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10 free Paramedic practice questions: Pulmonary Disease Processes: Sorting the Dyspneic Patient

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 paramedic treats two patients with wheezing on the same shift. A 7-year-old with a prescribed albuterol inhaler has had 2 days of a runny nose and now has diffuse expiratory wheezing, as with several earlier colds. A 7-month-old has had 4 days of nasal congestion and now has diffuse wheezing with retractions and a wet rattling sound, and this is the infant's first wheezing episode. Which of the following best describes what is narrowing the airways in each patient?

Show the answer and rationale

Correct answer · Infant: airway swelling and mucus; child: bronchospasm

The infant has bronchiolitis, and the child has asthma. Both patients had a cold first, and both are wheezing. The history is what splits them. The 7-year-old has a prescribed albuterol inhaler and has wheezed with several earlier colds. A prescribed inhaler and repeated wheezing colds point to asthma. Asthma is bronchospasm that can be reversed, and a cold can set it off. The 7-month-old is wheezing for the first time after days of congestion. A first wheeze after a cold points to bronchiolitis. In bronchiolitis, swollen airway walls and extra mucus narrow the small airways, with no bronchospasm. Narrowed airways wheeze either way, so wheezing alone never separates the two. The difference in what narrows the airways is why bronchodilators are standard for asthma and have fallen out of favor for routine use in bronchiolitis.

Why the others are wrong

Infant: bronchospasm; child: airway swelling and mucus: This option has the two patients swapped. The prescribed inhaler and repeated wheezing colds belong to the child with asthma. The first wheezing episode after days of congestion belongs to the infant with bronchiolitis.

Infant: bronchospasm; child: bronchospasm: The infant's wheeze is not spasm. A first episode after days of congestion and a wet rattling sound point to swelling and mucus. Only the child's wheeze, with repeated episodes and a prescribed inhaler, is bronchospasm.

Infant: airway swelling and mucus; child: airway swelling and mucus: The 7-year-old has a prescribed albuterol inhaler and has wheezed with several earlier colds, and that points to bronchospasm. A cold sets off asthma too, so having a cold first does not make the child's wheeze swelling and mucus.

Question 2 of 10

A 74-year-old patient with heart failure and hypertension has had difficulty breathing and a wet cough for two days. The patient took acetaminophen for aches three hours ago. The patient is sitting upright, and noisy lung sounds are heard at both bases. Both ankles have been swollen for months. The vital signs are BP 156/92, P 108, R 26, and SpO₂ 90% on room air. Which assessment would best help the paramedic decide what is causing the abnormal lung sounds?

Show the answer and rationale

Correct answer · Listen again over the same fields after a forceful cough

Listening again after a forceful cough is how you tell pneumonia from pulmonary edema here. Noisy sounds at both bases, a heart failure history, and swollen ankles could fit either one. What the sounds do after a cough is the finding the two do not share. Rhonchi come from secretions and sputum in the larger airways. A forceful cough often clears or changes rhonchi. Crackles come from fluid in the alveoli and small airways, which is pulmonary edema. A cough does not clear fluid out of the alveoli, so crackles stay the same. Sounds that clear or change after a cough point to pneumonia. Sounds that stay the same point to fluid. Listen again over the same fields after the cough, and then decide between the pulmonary edema treatment and the pneumonia treatment.

Why the others are wrong

Take the temperature with a tympanic thermometer: Fever is the classic sign of pneumonia. This patient took acetaminophen three hours ago, and older adults can have pneumonia with little or no fever. A normal temperature would not settle the question.

Count the respiratory rate over a full minute: Fast breathing happens with both pulmonary edema and pneumonia. The count is going to come out the same either way. A full minute count tells you how sick the patient is, not what is making the sounds.

Recheck the SpO₂ after oxygen has been running for several minutes: The SpO₂ comes up on oxygen with both conditions. A better reading after several minutes does not point to one over the other. The SpO₂ tells you the oxygen is working, not what is causing the sounds.

Question 3 of 10

A 3-year-old patient woke at 0300 with noisy breathing. The caregiver says the child was fine at bedtime. The child sits upright on the caregiver's lap and is anxious, with inspiratory stridor at rest and mild retractions. The vital signs are BP 98/60, P 142, R 38, SpO₂ 95% on room air, and T 101.8°F. Which question to the caregiver would best help the paramedic separate the likely causes of the stridor?

