1 - Which of the following acid-base abnormalities would cause a patient to present with a slowing of the

respiratory rate?
A. Respiratory alkalosis
B. Metabolic alkalosis
C. Metabolic acidosis
D. Respiratory acidosis

Answer: B

Metabolic alkalosis occurs any time there is an excess loss of acid from the body. For example, excessive intake
of antacids can result in metabolic alkalosis. The body’s compensatory system for metabolic alkalosis is the
respiratory system. To correct the reduced acid level, slowing of the respirations (bradypnea) occurs in order to
retain carbon dioxide and increase the levels of circulating acids. Metabolic acidosis would cause an increase in
the respiratory rate (tachypnea) in an attempt to eliminate excess acids from the body. Respiratory acidosis is
caused by hypoventilation; it does not cause hypoventilation. Respiratory alkalosis is caused by
hyperventilation.

2 - Which process occurs during normal breathing?

A. Negative intrathoracic pressure allows blood to be pulled back to the heart.
B. The walls of the airway are forced out of their normal anatomic shape.
C. Increased pressure in the chest cavity impairs venous return to the heart.
D. Inhalation forces the esophagus open, which allows air to enter the stomach.

Answer: A
During normal (unassisted) breathing, negative pressure is created in the thoracic cavity during inhalation; this
allows blood to naturally be pulled back to the heart. By contrast, positive-pressure ventilation (ie. BVM) forces
air into the chest cavity and has the opposite effect of negative-pressure ventilation. Positive pressure ventilation
causes an increase in intrathoracic pressure, which impairs venous return to the heart (preload) and can cause a
decrease in cardiac output. Because positive-pressure ventilation requires more volume to have the same effect
as normal breathing, the walls of the airway are forced out of their normal anatomic shape. During normal
breathing, esophageal opening pressure is not affected. During positive-pressure ventilation however, the
esophagus is forced open, which allows air to enter the stomach (gastric distention).

3 - The low normal partial pressure of oxygen in arterial blood is:

A: 80 mm Hg.
B: 60 mm Hg.
C: 120 mm Hg.
D: 100 mm Hg.

Answer: A
Arterial blood should have a high partial pressure of oxygen (PaO2) because it has been reoxygenated in the
lungs. The normal partial pressure of arterial blood should range between 80 and 100 mm Hg. A PaO2 less than
80 mm Hg indicates hypoxia.
4 - After your initial attempt to provide artificial ventilations to an unresponsive apneic patient, you note a
significant decrease in compliance with no movement of the chest. You should:

A: suction the oropharynx and reattempt ventilations.

B: provide the second breath with greater volume.
C: insert an oral airway and reattempt to ventilate.
D: reevaluate the position of the patient’s head.

Answer: D
If your initial attempt to ventilate an unresponsive patient is met with resistance and the chest does not visibly
rise, you should first reposition the patient’s head and reattempt to ventilate. Remember that the most common
cause of airway obstruction in unresponsive patients is the tongue. If manual repositioning of the head is
unsuccessful, you should assume that a severe (complete) foreign body airway obstruction is present and begin
chest compressions. If you are able to make the chest visibly rise with your ventilations, you should insert an
oral or nasal airway (or both) to help maintain airway patency. Suctioning is indicated if there are secretions in
the airway, as evidenced by gurgling breathing.

5 - A 49-year-old woman complains of chest pressure. She is conscious and alert; is breathing without
difficulty; and has pink, warm, dry skin. You apply the pulse oximeter and obtain a reading of 84%. Which of
the following conditions could cause this?

A: Chronic anemia.
B: Vasodilation.
C: Clear nail polish.
D: Polycythemia.

Answer: A

When assessing a patient’s oxygen saturation with a pulse oximeter, it is important to recall that pulse oximetry
is an adjunct, not a replacement, to a good clinical assessment. The patient in this scenario is not showing signs
of hypoxemia (cyanosis, altered mental status, and so forth), even though her oxygen saturation is low.
Conditions that can cause inaccurate pulse oximetry readings include anemia; peripheral vasoconstriction; dark
or metallic fingernail polish; dirty fingers; and abnormal hemoglobin binding (carbon monoxide poisoning).
Polycythemia is an increase in red blood cell production; if anything, you would expect the pulse oximeter to
produce a high reading in patients with this condition.

6 - Immediately after inserting a King LT airway to the proper depth, you should:

A: place a bite block in between the patient’s molars.

B: ensure that the base of the connector is 1 inch above the teeth.
C: inflate the cuffs with the recommended amount of air.
D: attach the bag-mask device and begin to ventilate.

Answer: C

The King LT airway is inserted until the base of the connector is aligned with the teeth or gums. After inserting
the device, inflate both cuffs with the recommended amount of air. The cuffs are inflated simultaneously using a
common inflation port; the amount of air used is dictated by the size of the airway device. It is normal to see the
King LT airway retract slightly out of the mouth during inflation of the cuffs. After inflating the cuffs, attach
the bag-mask device and begin ventilating the patient. You can consider placing a bite block in between the
patient’s molars.

7 - A 21-year-old man is found semiconscious with shallow, gurgling respirations. After opening his airway,
you should:

A: assess his oxygen saturation.

B: begin assisting his ventilations.
C: insert a King LT airway.
D: suction his oropharynx.

Answer: D

To manage a patient’s airway effectively, you must ensure that it is open and clear of foreign bodies, blood, or
other secretions. The presence of gurgling indicates that the airway contains large amounts of fluid; this is an
immediate threat to the airway and must be treated before proceeding with further airway assessment. Turn the
patient onto his side and suction his oropharynx for up to 15 seconds. After his airway is clear of secretions, you
should then assist his shallow ventilations with a bag-mask device and high-flow oxygen, and assess his oxygen
saturation with pulse oximetry. The King LT airway, as with any supraglottic or multilumen airway device, is
contraindicated in patients with an intact gag reflex; a semiconscious patient likely has an intact gag reflex.

8 - A patient with respiratory distress has a pH of 7.29, a PaCO2 of 58 mm Hg, and a PaO2 of 60 mm Hg.
These laboratory values are consistent with:

A: metabolic alkalosis.
B: respiratory alkalosis.
C: respiratory acidosis.
D: metabolic acidosis.

Answer: C

A pH of 7.29 indicates acidosis. A decreased ( 45 mm Hg) PaCO2 indicates that the patient is retaining carbon
dioxide. The “ROME” mnemonic (respiratory opposite, metabolic equal) is useful for determining whether the
problem is of a respiratory or metabolic origin. If the pH and PCO2 are going in opposite directions (increased
pH and decreased PCO2 or decreased pH and increased PCO2), the patient’s problem is of a respiratory origin.
If the pH and PCO2 are going in the same (equal) direction (increased pH and increased PCO2 or decreased pH
and decreased PCO2), the patient’s problem is of a metabolic origin. Because this patient’s pH is decreasing
and his PaCO2 is increasing (going in opposite directions), you can conclude that his problem is of a respiratory
origin. Because his pH is less than 7.35, you can further conclude that he has a respiratory acidosis.

9 - An unresponsive patient with slow, shallow breathing would be expected to have:

A: decreased pH, increased PaCO2, and decreased PaO2.

B: increased pH, increased PaCO2, and normal PaO2.
C: increased pH, decreased PaCO2, and normal PaO2.
D: decreased pH, decreased PaCO2, and increased PaO2.

Answer: A

Inadequate ventilation (slow rate of breathing, shallow depth of breathing [reduced tidal volume]) initially leads
to respiratory acidosis if not treated with ventilatory assistance. Any form of acidosis presents with a decreased
pH, which indicates an increase in hydrogen ion concentration in the blood. Remember that hydrogen ion
concentration and pH are inverse; where one goes, the other goes in the opposite direction. Respiratory acidosis
stems from an inability to breathe in enough oxygen, which causes a decrease in the partial pressure of oxygen
(PaO2). If the patient is not breathing in enough oxygen, carbon dioxide elimination decreases, resulting in an
increase in the partial pressure of carbon dioxide (PaCO2).

10 - When you transport a patient with a nasal cannula for a prolonged period of time, you should:

A: set the flow rate to no greater than 2 L/min.

B: ensure that the patient is supine.
C: set the flow rate to at least 4 L/min.
D: attach an oxygen humidifier.

Answer: D

Because oxygen delivered by nasal cannula can cause drying and irritation of the nasal mucosa, especially over
a prolonged period of time, an oxygen humidifier should be attached during long-range transports. The
appropriate oxygen flow rate for a nasal cannula is 1 to 6 L/min. The patient should be placed in the position in
which they are most comfortable.

11 - Which of the following describes the process of pulmonary respiration?

