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10 free Paramedic practice questions: Advanced Respiratory Emergencies

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.

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Question 1 of 10

A 31-year-old patient with a history of asthma is sitting upright, unable to speak, with almost no air movement heard over either lung field. The skin is cyanotic and diaphoretic. The vital signs are BP 104/70, P 138, R 8 and shallow, and SpO₂ 82% on high-flow oxygen. A nebulized bronchodilator treatment is running, and the mist is drifting out of the mask rather than being drawn in. Which action is most appropriate next?

Show the answer and rationale

Correct answer · Administer intramuscular epinephrine per protocol

This patient is in a severe asthma attack with a silent chest. There is almost no air movement over either lung, the respiratory rate is 8 and shallow, and the SpO₂ is 82% on high-flow oxygen. A nebulizer only works if the patient breathes the mist in. The drug rides in on each breath to reach the smooth muscle of the airways. This patient is not moving enough air to carry the drug there. That's why the mist is drifting out of the mask. Intramuscular epinephrine reaches the same receptors through the bloodstream. Epinephrine does not need the patient to move air to work. Give the epinephrine while you set up for positive pressure ventilation and an advanced airway. A silent chest with a saturation of 82% means this patient is minutes from arrest.

Why the others are wrong

Increase the nebulizer flow rate and continue the treatment: A higher flow rate makes more mist. More mist does not mean more drug gets breathed in. The patient's air movement is the problem, and turning up the flow does nothing to fix the air movement.

Apply CPAP at 10 cm H₂O and reassess in five minutes: CPAP needs an alert patient who can still take a good breath on their own. This patient cannot speak and is breathing 8 shallow times a minute. That's why CPAP is not the right call for this patient.

Administer a second nebulized bronchodilator treatment: A second treatment goes in the same way as the first one. The first treatment is not reaching the airway because the patient is not moving air. A second nebulizer treatment is going to fail for the same reason.

Question 2 of 10

A 70-year-old patient with chronic obstructive pulmonary disease is in respiratory distress with an SpO₂ of 79% on room air. The vital signs are BP 148/88, P 112, R 28, and T 37.1. A crew member suggests limiting oxygen to a nasal cannula at 2 L/min out of concern for suppressing the patient's respiratory drive. Which action is most appropriate?

Show the answer and rationale

Correct answer · Apply high-concentration oxygen and titrate to 88 to 92 percent

This COPD patient is severely hypoxemic, with an SpO₂ of 79% on room air. Hypoxemia this severe needs oxygen right now. The crew member's worry about suppressing the respiratory drive comes from the hypoxic drive theory. Hypoxic drive is not a real mechanism. A hypoxic patient always gets oxygen, and hypoxia kills faster than a rising carbon dioxide does. Start high-concentration oxygen to correct the hypoxemia. Then titrate down to the patient's normal baseline saturation. Many COPD patients normally run a lower saturation than a healthy patient. When you do not know the baseline, 88 to 92 percent is the target you use.

Why the others are wrong

Limit oxygen to 2 L/min by nasal cannula and watch mental status: Oxygen at 2 L/min by nasal cannula fits a patient who needs only a little extra oxygen. This patient's SpO₂ is 79%, which is severe hypoxemia. Capping the flow to protect the respiratory drive leaves the patient hypoxic over a theory that is not real. Watching the mental status does nothing to correct the hypoxemia.

Give high-concentration oxygen and hold the saturation at 100 percent: Giving high-concentration oxygen is the right first step for an SpO₂ of 79%. Holding the saturation at 100 percent is the problem. The target is this patient's own baseline saturation, or 88 to 92 percent when you do not know the baseline. Chasing 100 percent overshoots that target.

Delay oxygen until end-tidal carbon dioxide can be measured: End-tidal carbon dioxide is a monitoring tool. Waiting for a number from it leaves an SpO₂ of 79% untreated. Put capnography on alongside the oxygen, never ahead of it.

Question 3 of 10

An intubated patient is moved from a bed to the stretcher. Immediately afterward the previously rectangular capnography waveform drops to zero and stays there. Which action is most appropriate?

