Analgesia, Sedation, and Nausea Practice Questions

76 multiple-choice questions on Analgesia, sedation, and nausea for paramedic and EMT students, from Chapter 15 (Emergency Medications). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

76 practice questions

1. Fentanyl comes as 50 mcg/mL. What volume delivers a 75-mcg dose?

   1. A. 0.15 mL
   2. B. 15 mL
   3. C. 1.5 mL
   4. D. 7.5 mL
   Show answer

   Answer: C. 1.5 mL

   75 mcg divided by 50 mcg/mL = 1.5 mL. 0.15 mL (7.5 mcg) and 15 mL (750 mcg) are tenfold errors. 7.5 mL treats the dose in milligrams-style units and would deliver 375 mcg, five times the order.

2. A typical adult IV fentanyl analgesic dose is approximately:

   1. A. 250 to 500 mcg, titrated to effect
   2. B. 5 to 10 mcg, given once only
   3. C. 1 to 2 mg, titrated to effect
   4. D. 25 to 100 mcg, titrated to effect
   Show answer

   Answer: D. 25 to 100 mcg, titrated to effect

   Follow local protocol and titrate slowly.

3. After 2 mg of IV midazolam for cardioversion, an 84-year-old becomes more agitated, confused, and combative. What is the most likely explanation?

   1. A. A paradoxical reaction to midazolam
   2. B. An allergic reaction needing epinephrine
   3. C. Too little midazolam; give 5 mg more
   4. D. Opioid withdrawal; give fentanyl
   Show answer

   Answer: A. A paradoxical reaction to midazolam

   Benzodiazepines can cause paradoxical agitation and disinhibition, especially in older adults and children; giving more tends to worsen it, so stop, reassess (hypoxia, glucose), and consult medical control. Escalating the dose risks oversedation. Nothing suggests opioid withdrawal or allergy.

4. Ketamine at analgesic doses:

   1. A. Is contraindicated for traumatic pain
   2. B. Relieves pain at doses below those for sedation
   3. C. Requires intubation before it can be given
   4. D. Causes deep dissociative sedation at any effective dose
   Show answer

   Answer: B. Relieves pain at doses below those for sedation

   It is useful when hypotension limits opioid use.

5. When nitrous oxide is used in the ambulance, which measure protects the crew?

   1. A. Scavenging; ventilating the cab
   2. B. Holding the mask for the patient
   3. C. Wearing surgical masks while it runs
   4. D. Keeping the cab closed and warm
   Show answer

   Answer: A. Scavenging; ventilating the cab

   Exhaled nitrous oxide builds up in a closed patient compartment, so a scavenging circuit and the exhaust fan or open ventilation limit crew exposure (a particular concern for pregnant providers). A closed cab concentrates the gas, and surgical masks do not filter anesthetic gases.

6. Nitrous oxide is contraindicated in patients with:

   1. A. Renal colic with severe flank pain
   2. B. Partial-thickness burns of the extremities
   3. C. Suspected pneumothorax or bowel obstruction
   4. D. Isolated extremity fractures or dislocations
   Show answer

   Answer: C. Suspected pneumothorax or bowel obstruction

   It diffuses into and expands air-filled spaces. Decompression sickness is also a contraindication.

7. Ondansetron is used to:

   1. A. Sedate agitated or combative patients
   2. B. Relieve moderate to severe pain
   3. C. Reverse opioid respiratory depression
   4. D. Treat nausea and vomiting
   Show answer

   Answer: D. Treat nausea and vomiting

   Typical adult dose is 4 mg IV or orally disintegrating. Ondansetron is used both to prevent and to treat nausea and vomiting.

8. Acetaminophen and ibuprofen are useful in EMS for:

   1. A. Severe pain from major trauma
   2. B. Mild to moderate pain and fever
   3. C. Procedural sedation in children
   4. D. Ischemic cardiac chest pain
   Show answer

   Answer: B. Mild to moderate pain and fever

   Ibuprofen is avoided in suspected bleeding or renal problems. They are particularly useful in pediatric patients.