A: The transfer of carbon dioxide from the alveoli into the bloodstream is facilitated by a process called
diffusion.
B: Gases exchanged in the lungs always move from an area of greater concentration to an area of lesser
concentration.
C: Blood that returns to the lungs from the right side of the heart has a slightly lower level of carbon dioxide
than oxygen.
D: The partial pressure of oxygen in the alveoli is typically between 40 and 50 mm Hg at the end of a maximal
inhalation.

Answer: B

Gases exchanged in the lungs (pulmonary respiration) always move from an area of greater concentration to an
area of lesser concentration by a process called diffusion. Blood that enters the lungs from the right side of the
heart has a PaO2 of approximately 40 mm Hg and a PaCO2 of approximately 46 mm Hg. Within the lungs,
carbon dioxide diffuses from the bloodstream into the alveoli, whereas oxygen diffuses from the alveoli into the
bloodstream. The partial pressure of oxygen within the alveoli is near 100 mm Hg, whereas the partial pressure
of carbon dioxide is near 0 mm Hg.

12 - Which of the following conditions is the LEAST likely to skew the pulse oximetry reading?

A: Fingernail polish
B: Peripheral vasoconstriction
C: Carbon monoxide poisoning
D: Severe hypertension

Answer: D

Hypertension typically does not affect the pulse oximeter reading. Fingernail polish, especially thick red polish,
does not allow the beam of light from the pulse oximeter to penetrate the nail bed. Carbon monoxide, which
increases the carboxyhemoglobin level, turns the blood bright red; this is often misinterpreted by the pulse
oximeter as a falsely high oxygen saturation. By contrast, peripheral vasoconstriction shunts blood away from
the skin; as a result, the pulse oximeter may not even detect a pulse or it may provide a falsely low reading.
Always use pulse oximetry in conjunction with a careful clinical assessment of the patient.

13 - Which of the following statements regarding agonal respirations is correct?

A: Agonal respirations are commonly observed after cardiac arrest occurs

B: In most cases, agonal respirations are caused by diabetic ketoacidosis
C: Agonal respirations are characterized by a slow, deep, regular pattern
D: Agonal respirations increase and then decrease, with apneic periods

Answer: A

Agonal respirations (also called agonal gasps) are slow, irregular, or occasional gasping breaths that are the
result of cerebral anoxia. Agonal respirations may be seen for a short period of time after a patient’s heart has
stopped. Clearly, agonal respirations are not effective and require positive-pressure ventilation support. The
respiratory pattern commonly observed in patients with diabetic ketoacidosis is Kussmaul respirations; they are
characterized by a deep, rapid pattern of breathing. A patient with agonal respirations may require advanced
airway management. The pattern of breathing in which the respirations increase and then decrease with
intermittent periods of apnea is called Cheyne-Stokes respirations.

14 - Normal tidal volume in the average adult male is approximately:

A: 8 to 10 mL/kg.
B: 2 to 4 mL/kg.
C: 10 to 12 mL/kg.
D: 5 to 7 mL/kg.

Answer: D

The average tidal volume, the amount of air inhaled or exhaled per breath, for an average adult male is
approximately 5 to 7 mL/kg. This equates to an average of 500 mL per breath.

15 - You are providing continuous positive airway pressure (CPAP) therapy to a patient in respiratory distress,
and have the positive end-expiratory pressure (PEEP) valve set at 7.5 cm H2O. When you reassess him, you
note that his respiratory rate has markedly decreased, he is not following verbal commands, and his oxygen
saturation has fallen to 75%. You should:

A: decrease the PEEP setting to 5 cm H2O and reassess him.

B: increase the PEEP setting to 10 cm H2O and reassess him.
C: remove the CPAP device and ventilate with a bag-mask device.
D: auscultate his breath sounds to rule out a pneumothorax.

Answer: C

CPAP is an excellent tool to use for patients experiencing respiratory distress secondary to obstructive lung
disease or pulmonary edema. However, not all patients improve with CPAP therapy. CPAP is contraindicated in
patients who are in respiratory failure or arrest, patients with signs of a pneumothorax, and patients who are
unable to follow verbal commands. The patient in this scenario has signs of respiratory failure (markedly
decreased respiratory rate, not following verbal commands, and low oxygen saturation), despite CPAP therapy.
Therefore, you should remove the CPAP device and begin ventilating him with a bag-mask device. After you
have restored adequate minute volume, you should assess his breath sounds.

16 - The Hering-Breuer reflex is a protective mechanism of the respiratory system that:

A: increases the respiratory rate in response to hypoxia.

B: causes laryngospasm to prevent aspiration into the lungs.
C: limits the expiratory phase to retain carbon dioxide.
D: prevents overexpansion of the lungs during inhalation.

Answer: D

The Hering-Breuer reflex is a protective mechanism of the respiratory system in which stretch receptors in the
lungs sense the degree of inhalation and send messages to the respiratory centers in the brain via the vagus
nerve. This stops the inhalation process and prevents overexpansion of the lungs.

17 - Snoring respirations in an elderly woman found unresponsive in her bed are MOST rapidly and effectively
managed by:

A: inserting a supraglottic airway device.

B: manually maneuvering her head.
C: suctioning the oropharynx.
D: inserting an oral or nasal airway.

Answer: B

Snoring respirations indicate partial airway obstruction by the tongue. When a person becomes unresponsive,
the tongue falls back into the posterior pharynx and partially occludes the glottic opening. The quickest and
most effective way to treat this is by manually maneuvering the patient's head (head tilt-chin lift or jaw-thrust
maneuver). After opening the airway manually, an oral or nasal airway can be inserted to assist in maintaining
airway patency. Suctioning is not indicated unless the patient has gurgling respirations or you can clearly see
secretions in the oropharynx. The unresponsive patient may require a supraglottic airway device (ie, King LT,
LMA, CobraPLA), but not before first establishing a patent airway and ensuring adequate ventilation and
oxygenation with basic maneuvers.

18 - A selective beta-2 adrenergic agonist produces which of the following physiologic effects?

A: Bronchodilation
B: Decreased parasympathetic tone
C: Increased inotropy
D: Increased vascular resistance
Answer: A

Selective beta-2 adrenergic agonists, such as albuterol (Ventolin, Proventil) and metaproterenol (Alupent),
stimulate beta-2 receptors, which are found primarily in the lungs. When stimulated, beta-2 receptors cause
bronchodilation, which makes them the ideal drug to use for patients with certain airway diseases that are
associated with bronchospasm (asthma, bronchitis, or bronchiolitis). Stimulation of beta-1 receptors results in
an increase in heart rate (chronotropy) and cardiac contractility (inotropy). Increased vascular resistance
(vasoconstriction) occurs when alpha-1 adrenergic receptors are stimulated.

19 - While auscultating the lungs of a 60-year-old man who complains of shortness of breath, you hear fine,
moist crackles in all lung fields. These sounds indicate:

A: mild to moderate bronchospasm.

B: fluid in the small lower airways.
C: mucous plugs in the alveoli.
D: fluid in the large lower airways.

Answer: B

Crackles, formerly called rales, are fine, moist, thin sounds. They represent fluid in the smaller lower airways
and often indicate early pulmonary edema. Rhonchi are loud rattling sounds that can often be heard without a
stethoscope and indicate fluid in the larger airways. Bronchospasm (constriction of the bronchioles) produces a
characteristic whistling sound called wheezing. Thick mucous plugging of the alveoli would likely manifest
with diminished breath sounds.

20 - You are ventilating an apneic patient with a pocket face mask and one-way valve. Which of the following
is a disadvantage of this method of ventilatory support?

A: Hyperventilation can result in the rescuer who is providing ventilations.

B: Smaller amounts of tidal volume are delivered to the patient.
C: An adequate mask-to-face seal is difficult to maintain.
D: It is only effective if used in conjunction with the jaw-thrust maneuver.

Answer: A

Using the pocket mask device for a prolonged period of time can result in hyperventilation of the rescuer
providing the ventilations because he or she is ventilating the patient with his or her own breaths. Ease in
maintaining an adequate mask-to-face seal makes the pocket mask an effective method of providing artificial
ventilations. Because it is relatively easy to maintain an effective mask-to-face seal with the pocket face mask,
ventilation by this method provides greater tidal volume than the one-rescuer bag-mask device technique. The
pocket face mask can be used with either the head tilt-chin lift or jaw-thrust maneuvers.

21 - Kussmaul respirations indicate that the:

A: respiratory system is attempting to eliminate ketoacids from the blood.

B: brain stem is significantly injured because of increased intracranial pressure.
C: respiratory centers are increasing the rate and depth of breathing to bring in more oxygen.
D: pH of the blood is elevated and the patient is hypoventilating to retain carbon dioxide.