Show the answer and rationale

Correct answer · Reassess the tube and the patient immediately

This patient has a displaced tube until you prove otherwise. Reassess the tube and the patient immediately. The waveform was rectangular before the move and dropped to zero right after it. A transfer from the bed to the stretcher can dislodge a tube, and a tube in the esophagus gives an absent waveform. Loss of the waveform can also mean a disconnection or an arrest. Check the tube and the circuit, watch for chest rise, listen over the epigastrium and both lung fields, and check for a pulse.

Why the others are wrong

Increase the ventilation rate and recheck in one minute: A faster rate and a recheck in a minute is a wait-and-see. More rate does nothing for a tube that's no longer in the trachea. This waveform vanished right after a move, so you check the tube before you change anything.

Document the change and continue the transport: Documenting and continuing fits a waveform that stays rectangular through the move. This one dropped to zero and stayed there. A vanished waveform gets immediate reassessment, not a note in the chart.

Replace the capnography sensor and recheck the tracing: A bad sensor or a disconnected line can flatten a waveform too. Equipment is the last letter of DOPE, and you work displacement first. This waveform vanished the moment the patient moved, which points at the tube. Replacing the sensor first delays finding a dislodged tube.

Question 4 of 10

A 78-year-old patient with a fever and a productive cough is in respiratory distress and is raising large amounts of thick sputum. Auscultation finds coarse, low-pitched sounds over the larger airways that change after a strong cough. There is no jugular venous distention and no ankle swelling. Which lung sound is described, and what produces it?

Show the answer and rationale

Correct answer · Rhonchi, produced by secretions in the larger airways

These are rhonchi. The sounds are coarse and low-pitched, they are over the larger airways, and they change after a strong cough. Rhonchi come from secretions sitting in the larger airways. Air moving past the secretions makes them rattle. A strong cough moves the sputum, so the sound shifts or clears. This patient has a fever, a productive cough, and large amounts of thick sputum. All of those point to secretions in the larger airways. There is no jugular venous distention and no ankle swelling, so nothing points to fluid overload.

Why the others are wrong

Wheezes, produced by narrowing of the smaller airways: A wheeze is a high-pitched, musical sound from air squeezing through narrowed smaller airways. A cough does not clear a wheeze the way it moves secretions.

Stridor, produced by narrowing at the level of the larynx: Stridor is a harsh sound on inspiration from narrowing at the larynx. You hear stridor over the neck, not across the larger airways in the chest.

Crackles, produced by fluid filling the alveoli: Crackles come from fluid in the alveoli, like in pulmonary edema. The alveoli full of fluid pop open when the patient breathes in, and a cough does not change crackles. This patient has sputum in the larger airways and a sound that changes with a cough.

Question 5 of 10

A 55-year-old patient in respiratory failure has a palpable pulse but is not moving adequate air. The crew begins positive pressure ventilations with a BVM and high-flow oxygen. At which rate should those ventilations be delivered?

Show the answer and rationale

Correct answer · One breath every 6 seconds

This patient is in respiratory failure with a palpable pulse, so give one breath every 6 seconds. The pulse tells you the heart is still pumping, so this is not cardiac arrest. One breath every 6 seconds works out to 10 breaths per minute. Give each breath over about a second, just enough to see the chest rise. Bagging faster raises the pressure inside the chest and keeps it high between breaths. The high pressure cuts the blood flow back to the right side of the heart, and the cardiac output drops. This patient's perfusion is already poor. Bagging too fast can push a patient with a pulse into cardiac arrest.

Why the others are wrong

One breath every 2 to 3 seconds: the rate for an infant or child with a pulse. That works out to 20 to 30 breaths per minute. This patient is 55 years old. At that rate an adult gets stacked breaths and too much pressure in the chest.

One breath every 10 seconds: only 6 breaths per minute. An adult who is already failing to move enough air needs more help than that. Six breaths a minute is too slow to clear the carbon dioxide.

One breath every 4 seconds: 15 breaths per minute. The rate is closer to the target, and it is still too fast for an adult with a pulse. The pressure in the chest stays high longer than it would at one breath every 6 seconds, and less blood gets back to the heart.

Question 6 of 10

A 67-year-old patient in cardiac arrest has received several minutes of BVM ventilation, and the abdomen is now visibly distended. The crew carries both a first generation and a second generation supraglottic airway. Which feature of the second generation device most directly addresses this patient's risk?

