Adjunct Medications and Special Situations Practice Questions

25 multiple-choice questions on Adjunct medications and special situations for paramedic and EMT students, from Chapter 26 (Immunologic Emergencies). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. Before you arrive, a patient with a peanut allergy took oral diphenhydramine for hives. Her hives are fading, but she now has a hoarse voice. You should:

   1. A. Give epinephrine; it is worsening
   2. B. Reassure her that the drug is working
   3. C. Give a second dose of diphenhydramine
   4. D. Wait to see if the hoarseness clears
   Show answer

   Answer: A. Give epinephrine; it is worsening

   Antihistamines can quiet the skin signs while airway swelling progresses, which can falsely reassure everyone. A new hoarse voice means laryngeal involvement, so give IM epinephrine. Repeating the antihistamine does not treat the airway.

2. During a dental procedure with lidocaine and epinephrine, a patient has palpitations, tremor, and anxiety. There are no hives, wheezing, or swelling, and her BP is 148/90. The most likely cause is:

   1. A. Anaphylaxis to lidocaine
   2. B. The added epinephrine
   3. C. A vasovagal faint
   4. D. Hereditary angioedema
   Show answer

   Answer: B. The added epinephrine

   Dental anesthetic often contains epinephrine, and injection into a small vessel can cause brief palpitations, tremor, anxiety, and a rise in BP. True allergy to amide local anesthetics such as lidocaine is rare and would cause hives, swelling, wheezing, or hypotension. A vasovagal faint causes a slow pulse and low BP.

3. Ten minutes after an allergy shot at a clinic, a patient has hives, wheezing, and a BP of 84/52. This most likely represents:

   1. A. A vasovagal reaction to the needle
   2. B. A local reaction at the injection site
   3. C. Serum sickness from the injection
   4. D. Anaphylaxis to the injected allergen
   Show answer

   Answer: D. Anaphylaxis to the injected allergen

   Allergen immunotherapy injects small amounts of the very allergen the patient reacts to, so systemic reactions can occur, usually within 30 minutes. That is why patients wait in the clinic after each shot. Hypotension with hives and wheezing is anaphylaxis: give IM epinephrine. Vasovagal reactions cause a slow pulse without hives.

4. A woman has had itchy hives on most days for 3 months, with no swelling, breathing trouble, or dizziness. Today's hives look the same as usual. This most likely represents:

   1. A. Anaphylaxis that needs epinephrine right now
   2. B. A hereditary angioedema attack
   3. C. Chronic hives, usually not dangerous
   4. D. An early sign of sepsis
   Show answer

   Answer: C. Chronic hives, usually not dangerous

   Hives on most days for more than 6 weeks are chronic urticaria, which is usually not caused by a single allergen and rarely progresses to anaphylaxis. Without airway, breathing, circulation, or GI signs, epinephrine is not needed; she should follow up with her doctor. Hereditary angioedema causes swelling without hives.

5. A patient premedicated with prednisone and diphenhydramine before a CT scan with contrast still develops hives and wheezing. You should:

   1. A. Treat as anaphylaxis with epinephrine
   2. B. Assume the premedication will control it
   3. C. Give more prednisone and wait
   4. D. Treat it as a mild skin reaction
   Show answer

   Answer: A. Treat as anaphylaxis with epinephrine

   Premedication lowers the rate of contrast reactions but does not prevent them all, and breakthrough reactions can be severe. Hives plus wheezing is a systemic reaction, and steroids take hours to work, so give IM epinephrine.

6. Corticosteroids in anaphylaxis are given to:

   1. A. Reverse shock within minutes
   2. B. Possibly reduce late reactions
   3. C. Open the airway rapidly
   4. D. Replace epinephrine
   Show answer

   Answer: B. Possibly reduce late reactions

   Steroids take hours to work. Their role in preventing biphasic reactions is uncertain.

7. A commonly used corticosteroid in anaphylaxis is:

   1. A. Albuterol sulfate
   2. B. IV glucagon
   3. C. Oral ondansetron
   4. D. Methylprednisolone
   Show answer

   Answer: D. Methylprednisolone

   Typical doses are 125 mg IV in adults.