Answer: A

Kussmaul respirations, a pattern of deep, rapid breathing accompanied by a fruity or acetone breath odor, are
observed in patients with diabetic ketoacidosis. They represent the respiratory system’s attempt to eliminate
ketoacids from the blood. Central neurogenic hyperventilation, which is also characterized by deep and rapid
breathing, is seen in patients with brain stem injury secondary to increased intracranial pressure; unlike
Kussmaul respirations, however, they are not accompanied by a fruity or acetone breath odor. In metabolic
alkalosis, such as what may occur after ingestion of a large amount of base (eg, antacids), the patient may
hypoventilate to increase the carbon dioxide content of the blood and drive the pH down. Hypoxia is a very
powerful stimulus to breathe; if the chemoreceptors sense low blood oxygen levels, the respiratory centers
increase the rate and depth of breathing accordingly.

22 - Your uninjured patient is unresponsive, is breathing at a rate of 14 breaths/min with adequate depth, and
has heart rate of 90 beats/min and irregular. His oxygen saturation is 94% on room air. You should:

A: ventilate him with a bag-mask device and high-flow oxygen until his oxygen saturation reaches 100%.
B: keep the patient supine in case you need to suction his airway and administer high-flow oxygen by
nonrebreathing mask.
C: insert a supraglottic airway device, assist his ventilations, and request a paramedic to perform tracheal
intubation.
D: insert an oral or nasal airway, place him on his side, and give high-flow oxygen by nonrebreathing mask.

Answer: D

If an uninjured, unresponsive patient is ventilating adequately (adequate rate and depth), you should insert a
simple airway adjunct (oral or nasal airway) to help maintain airway patency; apply oxygen in a quantity
sufficient to maintain an oxygen saturation of greater than 94%; and position him on his side (recovery position)
to facilitate drainage if he vomits. Monitor his breathing adequacy carefully and be prepared to assist his
ventilations if he begins to hypoventilate (decreased rate, shallow depth [reduced tidal volume]). If you must
assist his ventilations, a supine position is required. An advanced airway is not necessary at this point; however,
if his condition deteriorates, a supraglottic airway device (ie, LMA, CobraPLA, King LT) should be considered.

23 - Which of the following assessment findings is MOST consistent with adequate ventilation?

A: Tachypnea
B: Bradypnea
C: Warm, dry skin
D: Cyanotic oral mucosa

Answer: C

Of the choices listed, warm and dry skin is the most consistent with adequate ventilation. Respirations that are
too slow (bradypnea) or too fast (tachypnea) are commonly associated with inadequate ventilation, especially in
the presence of reduced tidal volume (shallow breathing). Hypoxemia caused by inadequate ventilation results
in cyanotic or cool, clammy skin. The oral mucosa may also become cyanotic. It is important to note, however,
that the absence of cyanosis does NOT rule out hypoxemia or inadequate ventilation.

24 - After inserting a King LT airway into a cardiac arrest patient, you meet resistance when you attempt to
ventilate. Your initial action should be to:

A: remove the King LT and resume bag-mask ventilations.

B: withdraw the airway slightly while continuing to ventilate.
C: auscultate both sides of the chest and over the epigastrium.
D: deflate the cuffs of the King LT and reassess ventilation.
Answer: B

It is relatively common for the ventilation ramp at the distal end of the King LT airway to push the epiglottis
over the glottic opening, resulting in difficulty in ventilating the patient. Therefore, if you meet resistance after
inserting the device, your initial action should be to withdraw the tube slightly while continuing to ventilate; do
NOT deflate the cuffs to do this. If this does not correct the situation, you should then deflate the cuffs, remove
the King LT, insert an oral or nasal airway, and resume bag-mask ventilations. Auscultation of lung and
epigastric sounds is typically performed after an advanced airway device is inserted, and initial ventilations are
provided without difficulty.

25 - A decrease in pulmonary surfactant results in:

A: enhanced gas diffusion through thinning of the alveolar wall.

B: decreased alveolar surface tension and enhanced respiration.
C: increased alveolar surface tension and ineffective respiration.
D: easier expansion and recoil of the alveoli during respiration.

Answer: C

Surfactant, a substance that lines the alveolar walls and acts as a lubricant, functions by decreasing alveolar
surface tension. This effect allows the alveoli to expand and recoil, thus facilitating the process of respiration
(the exchange of oxygen and carbon dioxide). If pulmonary surfactant is decreased, alveolar surface tension
increases; this creates a barrier to diffusion, which impairs pulmonary (external) respiration.

26 - During transport of a 50-year-old man in severe respiratory distress, the patient suddenly gets off of the
stretcher, stands up, and pulls the oxygen mask from his face. What should you do?

A: Apply a nasal cannula and try to calm the patient.

B: Call for a paramedic to administer Valium to the patient.
C: Allow the patient to remain standing throughout transport.
D: Place the patient supine and assist ventilations.

Answer: A

This patient is obviously experiencing severe respiratory distress and is hypoxic, as evidenced by his extreme
restlessness. You should attempt to calm the patient and offer oxygen with a less oppressive device, such as a
nasal cannula. Should the patient’s level of consciousness decrease, you should assist his ventilations with a
bag-mask device. Central nervous system depressants, such as diazepam (Valium), should be avoided in
hypoxic patients with respiratory distress because they may cause respiratory arrest. For obvious reasons, it is
not safe to allow a patient to stand up in the back of a moving ambulance.

27 - What is the MOST appropriate initial action to take when a previously breathing adult patient suddenly
becomes unresponsive, apneic, and bradycardic?

A: Insert a Combitube and begin ventilating

B: Begin ventilating with a bag-mask device
C: Suction the oropharynx for up to 15 seconds
D: Open the airway with a manual maneuver

Answer: D

If any patient suddenly becomes unresponsive, apneic, and experiences an increase or decrease in his or her
heart rate, your initial action should be to manually open the airway with the head tilt-chin lift or jaw-thrust
maneuver. In some cases, this may be all that is needed to restore adequate breathing. Remember, when a
person loses consciousness, the tongue often falls back into posterior pharynx and occludes the airway.
Suctioning is indicated if there are secretions in the patient’s mouth, whether he or she is breathing or not. If
after opening the airway with a manual maneuver the patient is still not breathing, begin rescue breathing with a
bag-mask or pocket face mask device. An advanced airway (Combitube, CobraPLA, or King LT) may be
indicated, but not before ventilating with basic means first.

28 - Which of the following statements regarding ventilation and respiration is correct?

A: Ventilation is the exchange of gases in the body.

B: Respiration is the process of moving air into the lungs.
C: Ventilation can occur despite inadequate respiration.
D: Respiration can occur in the absence of ventilation.

Answer: C

Ventilation is the physical act of moving air into and out of the lungs. Respiration is defined as the exchange of
gases between the body and its environment. It is possible for ventilation to occur despite inadequate or absent
respiration. For example, if a patient is trapped in an environment that is devoid of oxygen (trench, grain silo,
structural fire), he or she may continue to move air into and out of the lungs; however, the exchange of oxygen
and carbon dioxide in the lungs (pulmonary [external] respiration) is impaired. Another example is a pulmonary
embolism; the patient may continue to ventilate, but reoxygenation of blood in the lungs is impaired. Although
it is possible for ventilation to occur without respiration, it is not possible for respiration to occur without
ventilation.

29 - Before applying a nonrebreathing mask on a conscious patient with respiratory distress, you should

A: ensure that the reservoir bag is fully inflated.

B: place the patient in the recovery position in case he or she vomits.
C: ask the patient to exhale fully and then hold his or her breath.
D: set the oxygen flowmeter to no more than 10 L/min.

Answer: A

Before placing a nonrebreathing mask on a patient, you must ensure that the reservoir bag is completely filled.
If the reservoir bag is not prefilled, the patient will not receive the maximum percentage of oxygen that the
device can deliver. The appropriate oxygen flow rate for a nonrebreathing mask is 12 to 15 L/min.

30 - Prehospital treatment for a patient with respiratory distress and diffuse wheezing should focus on:

A: ventilating the patient with a bag-mask device.

B: relieving bronchospasm and improving ventilation.
C: determining the underlying cause of the problem.
D: rapid transport with a paramedic intercept en route.

Answer: B

Patients with respiratory distress and wheezing, such as what is seen in patients with an acute asthma attack,
have two problems: bronchospasm and hypoxemia. In the prehospital setting, your primary focus should be on
relieving the bronchospasm by administering or assisting the patient with an inhaled bronchodilator (albuterol
[Proventil, Ventolin]). Inhaled bronchodilators open the bronchioles, thereby facilitating airflow and improving
ventilation and oxygenation. Asthma is but one cause of respiratory distress and wheezing; therefore, you
should focus on treating his or her symptoms, not diagnosing his or her problem. Some patients may require
assisted ventilation; however, your goal is to improve ventilation, which may be accomplished by simply
administering a bronchodilator. If the patient’s condition does not improve, transport immediately and consider
a paramedic intercept en route.

