Paramedic Practice for the National Registry

Earlier this month we were at the annual National Association of EMS Educators symposium, where we were able to talk to and learn from educators all over the country. For each of the three days in the exhibit hall, we had a paramedic-level NREMT-style question posted at our booth.

Some were more straightforward than others, but each question was a great exercise in critical thinking. We’re going to take those same questions and break them down for you here.

Choosing the Best Answer on the NREMT

We’ve done these questions at other conferences, and it’s always fun to hear people debate about what the answer is and pick apart the question stem. This is exactly what you should do when approaching NREMT questions! Don’t just read it and pick your answer immediately. Read two or three times, make sure you understand all the little pieces of information it’s giving you. Then go through the answer choices one by one and determine which one is the best fit.

Remember, the “best answer” on an exam is sometimes not what you think you might do in real life. In real life, you might have another EMS provider to help you, you might be able to gather more information about the patient’s condition as you work, and you might have state or local protocols to abide by. The National Registry doesn’t care about your local protocols and it doesn’t want you to assume information that isn’t there, like having a partner.

Let’s take a look at each of our questions and the answer rationales.

Paramedic Exam Practice Questions

These were all taken directly from our Paramedic PASS app. The questions in Paramedic PASS were developed by Bill Brown, former executive director of the NREMT, and Todd Vreeland, former exam coordinator for the NREMT. Question style and reasoning process closely resembles that of the National Registry.

First Question: Shortness of Breath When Sleeping

A 67 year old male complains of a sudden onset shortness of breath when sleeping. He tells you he had a heart attack six months ago. His skin is diaphoretic. His vital signs are P 118, R 26 and labored, BP 126/86, and SpO2 is 88% on room air. You should:

a. apply continuous positive airway pressure.

b. assist his ventilations with a BVM.

c. establish IV access and administer a fluid bolus.

d. administer oxygen by non-rebreather mask.

The best answer is A, apply continuous positive airway pressure.

Rationale: 

The patient awoke short of breath and has a history of a recent heart attack. He is diaphoretic and has a low oxygen saturation. All of these point in the CPAP direction. You wouldn’t give him fluid. He doesn’t need ventilation yet and oxygen by NRB doesn’t fix the problem.

We were able to watch and listen to educators as they made their choice. Some asked us questions. “Does he have rales?” or “Does he sleep on a lot of pillows?” But you can’t ask the National Registry paramedic exam for extra information!

Others went a bit more with the mantra, “Always start with oxygen.” Not a successful strategy. Oxygen isn’t always the answer when CPAP will fix the problem. Why put an NRB on when you’ll soon take it off for the CPAP?

What’s the patient’s real problem? He has fluid in his lungs. It woke him up from sleep—a classic presentation. If we (or the NREMT) gave additional information like lung sounds or orthopnea, it would be too easy. This question was looking for us to put the pieces together and choose the answer that fixes the problem.

Second Question: Abdominal Pain

A 58 year old male complains of abdominal pain. He tells you he’s had nausea and has been vomiting. His skin feels hot to touch. He points to his left lower abdominal quadrant when you ask him where it hurts the most. His vital signs are P 94, R 16, BP 132/88, and SpO2 is 97% on room air. You should suspect:

a. peritonitis.
b. diverticulitis.
c. ulcerative colitis.
d. renal calculi.

The best answer is B, diverticulitis.

Rationale:

Third Question: Bee Sting

This one was our most difficult and most controversial question. It certainly sparked a lot of debate, both in the exhibit hall and online when the answer was posted. Here it is:

A 42 year old male was hiking when he was stung by a bee. When you arrive, he has self-administered an epinephrine auto-injector. He is short of breath, has facial edema, and a hoarse voice. His vital signs are P 116, R 22 and labored, BP 100/78, and SpO2 is 90% on room air. You should first:

a. administer oxygen by non-rebreather mask.

b. administer epinephrine IV push.

c. obtain IV access and provide a fluid bolus.

d. perform endotracheal intubation.

The best answer is D, perform endotracheal intubation.

Rationale:

Look at the signs this patient is exhibiting: short of breath, facial edema, hoarse voice. These signs, much more than his vitals, tell you where the urgency is. His airway is closing.

The non-rebreather mask will increase the oxygen saturation, so A isn’t a bad choice. A lot of conference-goers even said they’d administer oxygen while preparing to intubate. But the question says, “You should first” and you can only pick one answer on the National Registry. So think about the task that addresses the most urgent issue. What’s going to kill the patient first? In this case, it’s that closing airway. Take care of that before anything else.

A lot of people want to say “BLS before ALS” on this one. While it’s a good rule of thumb, “always” and “never” rules can be traps that distract from the best choice.

Epinephrine on its own isn’t a bad idea, but you wouldn’t do an IV push in this situation. At some point, you probably will obtain IV access and provide a fluid bolus, but not yet. And definitely not first.

Paramedic PASS

The Paramedic PASS app puts medic students through topical reviews and exams that are tough. It’s a valuable study tool for the NREMT exam, but the challenging scenarios and critical thinking that they require will make you a better provider, too. The app contains 500 questions on 10 major areas of study, including pharmacology, immunology and infectious diseases.

Not at the paramedic level yet? We also have EMT PASS and AEMT PASS.