8. A teen with peanut allergy gets omalizumab injections, which reduce IgE activity. After accidentally eating peanut, she has hives and wheezing. You should:

   1. A. Withhold epinephrine; the drug protects her
   2. B. Give antihistamines and observe
   3. C. Give epinephrine as for any anaphylaxis
   4. D. Give her next omalizumab dose early
   Show answer

   Answer: C. Give epinephrine as for any anaphylaxis

   Omalizumab raises the amount of allergen needed to trigger a reaction, but it does not make reactions impossible. When a reaction happens, it is treated the usual way, with IM epinephrine first. Patients on omalizumab must still carry epinephrine. The drug works over weeks, so an early dose does nothing now.

9. During transfer of a sedated, intubated patient, an IV antibiotic is started. Minutes later, ventilation pressures rise, wheezes are heard on both sides, the BP falls, and the chest is flushed. You should suspect:

   1. A. A right tension pneumothorax
   2. B. Anaphylaxis to the antibiotic
   3. C. A kinked endotracheal tube
   4. D. Hypotension from the sedative
   Show answer

   Answer: B. Anaphylaxis to the antibiotic

   Sedated patients cannot report itching or throat tightness, so anaphylaxis shows up as rising airway pressures, bronchospasm, hypotension, and skin changes after a new drug. Stop the drug and give epinephrine. A tension pneumothorax gives one-sided findings, and a kinked tube does not cause flushing or low BP.

10. Patients taking ACE inhibitors may have:

    1. A. More severe reactions
    2. B. Protection against angioedema
    3. C. Milder hypotension
    4. D. Higher BP during reactions
    Show answer

    Answer: A. More severe reactions

    ACE inhibitors interfere with bradykinin breakdown, possibly worsening swelling and hypotension. ACE inhibitors raise the risk of angioedema rather than protect against it. Blood pressure tends to fall further, so hypotension is worse rather than milder.

11. Refractory anaphylaxis is defined as:

    1. A. Symptoms that come back several hours later
    2. B. Anaphylaxis with no known trigger
    3. C. No response to repeated epinephrine
    4. D. A reaction without skin signs
    Show answer

    Answer: C. No response to repeated epinephrine

    Consider an epinephrine infusion, aggressive fluids, glucagon if on beta blockers, and vasopressors. Symptoms that return hours later describe a biphasic reaction. Anaphylaxis with no trigger is idiopathic, and a reaction without skin signs is still ordinary anaphylaxis if it responds to epinephrine.

12. Which vasopressor may be used for persistent hypotension after epinephrine and fluids?

    1. A. Sublingual nitroglycerin
    2. B. Furosemide
    3. C. Labetalol
    4. D. Norepinephrine
    Show answer

    Answer: D. Norepinephrine

    Follow local protocol and consult medical control.

13. In pregnant patients with anaphylaxis, epinephrine should be:

    1. A. Withheld to protect the fetus
    2. B. Given as usual
    3. C. Given only IV
    4. D. Replaced by antihistamines
    Show answer

    Answer: B. Given as usual

    Treating the mother is the best way to protect the fetus. Place her left lateral if hypotensive.

14. A patient in anaphylactic shock is lying flat with her legs raised, then starts vomiting. You should:

    1. A. Sit her fully upright to vomit
    2. B. Raise her head and keep her face-up
    3. C. Roll her onto her side, still flat
    4. D. Lift her legs higher and keep her face-up
    Show answer

    Answer: C. Roll her onto her side, still flat

    Patients in anaphylactic shock should stay horizontal, because sitting or standing up can cause sudden collapse. If she vomits, turn her onto her side while keeping her body flat to protect the airway. A pregnant patient goes onto her left side. Keeping her face-up, whether the head is raised or the legs are raised higher, leaves vomit in the airway.

15. Elderly patients with heart disease in anaphylaxis should:

    1. A. Receive half-dose epinephrine by mouth
    2. B. Receive antihistamines instead
    3. C. Receive steroids instead
    4. D. Still receive epinephrine
    Show answer

    Answer: D. Still receive epinephrine

    The benefit of epinephrine outweighs cardiac risk.

16. In cardiac arrest from anaphylaxis, you should:

    1. A. Follow ACLS with aggressive fluids
    2. B. Give antihistamines and steroids instead
    3. C. Withhold epinephrine during CPR
    4. D. Restrict IV fluids to prevent edema
    Show answer

    Answer: A. Follow ACLS with aggressive fluids

    Large-volume fluid resuscitation and airway management are key.