31 - Respiratory acidosis caused by acute pulmonary edema:

A: does not allow enough time for the slow-acting renal system to compensate for the pH shift and can be
rapidly fatal.
B: should be treated with immediate hyperventilation to quickly eliminate hydrogen ions and normalize the pH.
C: requires immediate treatment with sodium bicarbonate in order to remove excess hydrogen ions from the
blood.
D: does not respond well to continuous positive airway pressure (CPAP) because the patient is usually
unresponsive.

Answer: A

Respiratory acidosis, also referred to as hypoxic acidosis, is always the result of hypoventilation. Immediate
treatment involves ventilatory support (bag-mask ventilation, CPAP) to eliminate excess hydrogen ions and
normalize the pH. Many patients with acute pulmonary edema respond well to CPAP, which is why it is
considered the first-line treatment if the patient is able to follow verbal commands. Sodium bicarbonate is NOT
indicated for respiratory acidosis because it dissociates into carbon dioxide and water when administered to the
patient. If the patient is not ventilating adequately, this increase in carbon dioxide only worsens their acidosis.
Any form of respiratory acidosis caused by an acute problem (acute pulmonary edema, drowning, chest trauma)
can be rapidly fatal because the slow-acting renal system does not have enough time to compensate for the acute
pH shift. By contrast, respiratory acidosis caused by chronic conditions, such as emphysema, is usually
survivable. In these cases, the renal system slowly moderates the acidosis, preventing the life-threatening
cardiac dysrhythmias that may result from acute acidosis. Hyperventilation should be avoided in any patient
because it increases intrathoracic pressure, which impairs venous return to the heart (preload) and can cause a
reduction in cardiac output.

32 - In which of the following situations would respiratory alkalosis MOST likely occur?

A: Fat metabolism that leads to ketoacid production.

B: Excessive intake of antacid medications.
C: Slow respirations with reduced tidal volume.
D: Sustained respiratory rate of 30 breaths/min.

Answer: D

Respiratory alkalosis is always the result of hyperventilation, which causes excess carbon dioxide elimination
and a reduction of circulating carbonic acid. By contrast, respiratory acidosis is always related to
hypoventilation, such as when a patient is breathing too slowly (bradypnea), too shallowly (reduced tidal
volume), or is not breathing at all. Metabolic alkalosis occurs any time there is excessive loss of acid from
excessive urination or from decreased gastric acid, such as when a person ingests a large quantity of antacid
medications. As a result, hydrogen ion levels in the blood decrease and the pH increases. Any acidosis that is
unrelated to the respiratory system is considered to be metabolic in origin. Lactic acidosis from anaerobic
metabolism and ketoacidosis from cellular fat metabolism cause an increase in the hydrogen ion concentration
of the blood, resulting in a decrease in pH.
33 - How does ventilation differ from respiration?

A: Ventilation is the process of exchanging gases between the body and its environment, whereas respiration is
the loading of oxygen molecules onto hemoglobin molecules.
B: Ventilation is the act of moving air into and out of the lungs, whereas respiration is the exchange of gases
between the body and its environment.
C: Ventilation is the process of loading oxygen molecules onto hemoglobin molecules, whereas respiration is
the movement of air into and out of the lungs.
D: Ventilation is the process of eliminating carbon dioxide from the body, whereas respiration is the process of
loading oxygen molecules onto hemoglobin molecules.

Answer: B

Ventilation is the simple act of moving air into and out of the lungs. Respiration is the process of exchanging
gases (oxygen and carbon dioxide) between the body and its environment. The process of loading oxygen
molecules onto hemoglobin molecules in the bloodstream is called oxygenation. The elimination of carbon
dioxide from the body occurs during the exhalation phase of breathing.

34 - Which of the following is the MOST appropriate device to use on a patient with labored breathing and
reduced tidal volume?

A: Oxygen-powered transport ventilator

B: Bag-mask device with high-flow oxygen
C: Nonrebreathing mask set at 15 L/min
D: Nasal cannula set at 1 to 6 L/min

Answer: B

Patients with labored breathing and reduced tidal volume (shallow breathing) are not taking in adequate
amounts of air to maintain optimum minute volume. Therefore, you should assist ventilations with a bag-mask
device and high-flow oxygen. If the patient does not tolerate this, apply a nonrebreathing mask, but be prepared
to resume assisted ventilations if the patient’s level of consciousness decreases. Portable transport ventilators
are used on apneic patients; if a patient requires ventilation assistance, the bag-mask device is the best device to
use.

35 - A 70-year-old man presents with acute respiratory distress. His past medical history includes congestive
heart failure, hypertension, and type 2 diabetes. He is conscious, but confused, and is unable to follow simple
commands. Auscultation of his breath sounds reveals diffuse crackles bilaterally. His respiratory rate is 30
breaths/min and labored, his heart rate is rapid and weak, and the pulse oximeter reads 78%. You should:

A: assist his ventilations with a bag-mask device.

B: apply high-flow oxygen by nonrebreathing mask.
C: insert a supraglottic airway device at once.
D: apply CPAP and reassess his breathing.

Answer: A

A patient with severe respiratory distress and signs of inadequate ventilation (confusion and low oxygen
saturation) requires assisted ventilation, which is typically performed with a bag-mask device attached to high-
flow oxygen. Continuous positive airway pressure (CPAP) is beneficial to patients with acute pulmonary edema
and obstructive lung disease; however, it is contraindicated in patients who are unable to follow simple
commands. Although the patient is confused, he is still conscious and likely has an intact gag reflex; therefore,
insertion of a supraglottic airway device (ie, King LT, LMA, CobraPLA) is contraindicated.

36 - A deficiency of pulmonary surfactant would MOST likely result in:

A: increased alveolar surface tension and impaired pulmonary respiration.

B: consolidated pus that collects in the lung tissue and causes an infection.
C: excess mucous production from the goblet cells and airway congestion.
D: widespread bronchoconstriction and decreased pulmonary ventilation.

Answer: A

The alveoli are lined with a lubricating substance called surfactant, which decreases alveolar surface tension and
helps keep the alveoli open. If the amount of surfactant is inadequate, surface tension on the alveolar walls
increases, which impairs the exchange of oxygen and carbon dioxide in the lungs (pulmonary respiration).
Internal and external factors can cause bronchoconstriction and impaired pulmonary ventilation; however, they
are unrelated to surfactant deficiency. Bronchitis occurs when the mucous-producing cells (goblet cells) that
line the airway tract produce excess amounts of mucous. Pneumonia occurs when consolidated pus collects
within the lung tissue (parenchyma) and becomes infected.

37 - Tidal volume is defined as the:

A: volume of air moved in and out of the lungs per breath.

B: residual volume of air in the lungs at the end of exhalation.
C: maximum volume of air that the lungs can accommodate.
D: volume of air moved in and out of the lungs each minute.

Answer: A

Tidal volume is defined as the volume of air (in milliliters) that is moved in and out of the lungs in a single
breath. The volume of air moved in and out of the lungs each minute is called minute volume (tidal volume,
minus dead space volume, multiplied by the respiratory rate) and is measured in liters. Tidal volume in an
average adult male is 5 to 7 mL/kg, or approximately 500 mL. The maximum volume of air that the lungs can
accommodate is called the total lung capacity; it is about 6 L in the average adult male. The amount of air that
remains in the lungs after a maximal exhalation is called the residual volume.

38 - Which of the following patients would benefit the MOST from continuous positive airway pressure
(CPAP)?

A: Semiconscious man with labored breathing, unilaterally absent breath sounds, and low oxygen saturation.
B: Conscious and alert man with severe respiratory distress and coarse crackles in all lung fields.
C: Conscious and alert woman with mild respiratory distress, fever and chills, and a productive cough.
D: Unresponsive woman with slow, shallow breathing and cyanosis to her face, neck, and upper chest.

Answer: B

CPAP is a noninvasive form of positive-pressure ventilation used to treat patients with respiratory distress
secondary to obstructive lung disease and acute pulmonary edema. The conscious and alert man in this scenario
is the ideal candidate for CPAP because he meets the clinical criteria (respiratory distress and coarse crackles in
the lungs [evidence of pulmonary edema]) and does not have any of the known contraindications, such as an
inability to follow verbal commands, signs of respiratory failure (slow, shallow breathing or diffuse cyanosis),
or a pneumothorax (unilaterally absent breath sounds). Respiratory distress, fever and chills, and a productive
cough are clinical signs of pneumonia. Although CPAP has clearly shown to be beneficial for patients with
obstructive lung disease and acute pulmonary edema, it has not shown to be beneficial for patients with
parenchymal lung diseases, such as pneumonia.