Show the answer and rationale

Correct answer · Whether the noisy breathing followed a day or two of a cold or began within hours

Ask whether the noisy breathing followed a day or two of a cold or began within hours. This child has stridor at rest and a temperature of 101.8°F and sits upright and anxious. Croup and epiglottitis can both look like this. Of the questions offered, the pace of the illness is the one that pulls them apart. Croup builds over one to two days after a cold. Epiglottitis comes on over hours. The cough is the other clear difference, because croup comes with a barking cough and epiglottitis does not. Waking at 0300 after a normal bedtime does not decide it. Croup stridor is worse at night, and a mild cold can go unnoticed. The fever does not decide it either. A temperature of 101.8°F sits between the low fever of croup and the high fever of epiglottitis. Both conditions start with the same calm, upright care. The caregiver's answer tells you which one you are treating. In croup, nebulized epinephrine is an option for moderate to severe stridor. In epiglottitis, nothing goes near the throat, and the child may refuse a mask.

Why the others are wrong

Whether the child has a history of asthma or wheezing with previous colds or exercise: An asthma history matters for a child who is wheezing. Asthma is a lower airway problem. This child has stridor on inspiration, and stridor comes from a narrowed upper airway. An asthma history does not help you choose between two upper airway causes.

Whether the child has had a fever at any point since the noisy breathing first began: A high fever is one of the classic signs of epiglottitis. The fever is already in the question at 101.8°F, and croup and epiglottitis both cause fever. Knowing when the fever started does not separate the two.

Whether anyone else in the household has had a similar illness in the last few days: Croup and epiglottitis are both infections, so a sick person at home sounds like a clue. A sick household member fits viral croup and bacterial epiglottitis equally. The caregiver's answer does not move you toward either one.

Question 4 of 10

A 71-year-old patient with a known history of chronic obstructive pulmonary disease and a long-term smoking history is found sitting in a tripod position with audible expiratory wheezing and a cough productive of sputum. The patient's spouse reports the patient has felt short of breath with daily activity for the past several years, and today's symptoms began after a recent respiratory infection. The paramedic administers a nebulized albuterol treatment, which produces only mild improvement in air movement. The vital signs are BP 158/92, P 116, R 26, and SpO₂ 87% on room air. What should the paramedic do next?

Show the answer and rationale

Correct answer · Administer nebulized ipratropium

Nebulized ipratropium is going to be your next medication. This patient has a long history of COPD. The albuterol treatment only gave mild improvement in air movement. Ipratropium is an anticholinergic bronchodilator. Ipratropium blocks the vagus nerve signals that tighten the airways and make mucus. Those vagus nerve signals play a bigger part in COPD than in asthma. Albuterol is a beta agonist, and ipratropium works on a different receptor. Giving both relaxes the airways more than albuterol alone.

Why the others are wrong

Administer intravenous magnesium sulfate: Intravenous magnesium sulfate relaxes the smooth muscle in the airways. Magnesium is an add-on for a severe asthma exacerbation when inhaled treatments are not enough. This patient has COPD and got some improvement from the albuterol. The next step is an inhaled anticholinergic, not a systemic medication held for severe asthma.

Administer intramuscular epinephrine: Intramuscular epinephrine is for life-threatening bronchospasm that does not respond to standard nebulizer treatment, like severe status asthmaticus or anaphylaxis. This patient is improving a little with albuterol. Mild improvement is not a life-threatening failure of treatment.

Administer subcutaneous terbutaline: Subcutaneous terbutaline is another beta agonist. Terbutaline is sometimes used in a severe asthma exacerbation when inhaled treatments are not working or cannot be given. This patient already got an inhaled beta agonist, albuterol, and had some response. Adding an inhaled anticholinergic makes more sense than a second beta agonist by injection.

Question 5 of 10

A 34-year-old patient reports sudden onset sharp chest pain that worsens with deep breathing, beginning during a business flight 3 days ago. The patient appears anxious and is breathing rapidly. Auscultation reveals clear breath sounds bilaterally. The right calf is swollen, warm, and tender to palpation compared to the left. The vital signs are BP 128/78, P 118, R 24, and SpO₂ 90% on room air. What condition does the paramedic most likely suspect?