Show the answer and rationale

Correct answer · A channel that opens into the esophagus for a gastric tube

This patient has gastric distention from bag-mask ventilation. Several minutes of BVM ventilation pushed air down the esophagus, past the lower esophageal sphincter, and into the stomach instead of the lungs. That's why the abdomen is now visibly distended. Air trapped in the stomach raises the pressure inside the stomach. The full stomach pushes up on the diaphragm and sets the patient up to regurgitate and aspirate. A second generation supraglottic airway has a channel that opens into the esophagus. You pass a gastric tube down that channel to let the air out and drain the stomach away from the glottis. Emptying the stomach makes the patient easier to ventilate and lowers the aspiration risk.

Why the others are wrong

A wider ventilation lumen that lowers airway resistance: A wider ventilation lumen is a real second generation feature. The wider lumen lowers the resistance when you ventilate. The lumen size does nothing for the air in the stomach or the aspiration risk.

A larger cuff that seals the trachea below the cords: A cuff that seals the trachea below the cords describes an endotracheal tube. No supraglottic airway, first or second generation, seals below the cords. A supraglottic airway sits above the larynx.

A reinforced tip that resists kinking during compressions: A reinforced tip helps the device hold up during CPR and handling. The reinforced tip does not let the stomach air out or lower the aspiration risk.

Question 7 of 10

A 38-year-old patient with extensive burns across the chest, abdomen, and both arms from a house fire has increasing stridor, soot in the mouth, and a falling SpO₂. The service authorizes rapid sequence intubation, and the crew carries both a depolarizing and a nondepolarizing paralytic. Which consideration applies to the paralytic choice in this patient?

Show the answer and rationale

Correct answer · Succinylcholine is avoided because it shifts potassium

Succinylcholine is avoided in this patient because succinylcholine shifts potassium. Succinylcholine raises the potassium for a short time in every patient who gets it. This patient has extensive burns across the chest, the abdomen, and both arms. In a patient with extensive burns, that extra potassium can cause a life-threatening dysrhythmia or cardiac arrest. A burn is a reason not to use succinylcholine at all. Use a nondepolarizing agent like rocuronium instead. Rocuronium gives you good intubating conditions without the potassium shift. The paralysis lasts much longer, so you have to manage the airway and ventilation until it wears off.

Why the others are wrong

Succinylcholine is preferred because of its short duration: A short duration is a real advantage of succinylcholine. A patient who cannot be intubated can wake up and breathe again once it wears off. In a patient with extensive burns, the same dose of succinylcholine can cause a deadly rise in potassium. The short duration does not make succinylcholine safe here.

Either agent is acceptable within the first 24 hours: Either agent works for a patient with no reason to avoid succinylcholine. A burn is that reason, and the burn has no safe window. Succinylcholine is not used with burns at any point, and that includes the first 24 hours.

A nondepolarizing agent is avoided because of its duration: A nondepolarizing agent does last much longer. A crew that gives one has to keep the airway and ventilation going for the whole time it lasts. The longer duration is a trade-off you manage, not a reason to avoid the drug. With extensive burns, the nondepolarizing agent is the preferred paralytic.

Question 8 of 10

A 5-year-old patient with massive facial trauma cannot be intubated, and ventilation with a BVM and with a supraglottic airway has both failed. The SpO₂ is 61% and falling. A surgical rescue airway is required. Which route is appropriate at this age?

Show the answer and rationale

Correct answer · A percutaneous needle cricothyrotomy

A percutaneous needle cricothyrotomy is the surgical rescue airway for a 5-year-old. In a young child, the cricothyroid membrane is small and soft. The cricoid cartilage is the only complete ring holding a child's airway open. A scalpel through the membrane can destroy the cricoid ring and make a false passage instead of an airway. A needle cricothyrotomy avoids cutting the ring and gets oxygen in fast. The needle only oxygenates and does not ventilate, so carbon dioxide climbs while the saturation comes back up. The needle buys you time to reach a definitive airway.

Why the others are wrong

An open surgical cricothyrotomy through the membrane: An open surgical cricothyrotomy is the surgical rescue airway for an older child or an adult. In a 5-year-old, the cricothyroid membrane is too small to cut safely. The cricoid cartilage right below the membrane is the child's only complete ring, and an open cut can destroy the ring.