39 - You are administering supplemental oxygen at 12 L/min with a nonrebreathing mask to a conscious patient
with signs of hypoxemia when he suddenly pulls the mask from his face. What should you do next?

A: Apply a nasal cannula at 2 to 6 L/min.

B: Give oxygen by partial rebreathing mask.
C: Increase the flow rate and replace the mask.
D: Securely tape the mask to the patient’s face.

Answer: A

Although not as common as with children, some adult patients cannot tolerate the oppressive feeling of an
oxygen mask over their face. Should this occur, the AEMT should offer the patient oxygen by nasal cannula at a
flow rate of 2 to 6 L/min. It is important to administer supplemental oxygen to any patient with signs of
hypoxemia; however, increasing their level of anxiety also increases the body’s demand and consumption of
oxygen, which may worsen their hypoxemia.

40 - A patient with a deficiency of oxygen in his or her arterial blood is said to be:

A: hypercarbic.
B: hypocarbic.
C: hypoxemic.
D: hypoxic.

Answer: C

Hypoxemia is defined as a deficiency of oxygen in arterial blood, and can be quantified by pulse oximetry.
Hypoxia is a condition in which there is an inadequate supply of oxygen at the tissue and cellular levels; it is a
dangerous condition that requires aggressive ventilation and oxygenation. Untreated hypoxemia leads to
hypoxia. When the arterial level of carbon dioxide decreases, hypocarbia exists. By contrast, when the arterial
level of carbon dioxide increases, hypercarbia exists. Hypoxemia and hypercarbia are present in patients with
inadequate ventilation.

41 - Appropriate treatment for a responsive, coughing patient with a mild airway obstruction involves:

A: administering oxygen as needed and encouraging the patient to cough.

B: standing behind the patient and administering abdominal thrusts.
C: visualizing the patient’s mouth using a tongue blade and a penlight.
D: inserting a nasopharyngeal airway and administering high-flow oxygen.

Answer: A

A responsive patient with a mild (partial) airway obstruction, who is coughing forcefully, is moving adequate
air; leave the patient alone! Encourage the patient to continue coughing as forcefully as possible and transport to
the emergency department. Administer supplemental oxygen as needed. Any attempts to relieve a mild airway
obstruction (abdominal thrusts) may result in a severe (complete) airway obstruction. Do not place anything in
the patient’s mouth and do not insert a nasal airway; these actions may also convert a mild airway obstruction to
a complete airway obstruction. Abdominal thrusts are indicated for responsive adults and children with a severe
airway obstruction, as evidenced by an inability to speak or cough.
42 - During your primary assessment of a 60-year-old woman with acute respiratory distress, you note that she
is conscious, but is unable to follow commands, and is gasping for air. You should:

A: apply high-flow oxygen by nonrebreathing mask.

B: insert an oropharyngeal airway.
C: determine the cause of her problem.
D: assist her breathing with a bag-mask device.

Answer: D

A patient who is gasping to breathe, especially if he or she has a decreased level of consciousness, is not
ventilating adequately and needs ventilation assistance with a bag-mask device. A nonrebreathing mask is of
limited benefit to a patient with inadequate ventilation because it takes a certain amount of negative-pressure
ventilation to open the one-way valve and breathe in oxygen from the reservoir on the mask. The oropharyngeal
(oral) airway is contraindicated in any conscious patient and in any patient with an intact gag reflex. The patient
requires further assessment to determine the underlying cause of her breathing difficulty, but not before
restoring adequate ventilation first.

43 - A 40-year-old man is unresponsive, hypoventilating, and bradycardic. You should

A: suction his airway, insert an oral or nasal airway, give him high-flow oxygen by nonrebreathing mask, and
transport.
B: insert a simple airway adjunct, assist his ventilations with a bag-mask device, suction his airway as needed,
and transport.
C: position him on his side, insert a simple airway adjunct, give him high-flow oxygen by nonrebreathing mask,
and transport.
D: insert a supraglottic airway device to prevent aspiration, ventilate him at a rate of 20 to 24 breaths/min, and
transport.

Answer: B

Unresponsive patients are unable to maintain their own airway; therefore, you should insert a simple airway
adjunct (oral or nasal airway) while manually maintaining the head in an appropriate position. Suction the
patient’s airway if there are any secretions that need to be removed. Hypoventilation, as defined as a slow rate
of breathing or a shallow depth of breathing, must be treated with some form of positive-pressure ventilation
(ie, bag-mask ventilation). The appropriate ventilation rate for an adult is 10 to 12 breaths/min. Patients who
hypoventilate are not breathing in adequate oxygen or eliminating enough carbon dioxide; if this is left
untreated, respiratory acidosis, followed by metabolic acidosis, occurs. A supraglottic airway device (ie, King
LT, LMA, CobraPLA) may be indicated if you are unable to adequately maintain the airway or ventilate the
patient with a bag-mask device. Placing a patient onto his or her side (recovery position) is appropriate for
uninjured patients with adequate spontaneous ventilation.

44 - You are dispatched to a residence for an 18-year-old man with respiratory distress. The patient’s mother
tells you that her son was recently fired from his job and had his car repossessed. The patient is conscious and
alert, but has a respiratory rate of 36 breaths/min. Further assessment reveals that his hands are contracted and
his oxygen saturation reads 96% on room air. Initial management for this patient should include:

A: applying an oxygen face mask at 2 L/min.

B: attempting to coach him to slow his breathing.
C: assisted ventilation with a bag-mask device.
D: applying a nonrebreathing mask with high-flow oxygen.
Answer: B

On the basis of the patient’s history and physical findings, this case is consistent with an anxiety attack and
hyperventilation syndrome. These patients initially need emotional support and respiratory coaching. If, after a
reasonable period of coaching, the patient’s respirations do not slow down, you should assume the presence of
another underlying cause, such as hypoxemia, and administer high-flow oxygen. Rebreathing into a paper bag
or any other action that causes the patient to rebreathe his or her own carbon dioxide (facemask with minimal
oxygen flow) is dangerous and should be avoided. There are many causes of hyperventilation; anxiety is but
one. In some cases, it may be necessary to assist a patient’s ventilations that are exceedingly fast, especially if
signs of physical exhaustion or hypoxemia (decreased mental status or falling oxygen saturation) are present.

45 - Which of the following patients has an obviously patent airway?

A: An older man who is found unresponsive

B: A semiconscious woman with gurgling breathing
C: A conscious man with a weak, ineffective cough
D: An injured woman who is screaming in pain

Answer: D

If a patient can scream, his or her airway is patent. An unresponsive patient’s airway should be considered
nonpatent until proved otherwise. Blood or other secretions in the airway, as evidenced by gurgling respirations,
present an immediate threat to the airway and must be treated immediately. A weak, ineffective cough in a
conscious patient indicates a severe upper airway obstruction, not a patent airway.

46 - A 59-year-old woman who was recently discharged from the hospital reports a sudden onset of difficulty
breathing with sharp chest pain that increases with breathing. Her skin is cyanotic and diaphoretic and the pulse
oximeter reads 82%. You should suspect:

A: acute bacterial pneumonia.

B: an acute pulmonary artery rupture.
C: a spontaneous pneumothorax.
D: an acute pulmonary embolism.

Answer: D

Hospitalization or prolonged bed rest can cause blood to stagnate in the lower extremities and form thrombi that
can break free and lodge in a pulmonary artery, causing an acute pulmonary embolism. The patient’s sudden
onset of difficulty breathing with sharp (pleuritic) chest pain is consistent with this condition. The presence of
cyanosis, diaphoresis, and low oxygen saturation level indicates a significant degree of hypoxemia. Pneumonia
is rarely of an acute onset; instead, it typically presents with increasing respiratory difficulty and fever that
progresses over a period of a few days. Spontaneous pneumothorax is also characterized by a sudden onset of
dyspnea and pleuritic chest pain; however, most patients do not present with significant hypoxemia.

47 - In contrast to negative-pressure ventilation, positive-pressure ventilation:

A: occurs when the diaphragm contracts and descends.

B: involves the forcing or pushing of air into the lungs.
C: is the process of normal, unassisted breathing.
D: occurs secondary to an increase in intrathoracic pressure.
Answer: B

Negative-pressure ventilation is the act of normal, unassisted breathing. It occurs when the diaphragm and
intercostal muscles contract, which causes intrathoracic pressure to fall below that of the atmospheric pressure.
This creates a vacuum effect and air is drawn into the lungs until intrathoracic and atmospheric pressures are
equal. Positive-pressure ventilation involves pushing or forcing air into the lungs, such as what occurs during
rescue breathing with a bag-mask device. Positive-pressure ventilation causes an increase in intrathoracic
pressure.

