory rate of 28 is high but not absolute. SpO2 92% is acceptable. Accessory muscle use and paradoxical
breathing are signs of severe distress but not definitive criteria for intubation if blood gases are stable.
7 A paramedic is attempting to ventilate a patient with a bag-valve-mask and notes increasing resistance to
ventilation. The patient has no history of lung disease. Which of the following is the most likely cause of
increased resistance?
A) Gastric distention
B) Bronchospasm
C) Pneumothorax
D) Kinked endotracheal tube
Answer: A
Rationale: Gastric distention from air entering the stomach during BVM ventilation increases abdominal pressure,
pushing the diaphragm upward and reducing lung compliance, leading to increased resistance. Bronchospasm and
pneumothorax are possible but less common without history. Kinked tube is unlikely if not intubated.
8 Which of the following statements regarding the use of a laryngeal mask airway (LMA) in cardiac arrest is most
accurate?
A) LMA provides a definitive airway equivalent to endotracheal intubation
,B) LMA insertion is associated with a higher incidence of aspiration compared to endotracheal intubation
C) LMA is contraindicated in patients with a gag reflex
D) LMA allows for effective ventilation even with poor mask seal
Answer: B
Rationale: LMA does not protect the trachea from aspiration, so aspiration risk is higher than with endotracheal
intubation. LMA is not a definitive airway. It can be used in cardiac arrest without a gag reflex. Effective
ventilation with LMA requires proper seal, but it is less affected by facial hair or anatomy than a face mask.
9 A patient with a flail chest and pulmonary contusion is being ventilated. Which of the following ventilation
strategies is most appropriate to minimize further lung injury?
A) Low tidal volume (6 mL/kg) and low plateau pressure
B) High tidal volume (10 mL/kg) to recruit atelectatic areas
C) Permissive hypercapnia with pH target >7.15
D) Pressure-controlled ventilation with peak pressure of 40 cmH2O
Answer: A
Rationale: Low tidal volume ventilation (6 mL/kg) and low plateau pressure are lung-protective strategies to avoid
volutrauma and barotrauma in pulmonary contusion. High tidal volumes can worsen injury. Permissive
hypercapnia may be used but is secondary to lung protection. High peak pressure (40 cmH2O) increases
barotrauma risk.
10 A paramedic is using a portable suction unit to clear a patient's airway. Which of the following techniques is
most effective for suctioning the oropharynx?
A) Insert the catheter to a depth of 15 cm and apply suction while withdrawing
B) Use a rigid tonsil-tip catheter with continuous suction
C) Use a flexible catheter with intermittent suction during insertion
D) Apply suction only after the catheter is fully inserted
Answer: B
Rationale: A rigid tonsil-tip catheter (Yankauer) is designed for oropharyngeal suctioning and allows effective
clearance with continuous suction. Flexible catheters are better for nasopharyngeal or endotracheal suction.
Suctioning during withdrawal (A) is less effective. Intermittent suction (C) is not recommended for oropharynx.
Suctioning only after insertion (D) may not clear secretions.
Section 2: Cardiology and Resuscitation (Questions 11-25)
11 A patient presents with acute chest pain and an ECG showing ST-segment elevation in leads II, III, and aVF
with reciprocal changes in I and aVL. Which of the following coronary arteries is most likely the culprit, and
what is the most appropriate immediate reperfusion strategy if the patient has no contraindications and
symptom onset was 2 hours ago?
A) Left anterior descending artery; immediate percutaneous coronary intervention (PCI) within 90 minutes
B) Left circumflex artery; fibrinolytic therapy if PCI not available within 120 minutes
C) Right coronary artery; fibrinolytic therapy if PCI not available within 90 minutes
D) Posterior descending artery; emergent coronary artery bypass grafting
Answer: C
Rationale: Inferior STEMI (II, III, aVF) typically involves the right coronary artery (RCA). Current AHA guidelines
recommend PCI within 90 minutes of first medical contact; if PCI cannot be performed within 120 minutes,
fibrinolytic therapy should be given within 30 minutes of arrival. Option C correctly identifies the RCA and the
90-minute fibrinolytic window when PCI is delayed. Option A describes anterior MI (LAD). Option B incorrectly
, associates LCx with inferior MI. Option D is not first-line.
12 During a cardiac arrest resuscitation, the patient has a shockable rhythm. After the third shock and 2 minutes of
CPR, the monitor shows a narrow-complex tachycardia at 150/min with palpable pulses. The patient is
hypotensive with a systolic BP of 70 mmHg. Which of the following is the most appropriate next intervention?
A) Administer adenosine 6 mg rapid IV push
B) Perform synchronized cardioversion at 100 J
C) Start amiodarone 150 mg IV over 10 minutes
D) Initiate a dopamine infusion at 5 mcg/kg/min
Answer: B
Rationale: The patient has post-arrest unstable tachycardia (hypotension with pulses). Synchronized cardioversion is
indicated for unstable tachyarrhythmias. Adenosine (A) is used for stable narrow-complex tachycardia.
Amiodarone (C) is for stable wide-complex tachycardia. Dopamine (D) may be considered after rhythm control but
is not first-line for unstable tachycardia.
13 A patient in pulseless electrical activity (PEA) arrest has a history of end-stage renal disease on hemodialysis.
Which of the following is the most likely reversible cause, and what is the corresponding treatment?
A) Hyperkalemia; administer calcium gluconate and sodium bicarbonate
B) Hypovolemia; rapid fluid bolus of 2 L normal saline
C) Tension pneumothorax; needle decompression
D) Pericardial tamponade; pericardiocentesis
Answer: A
Rationale: ESRD patients are prone to hyperkalemia, a common reversible cause of PEA. Treatment includes
calcium gluconate for cardiac membrane stabilization and sodium bicarbonate for acidosis. Hypovolemia (B) is less
likely in this population. Tension pneumothorax (C) and tamponade (D) are possible but not the most likely given
the history.
14 A 12-lead ECG shows ST-segment depression in leads V1-V3 and tall R waves in V1 with positive T waves.
Which of the following is the most likely diagnosis, and what is the immediate management?
A) Posterior STEMI; activate cath lab and consider fibrinolytic if PCI delayed
B) Anterior NSTEMI; start heparin and monitor troponin
C) Right ventricular hypertrophy; obtain echocardiogram
D) Left bundle branch block; no acute intervention needed
Answer: A
Rationale: ST depression in V1-V3 with tall R waves suggests posterior wall MI (often due to LCx occlusion). This
is a STEMI equivalent and requires emergent reperfusion. Option B is incorrect because it is not NSTEMI. Option
C is not acute. Option D is not supported by the findings.
15 A patient with acute decompensated heart failure presents with pulmonary edema and hypotension (SBP 80
mmHg). Which combination of pharmacological interventions is most appropriate?
A) Dobutamine 5 mcg/kg/min and furosemide 40 mg IV
B) Norepinephrine 0.5 mcg/min and nitroglycerin 10 mcg/min
C) Epinephrine 1 mg IV push and furosemide 80 mg IV
D) Milrinone 0.5 mcg/kg/min and metoprolol 5 mg IV
Answer: A
Rationale: In hypotensive heart failure, inotropic support with dobutamine is preferred to improve cardiac output,
and diuresis with furosemide reduces preload. Norepinephrine (B) increases afterload and is not ideal. Epinephrine
