NREMT Paramedic Exam Flashcards

Q: How is the NREMT Paramedic exam scored?

The NREMT Paramedic cognitive exam uses computerized adaptive testing (CAT) with 110-150 items, including 20 unscored pilot items. It is reported on a 100-1500 scaled-score metric, and a scaled score of 950 is required to pass. There is a 3.5-hour time limit.

Q: How is the Paramedic exam different from the EMT exam?

The Paramedic (ALS) exam tests advanced practice the EMT level does not: rapid sequence intubation, surgical airways, ventilator and capnography management, 12-lead ECG interpretation, the full ACLS algorithms, cardiac drug dosing, manual defibrillation/cardioversion/pacing, and complex medical, trauma, and OB/peds decision-making.

Q: What are the NREMT Paramedic content domains and weights?

The July 2024 test plan weights Clinical Judgment highest at 34-38%, Medical/Obstetrics/Gynecology at 24-28%, Cardiology and Resuscitation at 10-14%, Airway/Respiration/Ventilation and EMS Operations at 8-12% each, and Trauma at 6-10%.

Q: What is the NREMT Paramedic retest policy?

Candidates may retest 15 days after results are posted. After three failed attempts, remedial training documentation is required before further testing. A total of six attempts is permitted at the Paramedic level; after six failures a new education program is required.

Q: How much does the NREMT Paramedic exam cost and how long is it valid?

The exam fee is $175 per attempt, scheduled through Pearson VUE. National Registry Paramedic certification is valid for 2 years and must be maintained through recertification.

Q: What topics should a Paramedic candidate drill hardest?

Prioritize Clinical Judgment scenarios, then 12-lead ECG and STEMI recognition, ACLS arrest/bradycardia/tachycardia algorithms with exact drug doses, RSI and difficult-airway decisions, shock and hemorrhage management, and OB emergencies such as postpartum hemorrhage and eclampsia.

Question 1

Rapid Sequence Intubation (RSI) drug order

Accepted Answer

Give the induction (sedative) agent first to produce unconsciousness, then immediately the paralytic. A common pairing is etomidate followed by rocuronium or succinylcholine. Analgesia/sedation for maintenance comes AFTER the tube is confirmed, not during the RSI push.

Question 2

Succinylcholine vs rocuronium for paralysis

Accepted Answer

Succinylcholine: fast onset (~45-60 s), short duration (~5-10 min), but contraindicated with hyperkalemia, crush/burn >24-48 h old, and malignant hyperthermia history. Rocuronium: similar onset at higher dose but long duration (~30-45 min) with no hyperkalemia risk.

Question 3

Gold-standard confirmation of endotracheal tube placement

Accepted Answer

Continuous waveform capnography is the most reliable confirmation of correct ET tube placement and ongoing monitoring. A persistent square-wave ETCO2 tracing confirms tracheal placement; sustained near-zero ETCO2 after good CPR suggests esophageal placement or no circulation.

Question 4

When is a surgical (cricothyrotomy) airway indicated?

Accepted Answer

Indicated in a 'cannot intubate, cannot oxygenate/ventilate' failed-airway situation where BVM, supraglottic, and intubation attempts have failed. The cricothyroid membrane (between thyroid and cricoid cartilage) is the landmark. It is a rescue procedure, not a first-line technique.

Question 5

Difficult-airway prediction (paramedic field assessment)

Accepted Answer

Anticipate difficulty with limited mouth opening, short thyromental distance, large tongue/obesity, neck immobility or C-collar, facial/airway trauma, and blood/vomit. Plan a backup (supraglottic, surgical) and optimize positioning and preoxygenation BEFORE the first attempt.

Question 6

Normal end-tidal CO2 (ETCO2) range and what a sudden drop means

Accepted Answer

Normal ETCO2 is 35-45 mmHg. A sudden drop toward zero signals tube dislodgement, circuit disconnection, complete obstruction, or loss of cardiac output (arrest). A gradual rise suggests hypoventilation; a gradual fall suggests hyperventilation or falling perfusion.

Question 7

ETCO2 during CPR as a quality and ROSC indicator

Accepted Answer

ETCO2 below ~10 mmHg during CPR indicates inadequate compressions or poor perfusion—improve compression quality. A sudden, sustained rise (often >35-40 mmHg) is an early sign of return of spontaneous circulation (ROSC) before a pulse check.

Question 8

Ventilation rate to avoid hyperventilation harm in arrest

Accepted Answer

Over-ventilation raises intrathoracic pressure, reduces venous return and coronary perfusion, and worsens outcomes. With an advanced airway in cardiac arrest, deliver about 1 breath every 6 seconds (~10/min) with continuous compressions—do not bag fast.