48 - When treating a patient with respiratory distress and a history of chronic obstructive pulmonary disease
(COPD), it is important to remember that:

A: conditions such as COPD cause an increased amount of surfactant, which decreases alveolar surface tension.
B: the patient’s primary respiratory drive is based on chronically increased levels of carbon dioxide.
C: supplemental oxygen should be limited to 2 L/min, even if clinical signs of worsened hypoxia are present.
D: pulmonary damage has increased the amount of dead space volume, which impairs pulmonary respiration.

Answer: D

In addition to the normal anatomic dead space of the respiratory system (mouth, trachea, and large bronchi),
patients with chronic lungs diseases (COPD, congestive heart failure) have an increase in dead space volume,
called physiologic dead space, because of damage to or inefficient function of the lungs (atelectasis, pulmonary
edema). An increase in physiologic dead space volume impairs pulmonary respiration. Patients with COPD are
stimulated to breathe by chronically low oxygen levels in the blood (hypoxic drive), and although some patients
may hypoventilate if given high-flow oxygen, you should NEVER withhold oxygen from any patient who is
hypoxic. If the patient hypoventilates or becomes apneic, ventilate him or her with a bag-mask device. COPD
causes destruction of pulmonary surfactant, resulting in increased alveolar surface tension and impaired
pulmonary respiration.

49 - Which of the following structures in the brain is responsible for slow, shallow breathing associated with a
narcotic overdose?

A: Pons and cerebral cortex

B: Medulla oblongata and apneustic centers
C: Apneustic and pneumotaxic centers
D: Medulla oblongata and pons

Answer: D

The medulla oblongata and pons, which are parts of the brain stem, are the primary centers of breathing and are
responsible for the rate and depth of ventilation. Central nervous system depressant drugs (narcotics,
benzodiazepines, and barbiturates) suppress the function of the medulla and pons, resulting in decreases in
ventilatory rate and depth. The apneustic and pneumotaxic centers promote inhalation and exhalation,
respectively. The cerebral cortex can influence breathing by adjusting the rate at which neurons fire in the
medulla, thus allowing breathing to slow during activities, such as talking, eating, or breath-holding.

50 - A 60-year-old woman complains of dyspnea. She is conscious and alert and denies any other symptoms.
Her blood pressure is 134/60 mm Hg, pulse rate is 66 beats/min and strong, and respirations are 14 breaths/min
and unlabored. Her oxygen saturation is 95% on room air and her skin is pink, warm, and dry. You should give
her supplemental oxygen by:

A: nasal cannula at 2 to 4 L/min.

B: bag-mask device.
C: Venturi mask.
D: nonrebreathing mask at 12 L/min.

Answer: A

Although the patient complains of dyspnea, there are no obvious indicators of breathing difficulty (labored
breathing, retractions, or accessory muscle use) or hypoxemia (cyanosis, restlessness, or diaphoresis).
Furthermore, she denies any other symptoms and has a room air oxygen saturation of 95%. It is appropriate to
give her oxygen by nasal cannula at 2 to 4 L/min. You must continue to monitor her clinical status, however,
because it could change. The Venturi mask is rarely used in the prehospital setting; it is more often used when
patients with chronic respiratory diseases require precise oxygen concentrations. In an acute setting, the Venturi
mask is of limited benefit.

51 - A woman who was bitten by fire ants is unresponsive with severe edema to her face and neck and diffuse
hives. Breath sounds are difficult to auscultate and loud inspiratory stridor is noted. You should:

A: insert a supraglottic airway device and give epinephrine by the intramuscular route.
B: insert an oral airway and apply high-flow oxygen by nonrebreathing mask.
C: ventilate her with a bag-mask device and prepare to give her epinephrine.
D: give oxygen by nonrebreathing mask and start at least one large-bore intravenous line.

Answer: C

This patient’s airway is rapidly swelling as evidenced by the markedly diminished breath sounds and loud
inspiratory stridor. She needs immediate treatment or her airway will completely close and she will die.
Ventilate her with a bag-mask device and high-flow oxygen and prepare to administer epinephrine. Patients
with anaphylactic shock and upper airway swelling require endotracheal intubation; a supraglottic airway
device (King LT or CobraPLA) does little to facilitate ventilation in patients with upper airway swelling
because these devices are placed above the glottis.

52 - A young man experienced severe facial trauma. He is unresponsive, has sonorous respirations, and blood
draining from the corner of his mouth. You should:

A: assist his ventilations with a bag-mask device.

B: open his airway with the jaw-thrust maneuver.
C: insert a multilumen or supraglottic airway.
D: suction his oropharynx for up to 15 seconds.

Answer: B

The first step in treating any unresponsive patient is to open the airway. In the trauma patient, use the jaw-thrust
maneuver. Sonorous (snoring) respirations indicate partial obstruction of the airway by the tongue, and are
easily remedied by simply opening the airway. You should then suction the oropharynx of any blood or
secretions and insert a simple airway adjunct (an oral airway in this case). You cannot effectively assess a
patient’s breathing until the airway has been opened and maintained. If the patient is breathing adequately,
apply high-flow oxygen by nonrebreathing mask. Assist the patient’s ventilations if he is breathing
inadequately. If you cannot adequately ventilate the patient with basic means, an advanced airway device
(multilumen airway, supraglottic airway) should be inserted.

53 - An unresponsive 50-year-old man has agonal gasps and a rapid, irregular pulse. You should:
A: position him on his side and closely monitor his airway.
B: insert a nasal airway and give oxygen by nonrebreathing mask.
C: insert an oral airway and ventilate with a bag-mask device.
D: immediately secure his airway with a supraglottic device.

Answer: C

Agonal gasps are slow, shallow, irregular, or occasional gasping breaths. They produce little or no tidal volume,
resulting in little or no minute volume, and must be treated with positive-pressure ventilation. This patient
should initially be treated by maintaining his airway with manual positioning and a simple airway adjunct (oral
or nasal airway) and then by ventilating him with a bag-mask device. Passive oxygenation with a
nonrebreathing mask does not restore adequate minute volume. Insertion of an advanced airway device (ie,
LMA, King LT, Combitube) should not occur until you have restored adequate minute volume with basic
means first; the patient must be preoxygenated. Positioning a patient on his or her side (recovery position) is
appropriate for unresponsive, uninjured patients who are breathing adequately; this patient is clearly not
breathing adequately.

54 - Which of the following clinical presentations is MOST consistent with inadequate ventilation in an adult?

A: Eupneic respirations at a rate of 18 breaths/min

B: Audible rhonchi and flushed skin
C: Respirations of 10 breaths/min and shallow
D: Expiratory wheezing and pink, moist skin

Answer: C

Signs of inadequate ventilation in an adult include a slow ( 20 breaths/min) respiratory rate; a shallow depth of
breathing (reduced tidal volume); a grossly irregular pattern of breathing; a short inhalation time with a
prolonged exhalation time; and altered mental status. Cyanosis may be noted, but this is often a later sign.
Eupnea is defined as a normal rate, depth, and regularity of breathing; therefore, eupneic respirations are normal
respirations. A slow respiratory rate with shallow breathing results in an overall decrease in minute volume.

55 - The nasal turbinates function by:

A: increasing the surface area of the nasal mucosa.

B: acting as tributaries for fluid to and from the Eustachian tubes.
C: trapping bacteria and viruses that may be inhaled.
D: drying air as it enters the body through the nose.

Answer: A

The turbinates are three bony shelves that extend into the nasal passageway. They serve to increase the surface
area of the nasal mucosa, thereby improving filtration, warming, and humidification of inhaled air. As air enters
the body through the nose, it is humidified, not dried. The sinuses trap bacteria and viruses and act as tributaries
for fluid to and from the eustachian tubes.

56 - Hiccoughing, a modified form of breathing, is caused by a sudden:

A: inhalation from spasm of the diaphragm and intermittent spasm of the glottis.
B: exhalation from spasm of the diaphragm and transient relaxation of the glottis.
C: exhalation from relaxation of the diaphragm and transient spasm of the glottis.
D: inhalation from relaxation of the diaphragm and intermittent spasm of the glottis.
Answer: A

Hiccoughing is a modified form of breathing caused by a spasm of the diaphragm that is checked by
intermittent spasm of the glottis. This explains the sudden inhalation with an almost simultaneous, abrupt
stoppage.

57 - Which of the following assessment findings suggests a lower airway obstruction?

