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Free NREMT practice questionsFree Paramedic practice questions · Medical/Obstetrics/Gynecology

7 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.

Work through all 7, 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 7

A 27-year-old patient with asthma has wheezing and difficulty breathing that began 10 minutes after petting a friend's cat. The patient is sitting upright, using the accessory muscles of the neck, and speaking in short phrases. Expiratory wheezes are heard in both lung fields. The vital signs are BP 128/82, P 124, R 28, and SpO₂ 92% on room air. The paramedic starts oxygen and a nebulized albuterol treatment. Which additional finding would best support anaphylaxis rather than an asthma exacerbation?

Show the answer and rationale

Correct answer · Itching of the palms that began along with the wheezing

Itching of the palms that began with the wheezing would point to anaphylaxis. A known trigger like the cat is a normal part of an asthma attack. Asthma is a problem in the lower airways only. Anaphylaxis involves more than one body system. Itching is the skin, a second body system. Wheezes that do not clear, a shark-fin waveform, and an SpO₂ stuck at 92% all come from narrowed lower airways. Anaphylaxis with bronchospasm can cause every one of those. Only the skin finding tells the two apart. If the skin is involved, give intramuscular epinephrine for anaphylaxis, not only a bronchodilator.

Why the others are wrong

Wheezes that do not clear after the first nebulized albuterol treatment: Wheezes that do not clear after albuterol can happen in anaphylaxis, because albuterol only treats the lower airway part. A bad asthma attack can fail the first treatment too. Wheezes that do not clear tell you how bad the lungs are. The wheezes do not tell you whether a second body system is involved.

A shark-fin waveform on the capnography tracing: A shark-fin waveform is the classic tracing for bronchospasm. Asthma and anaphylaxis with bronchospasm draw the same shark fin. The narrowed lower airways empty unevenly in both. A shark fin tells you the airways are narrowed, and both conditions narrow them.

An SpO₂ that stays at 92% on high-flow oxygen: shows how narrowed the lower airways are. A severe asthma attack gives the same number. The SpO₂ does not tell you how many body systems are involved.

Question 2 of 7

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 3 of 7

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: An SpO₂ of 79% is severe hypoxemia, and capping the flow at 2 L/min 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: Holding the saturation at 100 percent overshoots the target for this patient. Start high for an SpO₂ of 79%, then titrate down to the patient's own baseline, or 88 to 92 percent when you do not know the baseline.

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 4 of 7

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 7

A 4-year-old patient who has a tracheostomy tube is in respiratory distress at home, and the caregiver reports thick secretions all morning. Ventilation through the tracheostomy tube with a BVM produces coarse gurgling and poor chest rise. The tube is seated at its usual depth and the flange sits flat against the neck. The vital signs are BP 92/58, P 148, R 40, and SpO₂ 84%. Which action is most appropriate?

Show the answer and rationale

Correct answer · Suction the tracheostomy tube with a premeasured catheter

This tracheostomy tube is plugged with mucus. The caregiver reports thick secretions all morning. Bagging through the tube gives coarse gurgling and poor chest rise. The tube is at its usual depth, and the flange sits flat against the neck. Those findings tell you the tube is in the right place and the inside of the tube is blocked. Air cannot get past the plug to the lungs. That's why the SpO₂ is 84%. Suction the tube with a premeasured catheter. The catheter is measured to the length of the tube so it does not pass beyond the tip. Put the catheter in without suction, then pull it back out with suction while you rotate it. Keep each pass to 10 seconds or less in a 4-year-old. Do this before you try anything more invasive.

Why the others are wrong

Replace the tube with one a half size smaller: A tube change, including a change to a smaller tube, is a later step. For a tube that is in place, you get there only when suctioning does not restore ventilation. Local protocol decides whether the tube may be changed. This tube sits at its usual depth with the flange flat, and the caregiver reports thick secretions all morning. A plug of mucus is the problem, and suction clears a plug. Changing the tube first costs time while this child's SpO₂ sits at 84%.

Remove the tracheostomy tube and ventilate over the stoma: Taking the tube out and bagging over the stoma comes after suctioning fails to restore ventilation. Your local protocol decides whether the tube may come out. Suctioning has not been tried yet. Thick secretions cause most tracheostomy emergencies, so suction comes first. This tube is seated where it belongs, and pulling it gives up a tube that is in the right place.

Seal the stoma and ventilate through the mouth and nose: Sealing the stoma and bagging through the mouth and nose is the backup when the stoma cannot be used. This child's stoma is intact, and the tube is seated at its usual depth. The tube is plugged. Suction has not been tried yet, and suction is the fix for a plug. Many children who have had a tracheostomy for a long time cannot be ventilated through the mouth and nose at all.

Question 6 of 7

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 7 of 7

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: The level of consciousness is falling, and a quiet chest with a falling level of consciousness means the patient is getting worse. In a patient who is really improving, the wheezing fades while the patient speaks in fuller sentences, the saturation rises, and the work of breathing eases.

The patient should be placed on CPAP instead of escalating further: A dropping level of consciousness means this patient cannot be relied on to breathe or to protect the airway. CPAP holds the airways open and makes breathing easier, and it only helps breaths the patient takes on their own. CPAP is a step below what this patient needs, because you have to breathe for this patient.

The bronchodilator dose should simply be repeated more frequently without escalating the level of care: 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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