17. At a vaccine clinic, a patient with no allergy history gets a routine vaccine. To watch for anaphylaxis, the patient is usually observed for:

    1. A. 2 to 3 minutes
    2. B. 2 hours
    3. C. 24 hours
    4. D. 15 minutes
    Show answer

    Answer: D. 15 minutes

    CDC advises observing vaccine recipients for 15 minutes, and 30 minutes for those with a history of anaphylaxis, because most vaccine anaphylaxis begins within that window. Vaccination sites must have epinephrine ready.

18. Nebulized epinephrine may help in anaphylaxis by:

    1. A. Replacing IM epinephrine
    2. B. Reducing upper airway swelling
    3. C. Treating the low blood pressure
    4. D. Preventing biphasic reactions
    Show answer

    Answer: B. Reducing upper airway swelling

    It is an adjunct for stridor and does not replace IM epinephrine.

19. Ondansetron may be given in anaphylaxis to treat:

    1. A. Bronchospasm and wheezing
    2. B. Hypotension and shock
    3. C. Nausea and vomiting
    4. D. Urticaria and itching
    Show answer

    Answer: C. Nausea and vomiting

    It is symptomatic treatment only.

20. A 74-year-old taking apixaban is in anaphylaxis with wheezing and a BP of 82/48. Regarding IM epinephrine, you should:

    1. A. Give it IM in the thigh as usual
    2. B. Give it subcutaneously instead
    3. C. Wait for IV access to avoid IM
    4. D. Withhold it due to bleeding risk
    Show answer

    Answer: A. Give it IM in the thigh as usual

    Anticoagulation slightly raises the chance of a bruise at the injection site, but that is minor next to untreated anaphylaxis. Give the usual IM dose and hold pressure afterward. Subcutaneous injection absorbs more slowly, and waiting for IV access delays treatment.

21. A runner with known food-dependent, exercise-induced anaphylaxis feels itchy and flushed halfway through a run. She should first:

    1. A. Finish the run at a faster pace
    2. B. Stop running and rest right away
    3. C. Slow to a walk and keep going
    4. D. Drink a sports drink and continue
    Show answer

    Answer: B. Stop running and rest right away

    Exercise is the cofactor, so stopping at the first symptom can keep the reaction from progressing. If she develops breathing, throat, or circulation symptoms, she needs epinephrine. Continuing to exercise, even at a slower pace, can push the reaction toward shock.

22. A child had anaphylaxis after eating a packaged snack at a party. Bringing the wrapper to the hospital helps mainly by:

    1. A. Proving the store was at fault
    2. B. Letting staff calculate a dose
    3. C. Allowing the lab to test for bacteria
    4. D. Identifying the likely allergen
    Show answer

    Answer: D. Identifying the likely allergen

    The ingredient list and allergen warnings help the hospital and the allergist pin down the trigger, which guides avoidance and later testing. The wrapper is not used for dosing or for assigning blame.

23. After anaphylaxis treatment, patients are usually observed in the hospital for at least:

    1. A. 15 to 30 minutes
    2. B. 30 to 60 minutes
    3. C. 4 to 6 hours
    4. D. 1 week
    Show answer

    Answer: C. 4 to 6 hours

    Patients with severe reactions may be observed longer.

24. Patients discharged after anaphylaxis should be prescribed:

    1. A. An epinephrine auto-injector
    2. B. An albuterol inhaler instead
    3. C. A daily antihistamine instead
    4. D. An oral steroid taper instead
    Show answer

    Answer: A. An epinephrine auto-injector

    They should also be referred to an allergist and taught to avoid the trigger. Albuterol, antihistamines, and steroids can help with symptoms but cannot replace epinephrine for a future reaction.

25. A playful 4-year-old on day 8 of amoxicillin develops a flat, blanching red rash over the trunk. Vital signs are normal, and there is no swelling, wheezing, or vomiting. This is most likely:

    1. A. Anaphylaxis needing epinephrine now
    2. B. A delayed, non-urgent drug rash
    3. C. Meningococcal sepsis
    4. D. Hereditary angioedema
    Show answer

    Answer: B. A delayed, non-urgent drug rash

    Flat rashes that appear days into a course of amoxicillin are common in children and are usually delayed, non-IgE reactions. With normal vital signs and no airway, breathing, or GI symptoms, this is not anaphylaxis. The child should see a clinician about the drug. A nonblanching rash with fever would raise concern for meningococcemia.