Show the answer and rationale

Correct answer · Pulmonary embolism

This patient most likely has a pulmonary embolism. The right calf is swollen, warm, and tender compared to the left. A calf like that means a deep vein thrombosis, a blood clot in the leg. The clot from the leg has traveled to the pulmonary arteries and is blocking blood flow there. A blocked pulmonary artery causes sudden, sharp chest pain that gets worse with deep breaths, and the oxygen saturation drops to 90%. The lungs still sound clear, because the problem is a blocked vessel, not damaged lung tissue. Transport rapidly. Be ready for the patient's circulation to suddenly collapse.

Why the others are wrong

Acute pulmonary edema: Clear breath sounds on both sides rule out acute pulmonary edema. Fluid in the lung tissue gives you crackles in both lungs, usually in a patient with a heart failure history who cannot breathe lying flat. The swollen, tender right calf points to a clot instead, and a clot blocking flow does not put fluid in the lungs.

Spontaneous pneumothorax: A spontaneous pneumothorax also gives sudden pleuritic chest pain. The collapsed lung makes the breath sounds much quieter or absent on that side. This patient's breath sounds are clear on both sides.

Pneumonia: builds slowly, and this pain started suddenly during a flight after a long time sitting still. Pneumonia brings a fever, a productive cough, and rhonchi over the infected part of the lung. This patient has clear breath sounds and no fever mentioned, and pneumonia does not explain a swollen, tender calf.

Question 6 of 10

A 45-year-old patient who underwent hip replacement surgery 8 days ago reports sudden difficulty breathing and dizziness that began 20 minutes ago. The patient reports sharp chest pain that worsens with deep breathing. Auscultation reveals clear breath sounds bilaterally. Jugular venous distention is noted, and the right calf is swollen and tender compared to the left. The cardiac monitor shows sinus tachycardia. The vital signs are BP 84/52, P 128, R 28, and SpO₂ 88% on room air. The paramedic determines the patient is experiencing a pulmonary embolism causing obstructive shock. What should the paramedic do next?

Show the answer and rationale

Correct answer · Administer a normal saline fluid bolus

This patient is in obstructive shock from a pulmonary embolism. The neck veins are distended, the lungs are clear, and the blood pressure is 84/52. A clot is blocking the pulmonary artery. The right ventricle is straining to push blood past that clot. Not enough blood gets through, and the heart cannot keep up forward flow. A cautious normal saline fluid bolus gives the right ventricle more preload, meaning more blood to fill it. More filling can improve cardiac output with this kind of blockage. Support the failing right heart this way until the hospital can deal with the clot. Stay away from anything that lowers preload.

Why the others are wrong

Administer nitroglycerin sublingually: Sublingual nitroglycerin is for acute pulmonary edema with a high blood pressure. Nitroglycerin lowers preload and afterload to take the load off fluid-filled lungs. This patient's pressure is 84/52, and the strained right ventricle depends on preload to keep pumping. Lowering preload would drop cardiac output even further. Nitroglycerin is contraindicated here.

Administer furosemide intravenously: IV furosemide causes diuresis, which pulls fluid off fluid-overloaded lungs in acute pulmonary edema. This patient's lungs are clear and the right calf is swollen and tender. Those findings point to obstructive shock from a clot, not fluid overload. Furosemide would lower preload even more and make the failing right ventricle worse.

Initiate continuous positive airway pressure: Continuous positive airway pressure (CPAP) is used for acute pulmonary edema. The positive pressure lowers preload and pushes fluid out of the alveoli. This patient is already hypotensive from right heart strain. Added pressure inside the chest would cut venous return even more and worsen the shock.

Question 7 of 10

A 23-year-old patient is breathing fast after an argument and says the fingers and the area around the mouth are tingling. The skin is warm and dry and the lung sounds are clear. The vital signs are BP 128/78, P 108, R 32, SpO₂ 99% on room air, and T 98°F. The blood glucose level is 96 mg/dL. What is most likely causing the fast breathing?

Show the answer and rationale

Correct answer · Anxiety hyperventilation

Anxiety hyperventilation fits a young patient who started breathing fast after an emotional trigger and has tingling in the fingers and around the mouth, with normal skin and a normal glucose. The rest of the picture is normal as well: clear lungs, an SpO₂ of 99%, and a temperature of 98°F. With any fast breather the separating question is whether anything else is wrong, because the deep rapid breathing of a metabolic acidosis is a compensation keeping the patient alive. A paramedic never assumes anxiety when the skin, glucose, or capnography says otherwise, and none of those findings is abnormal in this patient. That's why this patient's fast breathing is anxiety hyperventilation.

