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9 free Paramedic practice questions: Advanced Airway Management and Rapid Sequence Intubation Concepts

These are real questions from the same bank the app draws from. Each one is written to the NREMT Paramedic content specifications and kept inside the Paramedic scope of practice. Pick an answer and you get the full rationale, including why the other three options are wrong.

Work through all 9, then move on to the next topic. When you want the full picture, the free Paramedic diagnostic covers every topic in one sitting. No account needed for any of it.

Question 1 of 9

A 61-year-old patient in septic shock has a decreasing level of consciousness and needs the airway secured. The vital signs are BP 78/44, P 132, R 30, and SpO₂ 88% on high-flow oxygen. What should be done before the induction agent is given?

Show the answer and rationale

Correct answer · Give a fluid bolus, have a vasopressor ready, and reduce the induction dose

This patient is in septic shock, with a pressure of 78/44 and a pulse of 132. Induction drugs drop the tone in the blood vessels. Positive pressure ventilation cuts down the blood returning to the heart. This patient's pressure is already low. Together they can put this patient into cardiac arrest from the drug instead of from the disease. Resuscitate before you intubate. Give a fluid bolus, and have a vasopressor drawn up and running if needed. Lower the induction dose, because a patient in shock needs less of the drug than the usual dose.

Why the others are wrong

Withhold the paralytic and attempt an awake look with topical anesthesia alone: An awake look with topical anesthesia alone does nothing for the low blood pressure. Without the paralytic, you also give up the conditions that make success on the first try likely. This patient cannot handle a second attempt.

Increase the oxygen flow and defer the airway until the emergency department: The level of consciousness is falling, and the SpO₂ is 88% on high-flow oxygen. Turning up the oxygen does not protect the airway. Waiting until the emergency department leaves an unprotected airway in a patient who is still getting worse.

Give the full induction dose so the airway is secured before the pressure falls: Giving the full dose to get the tube in before the pressure falls sounds faster. In a patient with no reserve, a full dose is what is most likely to stop the heart. Getting the tube in fast does not keep a systolic pressure of 78 from falling after a full dose.

Question 2 of 9

A 58-year-old patient has a rapidly expanding neck hematoma after a fall, with worsening stridor and decreasing responsiveness. Two laryngoscopy attempts fail to reveal any glottic structures. A supraglottic airway is inserted, but there is no chest rise and no waveform on capnography. Positive pressure ventilations with a BVM and an oropharyngeal airway also produce no chest rise, and the SpO₂ has fallen from 88% to 71%. What should the paramedic do next?

Show the answer and rationale

Correct answer · Perform a surgical cricothyrotomy

This is a failed airway in its most urgent form. You cannot intubate and you cannot oxygenate, so the next step is a surgical cricothyrotomy. Two laryngoscopy attempts failed. The supraglottic airway gave no chest rise and no waveform. The BVM with an oropharyngeal airway gave no chest rise either. Meanwhile the SpO₂ has dropped from 88% to 71%. Every failed airway algorithm ends in a surgical airway at this point. An expanding neck hematoma distorts the anatomy of the neck. Another look with the laryngoscope will not fix distorted anatomy. Every extra attempt uses up oxygen this patient does not have. Make the call early and go to the surgical airway now.

Why the others are wrong

Reposition the supraglottic airway: Repositioning a supraglottic airway is worth trying when the device has not already failed. This one already gave no chest rise and no waveform on capnography. The supraglottic airway is not ventilating at all.

Attempt a third laryngoscopy: A third laryngoscopy uses more of an oxygen reserve that is already falling fast. Two attempts already failed against anatomy the hematoma has distorted. Another attempt will not change that anatomy.

Increase the ventilation rate with the BVM: A faster BVM rate only helps if each breath is moving air. These breaths produce no chest rise at all. More breaths that move no air do not help this patient.

Question 3 of 9

A 27-year-old patient was stung by a wasp 10 minutes ago and now has raised welts across the trunk, swelling of the lips and tongue, and audible stridor. The patient can speak only in single words. The vital signs are BP 82/50, P 128, and R 28, with SpO₂ 90% on high-concentration oxygen. What is the most appropriate next action?

Show the answer and rationale

Correct answer · Administer epinephrine intramuscularly

This patient is in anaphylaxis. An allergic reaction stays in the skin with mild symptoms. Anaphylaxis spreads to another body system. This patient has two more systems involved. The stridor and the swollen lips and tongue are the airway. A blood pressure of 82/50 with a pulse of 128 is the circulation. Epinephrine is the only drug here that treats both. Alpha-1 effects tighten the dilated, leaking blood vessels. The blood pressure comes up, and the swelling that is closing off the airway goes down. Beta-2 effects relax the muscle around the bronchioles and slow the release of more chemicals from the mast cells. Give epinephrine IM into the lateral thigh. The IM route absorbs fast and reliably, without the dysrhythmia risk of an IV push in a patient who still has a pulse. Diphenhydramine and albuterol only help after epinephrine, and neither one works fast enough while the tongue is closing off the airway.