9. A 4-year-old with a forearm fracture can talk but cannot rate pain with numbers. Which pain scale fits best?

   1. A. The Wong-Baker FACES
   2. B. A 0-to-100 visual analog scale
   3. C. The PAINAD dementia scale
   4. D. A 0-to-10 numeric scale
   Show answer

   Answer: A. The Wong-Baker FACES

   Self-report face scales such as Wong-Baker FACES suit children about 3 years and older who cannot use numbers; observational scales such as FLACC are used for infants and nonverbal children. A numeric scale needs number concepts most 4-year-olds lack. A 0-to-100 analog scale needs abstract judgment young children lack, and PAINAD is built for adults with advanced dementia.

10. Withholding pain medication out of concern that it will mask the diagnosis is:

    1. A. Not supported by evidence
    2. B. Recommended for multisystem trauma
    3. C. Required for all abdominal pain
    4. D. Standard practice for all patients
    Show answer

    Answer: A. Not supported by evidence

    Untreated pain is itself harmful. Appropriate analgesia does not prevent diagnosis.

11. Sedation for a procedure requires:

    1. A. Only the medication and a secure IV line
    2. B. Verbal consent without formal documentation
    3. C. Monitoring, airway gear, and a dedicated observer
    4. D. A single provider doing both sedation and monitoring
    Show answer

    Answer: C. Monitoring, airway gear, and a dedicated observer

    Capnography is the standard for monitoring ventilation.

12. Opioids and benzodiazepines given together:

    1. A. Cancel out each other's sedative effects
    2. B. No interaction, so each is dosed normally
    3. C. Safer than either drug alone when given at full doses
    4. D. Synergistic respiratory depression; lower the doses
    Show answer

    Answer: D. Synergistic respiratory depression; lower the doses

    Reduce doses when combining them. Closer monitoring is required.

13. Morphine for pain is dosed:

    1. A. 20 mg IV push (1 mg/kg), once
    2. B. 10–15 mg IV (0.5 mg/kg), titrated
    3. C. 2–5 mg IV (0.1 mg/kg), titrated
    4. D. 0.5 mg IV (0.01 mg/kg), once
    Show answer

    Answer: C. 2–5 mg IV (0.1 mg/kg), titrated

    Titrate to effect; monitor respirations and BP. Doses are repeated every 5 to 10 minutes.

14. A parent offers the child's prescribed codeine syrup for a 7-year-old's fracture pain. What is accurate?

    1. A. Codeine is contraindicated under age 12
    2. B. Codeine is safe if dosed by weight
    3. C. Codeine is the safest opioid for children
    4. D. Codeine is fine if he has had it before
    Show answer

    Answer: A. Codeine is contraindicated under age 12

    The FDA contraindicates codeine in children under 12 because some are ultra-rapid metabolizers who convert it to large amounts of morphine, causing respiratory depression and death; weight-based IN or IV fentanyl or non-opioids are used instead. Weight-based dosing cannot fix the problem because conversion depends on genetics, a prior uneventful dose does not prove the child is not an ultra-rapid metabolizer, and codeine is not the safest choice.

15. A patient took ibuprofen 800 mg 2 hours ago for back pain. Your partner suggests ketorolac. What is the concern?

    1. A. No concern; they work together
    2. B. Ketorolac is safe after 1 hour
    3. C. Two NSAIDs add risk
    4. D. The pair causes heavy sedation
    Show answer

    Answer: C. Two NSAIDs add risk

    Ketorolac and ibuprofen are both NSAIDs; combining them adds little pain relief but increases GI bleeding and kidney risk, so another class (acetaminophen, an opioid, or ketamine) is chosen. Waiting an hour does not clear an 800-mg ibuprofen dose, and NSAIDs are not sedating.

16. After a single IV dose, about how long does fentanyl's analgesic effect last?

    1. A. About 6 to 8 hours or more
    2. B. About 2 to 4 hours
    3. C. About 30 to 60 minutes
    4. D. About 5 to 10 minutes
    Show answer

    Answer: C. About 30 to 60 minutes

    IV fentanyl starts within 1 to 2 minutes and its analgesia lasts roughly 30 to 60 minutes, so longer transports may need repeat titrated doses. 2 to 4 hours or 6 to 8 hours fits morphine or longer-acting opioids, and 5 to 10 minutes is closer to its time to peak effect than its duration.