A: Inspiratory stridor
B: Supraglottic congestion
C: Coarse basilar rhonchi
D: Snoring on inhalation

Answer: C

The lower airway includes all structures below the vocal cords. Coarse rhonchi, which is a rattling sound,
indicates fluid in the larger lower airways (the larger bronchi); it may be heard at the bases and apices of the
lungs. Inspiratory stridor indicates an upper airway obstruction (foreign body, epiglottitis, or croup). Snoring is
caused by a partial upper airway obstruction, most commonly by the tongue. Supraglottic congestion is caused
by phlegm or other secretions above the level of the vocal cords.

58 - How should you ventilate a patient with suspected acidosis, regardless of the underlying cause?

A: Decreased tidal volume and increased rate

B: Increased tidal volume and decreased rate
C: Increased tidal volume and increased rate
D: Decreased tidal volume and decreased rate

Answer: C

Acidosis, regardless of the underlying cause, is managed initially by increasing the depth (tidal volume) and rate
of ventilations. Respiratory acidosis, for example, is associated with an increased level of carbon dioxide and
hydrogen ions. The quickest way to eliminate these from the body is to ventilate the patient at the proper rate
and with the proper depth. Use caution when ventilating any patient, however, because positive-pressure
ventilation can impair venous return to the heart and reduce cardiac output.

59 - You begin ventilating an apneic patient with a bag-mask device and note minimal rise of his chest with
each ventilation. You should:

A: check for damage to the bag-mask device.

B: insert a supraglottic airway device at once.
C: reposition the patient’s head as needed.
D: suction the patient’s oropharynx thoroughly.

Answer: C

If ventilations with a bag-mask or pocket face mask device produce minimal or no chest rise, your initial action
should be to reposition the patient’s head to ensure that the tongue is not obstructing the airway. You should
routinely insert an oral or nasal airway when ventilating an unresponsive, apneic patient; this, in conjunction
with manual head positioning, is often all that is needed to achieve adequate ventilation. If you are still unable
to ventilate after manually repositioning the patient’s head, you should consider that the patient may have a
foreign body obstruction. Suction the oropharynx if there are obvious secretions in the airway or if you hear
gurgling while ventilating. Insertion of a supraglottic airway device may be a consideration, but not if you are
able to effectively ventilate the patient with basic means.

60 - A 30-year-old woman has shallow respirations of 6 breaths/min after overdosing on heroin. Which of the
following conditions will she develop initially?

A: Metabolic alkalosis
B: Respiratory acidosis
C: Metabolic acidosis
D: Respiratory alkalosis

Answer: B

Slow, shallow respirations (reduced tidal volume) result in carbon dioxide retention, which causes an initial
state of respiratory acidosis. If tidal volume and oxygenation are not improved with assisted ventilation,
anaerobic metabolism occurs at the cellular level, which produces lactic acid. At this point, the patient would
develop metabolic acidosis. The initial treatment for acidosis, regardless of the underlying cause, is to ensure
adequate ventilation and oxygenation.

61 - Which of the following terms related to respiratory quality describes reduced tidal volume?

A: Sighing
B: Noisy
C: Labored
D: Shallow

Answer: D

Tidal volume is the volume of air moved into or out of the respiratory tract in a single breath. Tidal volume is
assessed by noting how visibly the chest rises with inhalation. Reduced tidal volume is evidence by a shallow
depth of breathing. Noisy breathing is an indicator of secretions in the airway or a partial airway obstruction by
a foreign body or swelling. Labored respirations are characterized by an increased work of breathing and are
often associated with accessory muscle use. Sighing is normal, and functions by preventing the alveoli from
collapsing. Healthy people sigh numerous times each minute.

62 - After inserting a supraglottic airway device, you begin to ventilate your patient. After several minutes, you
note decreased compliance with each ventilation. Which of the following could this indicate?

A: The bag-mask device is met with little or no resistance when squeezed.

B: Widespread alveolar collapse has been corrected with ventilation.
C: The lungs are easily ventilated with minimal ventilatory volume.
D: Possible injury or obstruction has made the lungs resistant to ventilation.

Answer: D

Pulmonary compliance is defined as the stiffness or flexibility of the lung tissue. Increased compliance
(decreased resistance) during ventilations indicates that the alveoli in the lungs are expanding easily and the
lung is inflating without difficulty. Decreased compliance (increased resistance) could indicate injury to the
lung (pneumothorax); inability of the alveoli to function normally (pulmonary edema); thick secretions in the
lungs; or obstruction of the upper airway.
63 - You are called for a 49-year-old man with acute shortness of breath. He is conscious, but confused, and is
gasping for air. You apply the pulse oximeter and it reads 84% on room air. Your initial management should
include:

A: inserting an oropharyngeal airway.

B: some form of positive-pressure ventilation.
C: a beta-2 agonist via small-volume nebulizer.
D: high-flow oxygen by nonrebreathing mask.

Answer: B

Gasping for air (air hunger), a pulse oximetry reading of 84%, and a change in mental status (confusion) are
clear signs of inadequate ventilation; therefore, he requires some form of positive-pressure ventilation, such as a
bag-mask device with high-flow oxygen. An oropharyngeal airway is contraindicated because the patient is
conscious and likely has an intact gag reflex. If his level of consciousness deteriorates further, however, you
should insert a nasopharyngeal airway. After restoring adequate ventilation and oxygenation, you may then
continue your assessment. Administer a beta-2 agonist (ie, albuterol, metaproterenol) if wheezing is present.

64 - You are assessing an unresponsive man’s respirations and note that he is taking irregular breaths that vary
in volume and rate, with intermittent periods of apnea. This breathing pattern is MOST consistent with:

A: Cheyne-Stokes respirations.
B: Biot respirations.
C: agonal respirations.
D: Kussmaul respirations.

Answer: B

The pattern of irregular breathing, which varies in depth and rate with intermittent periods of apnea, is referred
to as Biot (ataxic) respirations. This respiratory pattern is commonly seen in patients with increased intracranial
pressure, either from closed head trauma or hemorrhagic stroke. Clearly, patients displaying this respiratory
pattern need ventilatory assistance. Agonal respirations, also called agonal gasps, are characterized by slow,
shallow, irregular breaths. Kussmaul respirations are characterized by deep, rapid breathing, and are classically
seen in patients with diabetic ketoacidosis. Cheyne-Stokes respirations are characterized by a gradually
increasing rate and depth of breathing, followed by a gradual decrease, with periods of apnea.

65 - When using continuous positive airway pressure (CPAP) to treat a patient with respiratory distress, it is
important for the AEMT to remember that:

A: Any form of positive-pressure ventilation can cause a marked increase in blood pressure because of
decreased intrathoracic pressure.
B: Patients receive the most benefit from CPAP during the inhalation phase because it causes a marked increase
in tidal volume.
C: CPAP may improve the patient’s ventilation and oxygenation status, but does not treat the underlying cause
of the respiratory distress.
D: Most patients who require CPAP therapy require endotracheal intubation to treat the underlying cause of
their respiratory distress.
Answer: C

CPAP is used to treat the signs and symptoms of respiratory distress and to improve the patient’s ventilation and
oxygenation status. However, it does not treat the underlying cause of the patient’s respiratory distress. This
requires assessment by a physician and further diagnostic testing. Patients benefit from CPAP during the
exhalation phase, when positive-pressure is transmitted to the lower airways, forcing fluid from the alveoli and
dilating the bronchioles. CPAP has been shown to greatly reduce the need for endotracheal intubation, although
not in all cases. Any form of positive-pressure ventilation can cause a decrease in blood pressure secondary to
an increase in intrathoracic pressure, which can impair venous return to the heart (preload) and decrease cardiac
output.

66 - In which of the following situations is the nasopharyngeal airway contraindicated?

A: Penetrating trauma to the neck.

B: Blunt force trauma to the midface.
C: Unresponsive patient with a spinal injury.
D: Semiconscious patient with a gag reflex.

Answer: B

The nasopharyngeal (nasal) airway is contraindicated in patients with a severe head injury, especially when
blood or pink fluid is draining from the nose. It is also contraindicated in patients with a nasal fracture, which
should be suspected in patients who experience blunt force trauma to the midface region. Midface fractures may
also involve fractures of the cribriform plate; if a nasal airway is inserted, it may inadvertently enter the cranial
vault through the fractured plate. The nasal airway can be used in semiconscious or unconscious patients with or
without a gag reflex. It is not contraindicated in patients with a spinal injury.

67 -You are caring for a 33-year-old man with blunt head trauma. The patient is unresponsive and has slow,
irregular breathing. Further assessment reveals that he has bloody fluid draining from his nose. The MOST
appropriate airway management for this patient includes:

A: slightly extending his head, inserting an oropharyngeal airway, and ventilating him at a rate of 24
breaths/min.
B: keeping his head in a neutral position, inserting a nasopharyngeal airway, and ventilating him.
C: manually stabilizing his head, inserting an oropharyngeal airway, and ventilating him with a bag-mask
device.
D: flexing his neck slightly, inserting a multilumen airway device, and hyperventilating him.