Why the others are wrong

Acute asthma attack: An acute asthma attack is bronchospasm in the lower airways, and it brings wheezing. Clear lung sounds with an SpO₂ of 99% show no sign of bronchospasm.

Diabetic ketoacidosis: causes deep, rapid breathing that compensates for the acid, usually with a blood glucose above 300 mg/dL, vomiting, and dehydration. A glucose of 96 mg/dL rules ketoacidosis out.

Early sepsis: comes with a fever or hypothermia, a source such as a cough or burning urination, and a patient who looks ill. This patient has a temperature of 98°F, warm dry skin, and a history that points to an argument instead of an infection.

Question 8 of 10

A paramedic is assessing a 3-year-old patient with stridor and is deciding between croup and epiglottitis. Which finding is present in croup but absent in epiglottitis?

Show the answer and rationale

Correct answer · A barking, seal-like cough

Croup is a viral illness that inflames the airway below the vocal cords, and it is defined by a barking, seal-like cough. Epiglottitis is a bacterial infection that swells the epiglottis itself, and it produces no barking cough. Both conditions bring stridor and a fever, so the cough is the finding that separates them. That's why a barking, seal-like cough is present in croup and absent in epiglottitis.

Why the others are wrong

Stridor when the child breathes in: Stridor when breathing in comes with both croup and epiglottitis, and the child in the question already has it. A finding both conditions share cannot separate them.

Drooling with difficulty swallowing: Drooling and difficulty swallowing belong to epiglottitis, along with a muffled voice and tripod positioning. They are present in epiglottitis and absent in croup, the reverse of what the question asks.

Fever with difficulty breathing: Fever comes with both conditions: croup brings a low-grade fever and epiglottitis a high one. The presence of a fever alone does not separate them.

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 2-year-old patient has had a barking cough and a hoarse voice for 2 days that are worse tonight. A harsh sound is heard on inspiration while the patient sits quietly, and the muscles between the ribs draw in with each breath. The patient is alert, is drinking, and has no rash or swelling of the lips or tongue. The vital signs are P 148, R 40, and T 101.3°F, with SpO₂ 94% on room air. What is the most appropriate treatment?

Show the answer and rationale

Correct answer · Administer nebulized epinephrine

This child has croup. The barking cough and hoarse voice put the swelling in the airway just below the vocal cords. Symptoms that build over 2 days, get worse at night, and come with a low fever of 101.3°F fit croup too. Stridor on inspiration means the narrowing is in the upper airway. Wheezing on expiration means the narrowing is in the lower airways. This child has the harsh sound on inspiration while sitting quietly, not only when crying. Stridor at rest with retractions is moderate croup. Moderate croup needs a drug, not just a calm child and cool humidified air. Nebulized epinephrine lands right on the swollen tissue below the cords. Epinephrine constricts the blood vessels in the swollen tissue. The tissue shrinks, and the airway opens within minutes. The effect wears off in about 2 hours, so the child still gets transported and watched. A steroid is given too, but a steroid takes hours to work.

Why the others are wrong

Administer a nebulized beta-2 agonist: A nebulized beta-2 agonist treats bronchospasm, where smooth muscle constricts the bronchioles in the lower airways. You hear bronchospasm as wheezing on expiration, like in asthma. This child has stridor on inspiration, not wheezing. The obstruction is swollen mucosa below the vocal cords. Relaxing the smooth muscle in the lower airways does nothing for that swelling. The swelling needs the blood vessels constricted to shrink.

Administer intramuscular epinephrine: IM epinephrine is the route for anaphylaxis, when you need a fast effect through the whole body. This child has no rash and no swelling of the lips or tongue. The symptoms came on over 2 days, not suddenly. Options A and C both give epinephrine, so the difference is the route. For croup, the drug is nebulized epinephrine, which goes right onto the swollen tissue below the cords.

Perform endotracheal intubation: Intubation is for a child whose breathing is failing. A failing child turns lethargic or cyanotic, and the stridor gets quieter because less air is moving. This child is alert, drinking, and holding an SpO₂ of 94% on room air. The airway is narrowed but still working. In croup, anything that upsets the child can make the airway worse. An intubation attempt on an alert 2-year-old risks closing an airway that is still open.

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