Question 9

Tension pneumothorax recognition and immediate paramedic action

Accepted Answer

Severe dyspnea, hypotension, distended neck veins, tracheal deviation (late), absent breath sounds and hyperresonance on the affected side. Treat immediately with needle decompression (large-bore catheter, 2nd intercostal space midclavicular or 5th midaxillary line)—do not wait for X-ray.

Question 10

CPAP indication and key contraindication in the field

Accepted Answer

CPAP is first-line for acute pulmonary edema (CHF) and severe COPD/asthma in an awake, cooperative, spontaneously breathing patient with adequate BP. Contraindicated with apnea/inadequate respiratory drive, hypotension, decreased LOC, vomiting, or suspected pneumothorax.

Question 11

Reading the 12-lead: which leads localize an inferior MI?

Accepted Answer

Inferior wall: ST elevation in leads II, III, and aVF. Always obtain a right-sided lead (V4R) because inferior MI is frequently associated with right ventricular infarction, which changes management (nitrates can cause profound hypotension).

Question 12

STEMI threshold and reciprocal changes

Accepted Answer

STEMI is generally ST elevation ≥1 mm in two contiguous limb leads (or ≥2 mm in precordial leads V2-V3). Reciprocal ST depression in the opposite wall increases specificity. Anterior MI = V1-V4 (LAD); lateral = I, aVL, V5-V6; inferior = II, III, aVF.

Question 13

Right ventricular MI: why nitroglycerin is dangerous

Accepted Answer

RV infarction makes cardiac output preload-dependent. Nitroglycerin (a venodilator) drops preload and can cause severe, refractory hypotension. Manage RV MI with cautious fluid boluses to support preload instead of routine nitrates.

Question 14

Distinguishing monomorphic VT from polymorphic VT (torsades)

Accepted Answer

Monomorphic VT: uniform wide QRS complexes—treat per stable/unstable VT pathway. Torsades de pointes (polymorphic VT with twisting axis, often long QT): treat with IV magnesium sulfate; defibrillate if pulseless.

Question 15

Third-degree (complete) heart block recognition

Accepted Answer

P waves and QRS complexes are completely dissociated—no relationship between atrial and ventricular rates. Often symptomatic bradycardia. Atropine is usually ineffective in high-grade/3rd-degree block; prepare for transcutaneous pacing.

Question 16

Adult bradycardia algorithm: first drug and dose

Accepted Answer

For symptomatic unstable bradycardia: atropine 1 mg IV every 3-5 minutes, max total 3 mg. If atropine is ineffective, move to transcutaneous pacing and/or a chronotropic infusion (dopamine or epinephrine). Atropine is generally ineffective in high-grade AV block.

Question 17

Stable narrow-complex SVT: first intervention and adenosine dosing

Accepted Answer

Try vagal maneuvers first. If unsuccessful, give adenosine 6 mg rapid IV push followed by a saline flush; if no conversion, give 12 mg. Warn the patient about a brief pause/flushing. Use synchronized cardioversion if the patient is unstable.

Question 18

Unstable tachycardia: synchronized cardioversion vs defibrillation

Accepted Answer

Unstable patient WITH a pulse (and serious signs from the rate) → synchronized cardioversion (shock timed to the R wave). Pulseless VT or VF → unsynchronized defibrillation. Sync mode prevents an R-on-T shock that could induce VF.

Question 19

Adult tachycardia: stable wide-complex regular rhythm

Accepted Answer

If stable, regular, monomorphic and likely VT, consider an antiarrhythmic such as amiodarone or procainamide and seek expert consultation. If the patient becomes unstable at any point, proceed to synchronized cardioversion.

Question 20

Acute stroke field priorities (paramedic)

Accepted Answer

Establish last-known-well time, perform a validated stroke scale, check glucose (rule out hypoglycemia mimicking stroke), avoid aggressive BP lowering, keep airway protected, and provide early pre-arrival notification to a stroke-capable center.

Question 21

Two shockable cardiac arrest rhythms

Accepted Answer

Ventricular fibrillation (VF) and pulseless ventricular tachycardia (pVT) are shockable—defibrillate immediately. Asystole and pulseless electrical activity (PEA) are NOT shockable; treat with high-quality CPR, epinephrine, and reversible-cause correction.

Question 22

Epinephrine dosing in adult cardiac arrest

Accepted Answer

Epinephrine 1 mg IV/IO (1:10,000) every 3-5 minutes throughout the arrest. In shockable rhythms it is given after the second shock; in non-shockable rhythms it is given as soon as access is obtained.

Question 23

Antiarrhythmic for refractory VF/pVT and dosing

Accepted Answer

For VF/pVT that persists after defibrillation and epinephrine, give amiodarone 300 mg IV/IO first dose, then 150 mg for a second dose. Lidocaine 1-1.5 mg/kg is an acceptable alternative if amiodarone is unavailable.