A cuffed tube passed blindly through the nose: A blind nasotracheal tube is guided by air moving through the tube, so the technique needs a patient who is breathing on their own. Significant facial trauma rules out a tube passed through the nose, and this child has massive facial trauma. Nasotracheal intubation is also contraindicated in pediatric patients.

A tracheostomy placed below the cricoid cartilage: A tracheostomy below the cricoid cartilage would spare the ring. A tracheostomy is a surgical operation done in a hospital, not a rescue airway you do on scene. Cricothyrotomy is the surgical airway in the paramedic scope of practice, and this child is desaturating at 61% and needs an airway now.

Question 9 of 10

A patient with a long history of chronic obstructive pulmonary disease and known carbon dioxide retention is hypoxic with an SpO₂ of 84%. A crew member expresses concern about giving supplemental oxygen because of the hypoxic drive theory. What is the most appropriate response?

Show the answer and rationale

Correct answer · Administer oxygen and titrate to a target saturation, such as 88-92%, per protocol

Hypoxic drive is not a real mechanism. The theory is an old teaching, and it is never a reason to hold oxygen from a hypoxic patient with COPD. This patient's SpO₂ is 84%, so this patient needs oxygen now. Carbon dioxide can climb when a COPD patient gets high-flow oxygen. That rise comes from the release of hypoxic pulmonary vasoconstriction and from the Haldane effect. The rise does not come from losing the drive to breathe. That's why you give oxygen and titrate it to this patient's target saturation. In a known carbon dioxide retainer, the target is commonly 88 to 92% per protocol. You do not withhold the oxygen, and you do not push the saturation to 100%.

Why the others are wrong

Administer oxygen at a fixed 2 L/min by nasal cannula without titrating to the saturation: A fixed 2 L/min by nasal cannula is the same hypoxic drive worry in a milder form. This patient is sitting at 84%. A preset flow with no titrating can leave the patient hypoxic. You adjust the oxygen to reach the target range, not to match a set flow rate.

Administer oxygen only if the respiratory rate falls below normal: Oxygen is not held until the respiratory rate drops. The SpO₂ of 84% is what tells you this patient needs oxygen now. Waiting on the breathing rate only keeps the patient hypoxic longer.

Administer oxygen to raise the saturation to 100%: Raising the saturation all the way to 100% gives more oxygen than the goal calls for in a known carbon dioxide retainer. For this patient, you titrate to a range like 88 to 92% instead.

Question 10 of 10

A patient being treated for a severe asthma exacerbation with nebulized bronchodilators develops a silent chest and a decreasing level of consciousness despite ongoing treatment. What does this indicate?

Show the answer and rationale

Correct answer · Impending respiratory failure requiring escalation to assisted ventilation and advanced airway management

This patient is heading into respiratory failure. The question gives you a silent chest and a decreasing level of consciousness, even with ongoing treatment. A wheeze is the sound of moving air squeezing through narrowed airways. When the chest goes silent in a patient who is getting worse, the bronchospasm has not broken. Almost no air is moving at all. The falling level of consciousness comes from rising carbon dioxide and exhaustion. Nebulized medication only reaches the small airways if the patient can breathe the medication in. This patient is no longer moving enough air to carry the medication down. You have to breathe for this patient. Ventilate with a BVM and a good seal. Use a slow rate with a long time to exhale, so you do not stack breaths on top of trapped air. Get ready for advanced airway management.

Why the others are wrong

The patient is improving, so the current treatment plan should continue without any changes: A quieter chest is good news in an asthma patient who is improving. In that patient, the wheezing fades while the patient speaks in fuller sentences, the saturation rises, and the work of breathing eases. This patient's level of consciousness is decreasing. A quiet chest with a falling level of consciousness means the patient is getting worse.

The patient should be placed on CPAP instead of escalating further: CPAP is the right call for an awake patient in distress who can protect the airway and follow coaching. CPAP holds the airways open and makes breathing easier. CPAP only helps breaths the patient takes on their own. This patient's level of consciousness is dropping, so the patient cannot be relied on to breathe or to protect the airway. CPAP is a step below what this patient needs.

The bronchodilator dose should simply be repeated more frequently without escalating the level of care: Repeating bronchodilators is right in severe asthma when the patient is still moving air. A silent chest means there is no air moving to carry the medication to the airways. Giving the same medication more often does not help while the patient stops moving air and the level of consciousness falls.

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