Why the others are wrong

Administer diphenhydramine intravenously: Diphenhydramine is an H1 antihistamine, and it does belong in anaphylaxis care. Diphenhydramine blocks histamine at the receptor and blunts the next round of effects. The antihistamine does nothing for the histamine already causing the stridor and the blood pressure of 82/50. The antihistamine also takes far longer to work than this airway has. Both drugs get given, and diphenhydramine comes after epinephrine. The question asks what comes first.

Administer nebulized albuterol: Albuterol is right for bronchospasm in the lower airway. If this patient were wheezing after epinephrine, albuterol would be a reasonable add-on. This patient has stridor. Stridor is a high-pitched sound from swelling at or above the vocal cords. A nebulized beta-2 drug does not shrink swelling in the larynx and tongue. Albuterol also does nothing for the low blood pressure, which is the other half of what is killing this patient.

Perform rapid sequence intubation: Rapid sequence intubation is what you get ready for when the airway swelling does not respond to epinephrine. This patient may still need RSI. Paralyzing a patient whose glottis is already narrowed by swelling can turn a partly blocked airway into a can't intubate, can't ventilate emergency. RSI also does nothing for the shock. Give epinephrine first to reverse the swelling, and keep the airway plan ready in case epinephrine does not work.

Question 4 of 9

A paramedic responds for a 71-year-old patient with a long-standing tracheostomy who has increasing difficulty breathing. The patient is restless, and the skin is pale. Ventilation through the tracheostomy tube with a BVM device meets high resistance and produces no chest rise. A suction catheter passes only a short distance into the tube before meeting an obstruction, and suctioning does not improve ventilation. What should the paramedic do next?

Show the answer and rationale

Correct answer · Remove the inner cannula and reattempt ventilation

This tracheostomy tube is blocked, and the blockage is inside the tube itself. The BVM meets high resistance and gives no chest rise. High resistance with no chest rise tells you the tube is blocked, not out of place. The suction catheter only passes a short distance before it hits the obstruction. A catheter that stops that short tells you the blockage is inside the tube near the top, not down in the trachea or a bronchus. In a long-standing tracheostomy, the most common cause is dried secretions crusted onto the inner cannula. The inner cannula is a removable liner inside the tube, made to be taken out and cleaned. Pulling the inner cannula takes seconds and needs no equipment. You can put the inner cannula back in. The outer cannula stays in place and holds the stoma open. Anything that will not pass a catheter and will not take a breath gets the inner cannula out before you try anything more aggressive.

Why the others are wrong

Instill sterile saline and suction the tube again: Suctioning again is right when the catheter passes and you just need to clear more secretions than one pass got. Here the catheter already hit a firm obstruction, and suctioning already failed to improve ventilation. Repeating the suction leaves a restless, pale patient without ventilation. Saline instillation is not supported as a way to break up a plug, and saline can push debris further in. Pulling the inner cannula takes the whole plug out with it.

Ventilate through the mouth and nose with a mask: Ventilating through the mouth and nose is a real rescue for a tracheostomy patient. The rescue only works when the upper airway still connects the pharynx to the trachea. A patient with a total laryngectomy does not have that connection. You also have to cover the stoma, or the air escapes out of the stoma. Ventilating from above is the workaround for a tube you cannot fix. This tube can likely be fixed in seconds by pulling the inner cannula, so skipping that step only adds a delay.

Remove the entire tracheostomy tube from the stoma: Removing the whole tube is the next step if the obstruction is still there after the inner cannula is out. The whole tube also comes out when the tube is clearly displaced into a false passage. Pulling the outer cannula can cost you the stoma tract. If the tract closes, you may not be able to get an airway back in. Pull the inner cannula first, and pull the whole tube only if the obstruction stays.

Question 5 of 9

A paramedic is unable to intubate a patient who was eating a large meal immediately before collapsing and who has already vomited once. BVM ventilation is producing adequate chest rise, and a supraglottic airway will be placed as a rescue device. Which feature of the device is most important in this patient?

Show the answer and rationale

Correct answer · A channel that allows gastric drainage

This patient has a full stomach and a high risk of aspiration. The patient ate a large meal right before collapsing and has already vomited once. BVM ventilation has also been pushing air into the stomach with every breath. The stomach is full, swollen with air, and bringing contents back up. No supraglottic airway seals off the trachea. Vomit that comes up can still get into the trachea. A gastric drainage channel lets you pass a tube into the stomach. Through that tube you vent the trapped air and suction out the contents before they get past the seal. Draining the stomach lowers the risk of aspiration. Venting the air also takes pressure off the diaphragm, so ventilation gets easier.