Question 24

The H's and T's (reversible causes of arrest/PEA)

Accepted Answer

H's: Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo-/Hyperkalemia, Hypothermia. T's: Tension pneumothorax, Tamponade (cardiac), Toxins, Thrombosis (pulmonary or coronary). Actively search for and correct these, especially in PEA/asystole.

Question 25

Post-ROSC care priorities

Accepted Answer

Optimize oxygenation (target SpO2 ~94-99%, avoid hyperoxia), support BP (treat hypotension with fluids/vasopressors), obtain a 12-lead for STEMI, maintain normocapnia, avoid routine hyperventilation, and consider targeted temperature management at the receiving facility.

Question 26

Cardiac tamponade (Beck's triad) and field implication

Accepted Answer

Beck's triad: hypotension, muffled heart sounds, jugular venous distension. Pulsus paradoxus may be present. Tamponade is a reversible 'T' cause of PEA arrest; definitive treatment is pericardiocentesis at the hospital—rapid transport is key.

Question 27

Acute decompensated heart failure / flash pulmonary edema management

Accepted Answer

Sit the patient upright, apply CPAP, give high-flow oxygen, and use nitroglycerin to reduce preload/afterload if BP is adequate. Avoid large fluid boluses. Diuretics may be given per protocol but airway/CPAP and nitrates drive early field improvement.

Question 28

Cardiogenic shock recognition

Accepted Answer

Hypotension with signs of poor perfusion (cool, mottled skin, altered mentation, oliguria) due to pump failure—often after large MI. Unlike hypovolemic shock, lungs may be wet; aggressive fluids can worsen pulmonary edema. May need inotropes/pressors and rapid transport for revascularization.

Question 29

Transcutaneous pacing setup and capture verification

Accepted Answer

Set a rate (commonly 60-80/min), increase milliamps until electrical capture (a wide QRS after each pacer spike) AND mechanical capture (a palpable pulse matching the set rate) are confirmed. Provide analgesia/sedation for the pain of pacing in a conscious patient.

Question 30

Nitroglycerin contraindications in chest pain

Accepted Answer

Withhold nitroglycerin with hypotension/SBP below protocol threshold, suspected right ventricular infarction, severe bradycardia/tachycardia, and recent phosphodiesterase inhibitor use (sildenafil/tadalafil/vardenafil) due to risk of profound, refractory hypotension.

Question 31

Adenosine: mechanism and key cautions

Accepted Answer

Adenosine briefly blocks AV node conduction to break reentrant SVT; expect a short asystolic pause then conversion. Give rapid push with immediate flush. Less effective and use caution in patients on theophylline; dipyridamole/carbamazepine potentiate it. Not effective for atrial fibrillation/flutter.

Question 32

Amiodarone vs lidocaine roles

Accepted Answer

Amiodarone: broad antiarrhythmic for refractory VF/pVT (300 mg then 150 mg) and stable VT. Lidocaine (1-1.5 mg/kg, then 0.5-0.75 mg/kg repeats) is the alternative for VF/pVT. Watch for hypotension with amiodarone and CNS toxicity (slurred speech, seizures) with lidocaine.

Question 33

Calcium channel blocker vs beta-blocker for rate control caution

Accepted Answer

Diltiazem (a calcium channel blocker) controls rate in stable atrial fibrillation/flutter with rapid ventricular response. Avoid AV-nodal blockers in WPW with pre-excited AFib (can accelerate conduction) and in wide-complex tachycardia of uncertain origin.

Question 34

Permissive hypotension in penetrating trauma

Accepted Answer

Before definitive hemorrhage control, titrate fluids to a lower target (e.g., a palpable radial pulse / SBP ~80-90) rather than normalizing BP. Over-resuscitation can pop clots, dilute clotting factors, and worsen bleeding. Rapid transport to surgery is the priority.

Question 35

Hemorrhagic shock class progression key sign

Accepted Answer

Early compensated shock shows tachycardia, narrowing pulse pressure, anxiety, and cool/pale skin with a still-normal systolic BP. Hypotension is a LATE finding (often after ~30% blood loss). Treat based on perfusion signs, not on a normal blood pressure alone.

Question 36

External hemorrhage control sequence

Accepted Answer

Direct pressure first; if life-threatening extremity bleeding is uncontrolled, apply a tourniquet high and tight proximal to the wound, tighten until bleeding stops, and note the application time. Use hemostatic-gauge packing for junctional wounds not amenable to a tourniquet.