Answer: C

You must assume that any patient with significant head trauma also has an accompanying spinal injury. In this
patient, the most appropriate airway management involves manually stabilizing his head in a neutral position,
inserting an oropharyngeal airway, and ventilating him at a rate of 10 to 12 breaths/min. Do not flex or extend
the patient’s neck, even slightly, because this may exacerbate an existing spinal injury. The nasopharyngeal
airway is contraindicated in patients with a head injury, especially when there is fluid drainage from the nose.
Hyperventilation is not routinely performed in patients with a head injury unless signs of brain herniation are
present (decerebrate posturing or unequal pupils).

68 - After inserting a King LT airway device into an unresponsive, apneic 25-year-old man, you resume
ventilations at a rate of 28 breaths/min. During your reassessment, you note that his blood pressure has dropped
from 114/66 mm Hg to 90/52 mm Hg. Which of the following has MOST likely caused this patient’s blood
pressure to drop?
A: Increased intrathoracic pressure from hyperventilation has impaired venous return to the heart.
B: The King airway has inadvertently entered the trachea, resulting in a complete lack of ventilation.
C: Decreased intrathoracic pressure has caused a drop in cardiac output, thus lowering the blood pressure.
D: Gastric distention has placed pressure on the abdominal aorta, resulting in a drop in cardiac output.

Answer: A

One of the dangers of hyperventilation is decreased cardiac output (and blood pressure) secondary to increased
intrathoracic pressure. When the lungs are hyperinflated, they literally squeeze the heart, thus impairing the
amount of blood that returns to it from the body (preload). It is important to ventilate the patient at the
appropriate rate. If the adult patient is apneic and has a pulse, give one breath every 5 to 6 seconds (10 to 12
breaths/min). If any patient (adult, child, or infant) is pulseless and apneic, you should deliver one breath every
6 to 8 seconds (8 to 10 breaths/min) after an advanced airway device has been inserted.

69 - The entire process of inhalation is focused on:

A: delivering oxygen to the alveoli.

B: removing carbon dioxide from the body.
C: delivering oxygen to the cells.
D: removing carbon dioxide from the cells.

Answer: A

The process of inhalation (inspiration) has one focus: to deliver oxygen to the alveoli. As oxygen diffuses into
the alveoli, carbon dioxide diffuses out of the alveoli and is eliminated from the body during exhalation
(expiration). This process of gas exchange in the lungs is called pulmonary (external) respiration. The process
of delivering oxygen to and removing carbon dioxide from the tissues and cells of the body is called cellular
(internal) respiration.

70 - Fraction of inspired oxygen (FiO2) is defined as the:

A: amount of air that can be inspired in addition to tidal volume.

B: pressure of oxygen in the blood plasma.
C: amount of air that reaches the alveoli and participates in respiration.
D: percentage of oxygen in inspired air.

Answer: D

FiO2 is the percentage of oxygen in inspired air; it is documented as a decimal (1 = 100%, 0.9 = 90%, and so
forth). The pressure of oxygen in the blood plasma is called the partial pressure; it is measured in millimeters of
mercury (mm Hg), or torr. The volume of air that can be inspired in addition to tidal volume is called
inspiratory reserve volume. The volume of air that reaches the alveoli and participates in pulmonary respiration
is called alveolar volume.

71 - Which of the following is the MOST effective way to minimize gastric distention when ventilating an
apneic adult with a bag-mask device?

A: Ventilate the patient with the head slightly flexed.

B: Deliver each ventilation over a period of 1 second.
C: Consistently deliver one breath every 3 to 5 seconds.
D: Manually decompress the stomach every 2 minutes.
Answer: B

To minimize the incidence of gastric distention while ventilating an apneic adult with a bag-mask device, you
should deliver each breath over a period of 1 second (just enough to produce visible chest rise), and deliver
ventilations at the appropriate rate (one breath every 5 to 6 seconds [10 to 12 breaths/min]). Manual gastric
decompression, which involves applying manual pressure to the epigastrium, is dangerous and should be
avoided. It will cause the patient to regurgitate, thus significantly increasing the risk of aspiration. The ONLY
indication for manual gastric decompression is if gastric distention is so severe that it makes ventilation
impossible and a paramedic is not present to insert a gastric tube.

72 - Which of the following describes the Hering-Breuer reflex?

A: A lack of oxygen at the cellular level causes the cells to metabolize carbon dioxide, resulting in lactic acid
production.
B: Stretch receptors in the lungs send a signal to the apneustic center in the brain to inhibit the inspiratory
center.
C: An irritant in the upper airway causes closure of the glottis as a protective mechanism to prevent aspiration.
D: An increase in the rate and depth of breathing occurs when the arterial level of carbon dioxide increases.

Answer: B

The Hering-Breuer reflex is a protective mechanism that prevents overexpansion of the lungs. As the chest
expands, mechanical stretch receptors in the lungs send a signal to the apneustic center in the brain via the
vagus nerve to inhibit the inspiratory center; as a result, exhalation occurs. Closure of the glottis because of an
irritant in the upper airway is called laryngospasm. An increase in the arterial level of carbon dioxide and a
decrease in the pH of the cerebrospinal fluid cause an increase in respiratory rate and depth; this is called the
primary respiratory drive. Anaerobic metabolism occurs when the cells do not receive adequate oxygen. As a
result, they do not completely convert glucose into energy and metabolize carbon dioxide. The by-product of
anaerobic metabolism is lactic acid.

73 - You and your AEMT partner are standing by at the scene of a structural fire when one of the firefighters
approaches you in obvious respiratory distress. He entered the structure without a self-contained breathing
apparatus and inhaled a lot of smoke. He is conscious and alert and in moderate respiratory distress. His blood
pressure is 156/90 mm Hg; pulse is 120 beats/min and strong; and respirations are 24 breaths/min and labored.
The pulse oximeter reads 93% on room air. Given his clinical presentation, the MOST appropriate method of
oxygen delivery for him involves:

A: a simple facemask at 10 L/min.

B: a nasal cannula at 2 to 6 L/min.
C: a nonrebreathing mask at 12 to 15 L/min.
D: assisted ventilation with a bag-mask device.

Answer: C

A room air oxygen saturation of 93% indicates mild hypoxemia. Because the patient is conscious, alert, and not
showing any obvious signs of inadequate breathing (shallow [reduced tidal volume] breathing or two-word
dyspnea), a nonrebreathing mask set at 12 to 15 L/min is the most appropriate initial method of oxygen
delivery. You must carefully monitor his clinical status, however, and be prepared to assist his ventilations if his
oxygen saturation continues to fall despite high-flow oxygen or if his breathing becomes inadequate.
74 - Ventilation is defined as:

A: delivery of oxygen at the cellular level.

B: the exchange of gases within the lungs.
C: the removal of carbon dioxide from the body.
D: movement of air in and out of the lungs.

Answer: D

Ventilation is defined as the movement of air into and out of the lungs and consists of an inhalation and
exhalation phase. Respiration is defined as the exchange of gases between a living organism and its
environment (oxygen and carbon dioxide). The delivery of oxygen at the cellular level is part of cellular
(internal) respiration, whereas the exchange of gases in the lungs, including elimination of carbon dioxide from
the body, is called pulmonary (external) respiration.

75 - A man was injured when his tractor overturned, pinning him underneath it. Your primary assessment
reveals that he is responsive to pain only. You should:

A: maintain his airway in an open position and ventilate him with a bag-mask device
B: carefully perform the head tilt-chin lift maneuver and suction his oropharynx.
C: apply oxygen by nonrebreathing mask and assess him for life-threatening injuries.
D: open his airway with the jaw-thrust maneuver and insert a simple airway adjunct.

Answer: D

When treating any injured patient with a decreased level of consciousness, your first action should be to
manually stabilize the head; open the airway with the jaw-thrust maneuver; and insert a simple airway adjunct
(oral or nasal airway) to maintain airway patency. If you are unable to open the airway with the jaw-thrust
maneuver in an injured patient, you should carefully perform the head tilt-chin lift maneuver. After ensuring a
patent airway, assess the patient’s breathing and treat accordingly. If the patient has adequate breathing,
administer high-flow oxygen by nonrebreathing mask. If the patient is not breathing adequately or is apneic,
begin positive-pressure ventilations. The airway should be suctioned only if blood or other secretions are in the
mouth; routine suctioning is not indicated.

76 - During your primary assessment of a 49-year-old man with chest pressure, you note that his respirations are
eupneic. This means that:

A: supplemental oxygen is likely not indicated.

B: he has a grossly irregular respiratory pattern.
C: he requires positive-pressure ventilation.
D: his respiratory rate and depth are normal.