Why the others are wrong

An inflatable cuff that seals the hypopharynx: A cuff that seals the hypopharynx is what lets any supraglottic airway ventilate. Without a seal, air leaks around the device instead of going to the lungs. Every supraglottic airway already has a cuff like this. The cuff stops air from escaping upward. The cuff does nothing about vomit coming up from the stomach below the device.

A color-coded sizing scale based on weight: A weight-based color scale helps you pick the right size. The wrong size causes leaks or poor seating in any patient. Sizing matters for every patient and has nothing to do with this patient's full stomach. A color scale does nothing about the vomit already coming up the esophagus.

A reinforced tube that resists kinking: A kink-resistant tube protects against the tube bending closed when the head turns during movement or transport. A kinked tube is a real problem once the device is in. This patient's problem is already happening, because the patient has already vomited. Draining the stomach matters more than guarding against a kink that has not happened.

Question 6 of 9

A 70-year-old patient with a history of a total laryngectomy is found unresponsive and apneic with an opening in the anterior neck. A first responder is ventilating with a BVM device over the mouth and nose, and the chest does not rise. The airway has been repositioned and the mouth is clear of fluid and debris. What is the most appropriate next action?

Show the answer and rationale

Correct answer · Ventilate through the neck opening

This patient had a total laryngectomy, and every breath has to go through the neck opening. A total laryngectomy removes the larynx. The surgeon brings the cut end of the trachea out to the skin as a permanent stoma. After that surgery, the mouth and nose no longer connect to the lungs. That's why the chest does not rise with the BVM over the mouth and nose. A breath given at the face cannot reach the lungs, no matter how good the mask seal or the technique is. Seal an infant or pediatric mask over the stoma and ventilate. If you need to ventilate for a long time, pass an endotracheal tube a short way into the stoma. A tracheostomy is different. With a tracheostomy, the upper airway still connects to the trachea, and breaths from above can still work.

Why the others are wrong

Perform a jaw-thrust maneuver and reattempt: A jaw thrust is right for the most common reason a chest will not rise, which is the tongue falling back in an unresponsive patient. A jaw thrust is also the version you use when you suspect a spine injury. The jaw thrust opens the path between the mouth and the trachea. This patient has no such path, because surgery removed it. Opening the throat does nothing for the lungs here.

Insert an oropharyngeal airway and reattempt: An oropharyngeal airway holds the tongue off the back of the throat. In an ordinary failed ventilation, an oral airway is a fair next step. The oral airway still depends on the mouth leading to the lungs, and in this patient the mouth leads nowhere. The question also tells you the airway was already repositioned and the mouth is clear.

Suction the mouth and reattempt: Suctioning is right when something physically blocks the airway, such as blood, vomit, or secretions. Suction should always be considered early. The question says the mouth is clear of fluid and debris, so there is nothing to suction. Another attempt through the face fails the same way. Only moving the breaths to the stoma changes the outcome.

Question 7 of 9

During laryngoscopy on a 49-year-old patient undergoing rapid sequence intubation, an assistant is applying firm pressure to the cricoid cartilage. The paramedic can see only the posterior cartilages at the laryngeal inlet and cannot pass the tube. The SpO₂ is 97% and there is no vomiting. What is the most appropriate next action?

Show the answer and rationale

Correct answer · Have the assistant release the pressure

The cricoid pressure is making the view worse, so have the assistant let go. Firm cricoid pressure is on, and you can see only the posterior cartilages at the laryngeal inlet. Cricoid pressure was taught for decades on the idea that pressing the cricoid ring back closes the esophagus and stops regurgitation. Cricoid pressure has never been shown to do that reliably, and it is no longer recommended as a routine part of rapid sequence intubation. Firm cricoid pressure does reliably push the laryngeal inlet out of shape and worsen your view. Seeing only the posterior cartilages is exactly the view firm cricoid pressure gives you. When cricoid pressure is on and the view is poor, releasing or adjusting the pressure is the first fix. Releasing the pressure often turns a partial view into a full view within seconds. The SpO₂ is 97% and there is no vomiting. You have time to make the change during this attempt instead of giving the attempt up.

Why the others are wrong

Have the assistant increase the pressure: More pressure on the neck is what you ask for when the larynx sits too far forward. The pressure that helps a forward larynx is external laryngeal manipulation. A second set of hands moves the thyroid cartilage, and the view does improve. Cricoid pressure pushes the airway backward instead, to try to close the esophagus behind it. Pressing harder on the cricoid flattens the laryngeal inlet even more and makes the view worse.