Question 37

Tourniquet application time documentation—why it matters

Accepted Answer

Always record the exact time a tourniquet is applied (often written on the device and the patient). Prolonged ischemia time guides hospital limb-salvage and reperfusion decisions; never loosen a tourniquet in the field once a hemorrhage is controlled unless ordered.

Question 38

Cushing's triad and herniation in severe TBI

Accepted Answer

Cushing's triad = hypertension (widening pulse pressure), bradycardia, and irregular respirations—a late sign of rising intracranial pressure/impending herniation. Manage with oxygenation, normocapnia (avoid routine hyperventilation), and head elevation; brief controlled hyperventilation only for active herniation signs.

Question 39

Flail chest pathophysiology and treatment

Accepted Answer

Two or more adjacent ribs fractured in two or more places create a free segment with paradoxical movement. The main threat is the underlying pulmonary contusion and hypoventilation. Support oxygenation/ventilation (consider positive pressure) and watch for respiratory failure.

Question 40

Burn fluid resuscitation: estimating severity

Accepted Answer

Use the Rule of Nines and depth to estimate TBSA. Significant burns require warmed isotonic fluid resuscitation (parkland-type formula at the hospital), early airway assessment for inhalation injury (singed nasal hair, soot, stridor, hoarseness), and pain control.

Question 41

Hypoglycemia vs hyperglycemic crisis (DKA) field distinction

Accepted Answer

Hypoglycemia: rapid onset, diaphoretic, altered/combative, may seize—treat with glucose (oral if able, otherwise IV dextrose or glucagon). DKA: gradual onset, dehydration, Kussmaul respirations, fruity breath, hyperglycemia—needs IV fluids and hospital insulin, NOT field glucose.

Question 42

Sepsis recognition and early field bundle

Accepted Answer

Suspect sepsis with infection plus hypotension, tachycardia, tachypnea, altered mentation, and high or low temperature. Field priorities: high-flow oxygen, large-bore IV access, isotonic fluid resuscitation for hypoperfusion, and early pre-arrival notification for time-sensitive treatment.

Question 43

Anaphylaxis: first-line drug, dose, and route

Accepted Answer

Epinephrine 0.3 mg (adult) of 1:1,000 IM in the anterolateral thigh is first-line and given EARLY—do not delay for antihistamines or steroids. Repeat every 5-15 minutes as needed; add fluids for hypotension and consider an epinephrine infusion for refractory shock.

Question 44

Status asthmaticus / severe bronchospasm escalation

Accepted Answer

Escalate: continuous nebulized albuterol + ipratropium, IM/IV epinephrine for severe/impending failure, IV/IM steroids, and magnesium sulfate as an adjunct bronchodilator. A 'silent chest' with rising CO2 and exhaustion signals impending respiratory failure—prepare for ventilatory support.

Question 45

Opioid overdose: naloxone goal and titration

Accepted Answer

Titrate naloxone to restore adequate ventilation (rate/tidal volume), NOT full alertness—abrupt full reversal can precipitate severe withdrawal and agitation. Support ventilation with BVM first; re-dosing may be needed because naloxone's duration is shorter than many opioids.

Question 46

Tricyclic antidepressant (TCA) overdose hallmark and antidote

Accepted Answer

Look for a widening QRS, tachycardia, hypotension, seizures, and altered mentation. A QRS widening (often >100 ms) signals cardiotoxicity—treat with sodium bicarbonate. Manage seizures and airway aggressively; TCA overdose can deteriorate rapidly.

Question 47

Postpartum hemorrhage immediate field management

Accepted Answer

After delivery, the most common cause is uterine atony. Perform vigorous fundal massage, encourage the newborn to breastfeed if possible, ensure the placenta is delivered, give isotonic fluids for shock, and transport rapidly; uterotonics (e.g., oxytocin) per protocol.

Question 48

Eclampsia seizure management in the field

Accepted Answer

Eclampsia is seizures in pregnancy/postpartum with preeclampsia features (hypertension, edema, headache, visual changes). Position left-lateral, protect the airway, control the seizure, and treat with magnesium sulfate per protocol. Definitive treatment is delivery—transport without delay.

Question 49

Neonatal resuscitation first steps and the inverted pyramid

Accepted Answer

Most newborns need only warming, drying, stimulation, and airway positioning/suctioning. If HR stays below 100 with apnea/gasping → positive-pressure ventilation. If HR remains below 60 despite 30 s of effective PPV → start chest compressions (3:1 with ventilations), then epinephrine.

Question 50

NREMT Paramedic exam format, passing point, and retest rule

Accepted Answer

Computerized adaptive test of 110-150 items (20 unscored pilot) in 3.5 hours; pass at a scaled score of 950 on the 100-1500 scale. Fee is $175/attempt via Pearson VUE, certification valid 2 years; retest 15 days after results, six attempts allowed with remediation after three failures.

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