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By Dan Limmer

AEMT and paramedic students now have new question styles on the cognitive exam. While these are likely only in the pilot phase for some time, the appearance of these questions shouldn’t be a surprise to your students.

Look for this on the NREMT website.

This new style involves a series of questions based on an ongoing scenario. If you aren’t familiar with the new questions, use this link, and then go to the “Quick Links” section on the right side of the page. Click on “NEW! Experience an interactive performance scenario.”

Once you have gone through this experience, your first thought may be, “How can I possibly do this on my exams?” The NREMT uses a lot of drag and drop functionality to place things in order procedurally or to set priorities using clinical judgment.

Using multiple questions based on a single scenario was out of fashion for some time. It is obvious that it is back with a vengeance in this new model. Let’s take a look at how we can prepare our students for these questions.

Note: As of June 1, 2023, our apps AEMT Review, AEMT PASS, Paramedic Review, and Paramedic PASS all contain performance scenarios in the test module. In each AEMT app, there is one scenario consisting of 10-12 questions. In each paramedic app, there are two scenarios consisting of 10-12 questions each.

All our apps are regularly updated to keep up with AHA guidelines, NREMT changes, and EMS best practices. Updates are automatically rolled out to any apps your students have on LC-Ready or mobile devices.

NREMT Sequencing Questions

You can create sequencing questions without technology—and even keep using your ZipGrade or other bubble grading sheets. The key is to be straightforward and unambiguous. Here are two examples: the first one good, and the second with pitfalls.

Good Example of a Sequencing Question

A 54-year-old patient with a history of angina is experiencing chest discomfort and mild respiratory distress. She states the pain is 5 on the 0 – 10 scale, her skin is cool and moist, and SpO2 is 95%. Place the following actions in the order you would perform them.

1.) Administer nitroglycerin if indicated
2.) Administer aspirin
3.) Obtain a blood pressure
4.) Administer oxygen

Answer Choices:

A.)  2, 3, 1, 4
B.)  4, 3, 1, 2
C.)  4, 3, 2, 1
D.)  3, 1, 4, 2

The correct answer to this question is choice A. Aspirin is the first thing to do. There is no need to check blood pressure before aspirin is given. You would check the blood pressure before nitroglycerin and then give that if indicated. The patient has a saturation of 95%, but their skin color is poor, and they have some respiratory distress, so oxygen, if given, would be a lower priority.

Structure your answers so that the most appealing choices have more than one distractor starting the sequence. In this question, we have one that starts with checking blood pressure (something people would falsely believe) and two for oxygen administration (another common fallback choice).


You can see how subjectivity could sneak in. Creating these exam items and having other faculty members review them is helpful. Have your own item writing session. Be careful. One of the pitfalls of this process is ending up with questions that have a minimal difficulty level. This is because taking everyone’s feedback often dilutes the difficulty level of the question.

Problematic Example of a Sequencing Question

There are questions to avoid. Here is an example of a question with subjectivity that makes it invalid.

Which of the following conditions is most serious?

1.) Status asthmaticus
2.) Cardiac arrest
3.) Anaphylaxis
4.) Status epilepticus

Answer Choices:

A.)  1, 2, 3, 4
B.)  4, 3, 2, 1
C.)  2, 3, 1, 4
D.)  2, 3, 4, 1

This question can’t be answered with any certainty. You can see what the educator was going for in determining severity, but there is too much subjectivity in choosing the correct sequencing.

Multiple Questions Based on a Single Scenario

national registry flow chart showing the pathway that new scenario questions will follow

Source: NREMT.org

screenshot of LC-Ready app (paramedic review plus) showing two new butttons in the testing menu. Buttons say "NREMT Performance Scenario"

Scenario questions are part of our AEMT & paramedic NREMT prep apps

We don’t recommend building a question scheme as complicated as the NREMT in the beginning. Creating a scenario with 2 – 4 questions is a good start. Remember that the goal is to familiarize your students with scenarios where they are required to complete multiple questions. There are a few critical skills they need to master, namely reading carefully and either remembering information or going back to the original scenario as necessary. We are concerned about how this will affect poor readers or those with significant attention span issues when they take the NREMT cognitive exam.

There are a few basic rules when creating multiple items based on the same stem. These include ensuring that each question stands independently without affecting other questions. Avoid situations where getting one question wrong causes the student to get subsequent questions wrong. Also, be sure to give enough information in the stem, but not too much. This is always a concern, but here the tendency may be to use more information.

You can download a sample set of scenario-based questions here.

thumbnail for sample exam style for new NREMT sequencing questions

Click for the test question sample set

The NREMT has taken an uncharacteristically flowery style in the new interactive performance scenario exams. Very different than the minimalist approach to their individual items. Those of you who have worked with the integrated out-of-hospital scenario and oral stations in the paramedic psychomotor exam will find the content and approach very similar. This material in written format is another reason we are concerned about students reading the questions. In the actual questions, there are three tabs of escalating information. This is a lot to remember and process.

In seminars presented by the NREMT in the past, they stated that these new items could potentially increase the time students need to take the exam. This adds another layer of difficulty and difference between the current and future exams. We believe that the process and item types used by the NREMT will successfully meet their goal of sunsetting the psychomotor exam on June 30, 2024. Still, as educators, we must do our share to prepare students for the different types of items, a more complex presentation, and ultimately a longer examination.

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