Withdraw and reattempt with a smaller blade: Changing blades is a fair response to a failed attempt, and blade type and size do affect the view. This attempt has not failed. The SpO₂ is 97% and you are still looking. Pulling out to swap blades costs the whole attempt plus the time to change equipment. The cause of the poor view is the assistant's hand on the cricoid, and you can fix that pressure without starting over.

Abandon the attempt and place a supraglottic airway: Moving to a supraglottic airway is right when the patient is desaturating, the attempt has run long, or repeated attempts have failed. None of those are true here. The SpO₂ is 97%, this is one attempt still in progress, and the poor view has a cause you can fix. Placing a supraglottic airway now gives up a definitive airway when one sentence to the assistant would fix the view.

Question 8 of 9

A 62-year-old patient with a fixed, flexed neck from long-standing rheumatoid arthritis received etomidate and rocuronium at 1.2 mg/kg for rapid sequence intubation. The first laryngoscopy attempt failed. BVM ventilation with an oropharyngeal airway is maintaining an SpO₂ of 97%, and a crew member suggests allowing the patient to wake up and breathe spontaneously instead of making a second attempt. Which factor makes that plan unavailable?

Show the answer and rationale

Correct answer · Rocuronium will last 45 to 60 minutes

Rocuronium lasts 45 to 60 minutes, so this patient cannot be woken up to breathe on their own. Paralytics come in two groups based on how long they last. Succinylcholine is depolarizing and short. Succinylcholine wears off in about eight to ten minutes, so a crew that used it can fall back on letting the patient breathe again. Rocuronium is non-depolarizing. At an intubating dose of 1.2 mg/kg, rocuronium causes complete paralysis for about 45 to 60 minutes. No patient can go that long without someone breathing for them. Choosing rocuronium commits you to managing the airway the whole time. Every backup plan has to be a rescue airway: keep ventilating with the BVM, place a supraglottic airway, or perform a surgical airway. Know that before you push the drug. This patient's fixed, flexed neck already made the first attempt fail.

Why the others are wrong

Etomidate will suppress breathing for an hour: Etomidate is the reason this patient is unconscious, and sedation does add to apnea. One induction dose of etomidate only lasts a few minutes, nowhere near an hour. Even after the etomidate wears off, the rocuronium still keeps the patient from taking a breath.

Rocuronium does not affect the diaphragm: Rocuronium paralyzes the diaphragm along with every other skeletal muscle. The diaphragm is one of the harder muscles to block and one of the first to recover. If rocuronium really spared the diaphragm, the crew member's plan would work. The diaphragm is paralyzed too, so the plan fails.

BVM ventilation prevents spontaneous effort: Overventilating with a BVM can lower carbon dioxide and blunt the drive to breathe in a patient who is not paralyzed. The BVM is not why this patient is apneic. Right now the BVM is the only thing holding the SpO₂ at 97%. The rocuronium is what stops the breathing.

Question 9 of 9

A paramedic places a bougie beneath the epiglottis of a 61-year-old patient and feels the clicks of the tracheal rings along its length as it is advanced. The endotracheal tube is then advanced over the bougie but stops against firm resistance a few centimeters short of its intended depth and will not pass. The laryngoscope is still in place and the view is unchanged. The SpO₂ is 96%. What should the paramedic do next?

Show the answer and rationale

Correct answer · Withdraw the tube slightly and rotate it counterclockwise

The bougie is in the trachea, and the endotracheal tube is caught at the larynx on the way in. You felt the clicks of the tracheal rings as the bougie went in. Those clicks tell you the bougie is in the right place. When a tube stops while sliding over a bougie in the trachea, the bevel of the tube is almost always caught. The tube is normally held with the bevel facing left. That's why the leading edge of the bevel catches on the right arytenoid cartilage or the aryepiglottic fold. Back the tube out about a centimeter and rotate the tube 90 degrees counterclockwise. Rotating the tube turns the bevel away from the cartilage, and the tip slips between the vocal cords. Keep the laryngoscope in place the whole time. The laryngoscope holds the tissue out of the way and keeps the path to the cords open.

Why the others are wrong

Withdraw the bougie a few centimeters and readvance it: Moving the bougie moves the guide, not the part that is stuck. The bevel of the tube still faces the same way, and it hits the same cartilage again. Pulling the bougie back also risks losing the tracheal placement you already have.

Push the tube firmly past the resistance: Pushing harder does not change the angle that is causing the hang-up. The bevel stays hooked on the same cartilage. The extra force can dislocate an arytenoid or tear the lining of the larynx, and the bleeding makes every attempt after that harder.

Remove the bougie and reattempt with a stylet: The bougie already did the hard part, and the clicks confirm the bougie is in the trachea. Pulling the bougie out starts the intubation over from the beginning. A stylet does nothing to free a bevel caught on the arytenoid.

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