17. A patient with a fracture has an active nosebleed and heavy nasal congestion. Why is IN fentanyl a poor choice?

    1. A. Absorption becomes unreliable
    2. B. IN fentanyl causes nosebleeds
    3. C. IN fentanyl is contraindicated
    4. D. It stops the nosebleed's clotting
    Show answer

    Answer: A. Absorption becomes unreliable

    IN drugs must reach the nasal mucosa to be absorbed; blood, mucus, or congestion wash it out or block it, so absorption is unreliable and another route such as IV or IO is preferred. IN fentanyl does not cause nosebleeds, is not otherwise contraindicated, and does not affect clotting.

18. A diver surfaced 30 minutes ago and now has joint pain and tingling. He asks for nitrous oxide for the pain. Why is it avoided?

    1. A. It raises the risk of oxygen toxicity
    2. B. It causes lung barotrauma on ascent
    3. C. It enlarges gas bubbles in tissues
    4. D. It is too weak for joint pain
    Show answer

    Answer: C. It enlarges gas bubbles in tissues

    Nitrous oxide diffuses into gas-filled spaces faster than nitrogen leaves them, so it can enlarge the nitrogen bubbles of decompression sickness (as it does a pneumothorax); 100% oxygen and transport for hyperbaric evaluation are indicated. It is an effective analgesic in other settings, it does not raise oxygen toxicity risk, and barotrauma comes from pressure change during ascent, not from the gas.

19. Medical control orders hydromorphone 1 mg IV. The vial is 2 mg/mL. What volume is given?

    1. A. 5 mL
    2. B. 0.5 mL
    3. C. 0.05 mL
    4. D. 2 mL
    Show answer

    Answer: B. 0.5 mL

    1 mg divided by 2 mg/mL = 0.5 mL. 2 mL would be 4 mg, four times the order (hydromorphone is several times more potent than morphine, so this is dangerous). 5 mL would be 10 mg. 0.05 mL would be 0.1 mg, a tenfold underdose.

20. Ketorolac is an:

    1. A. Antiemetic for nausea
    2. B. Opioid for severe pain
    3. C. NSAID for moderate pain
    4. D. Anxiolytic for agitation
    Show answer

    Answer: C. NSAID for moderate pain

    Avoid in renal impairment, bleeding, and in patients >65 at higher doses. The dose is 15 to 30 mg IV/IM; it is especially useful in renal colic.

21. An 84-year-old with vertigo is offered meclizine. Which risk is most important in this patient?

    1. A. Severe hypertension
    2. B. Severe hypoglycemia
    3. C. Sedation, confusion, falls
    4. D. Acute bronchospasm and wheezing
    Show answer

    Answer: C. Sedation, confusion, falls

    Meclizine and similar antihistamines are anticholinergic and sedating, so in older adults they raise the risk of confusion, urinary retention, and falls; the Beers criteria advise caution. Hypertension, hypoglycemia, and bronchospasm are not typical effects.

22. Acetaminophen IV dose is:

    1. A. 100 mg IV over 15 minutes
    2. B. 1 g IV over 15 minutes
    3. C. 5 g IV over 15 minutes
    4. D. 1 g IV push over 30 seconds
    Show answer

    Answer: B. 1 g IV over 15 minutes

    Max 4 g/day; useful as opioid-sparing analgesia. The pediatric dose is 15 mg/kg.

23. Nitrous oxide for analgesia is:

    1. A. Mixed 90:10 with room air by face mask
    2. B. Given by provider-held mask, 70:30
    3. C. Given steadily by nasal cannula
    4. D. Self-administered 50:50 with oxygen
    Show answer

    Answer: D. Self-administered 50:50 with oxygen

    Contraindicated in pneumothorax, bowel obstruction, and altered mental status. It is used for moderate pain. A provider-held mask defeats the self-administration safety feature, a 70% nitrous mix leaves too little oxygen, and a nasal cannula cannot deliver it on demand.

24. A patient who had retinal surgery a week ago with a gas bubble in the eye now has a wrist fracture. Why is nitrous oxide avoided?

    1. A. It causes retinal bleeding
    2. B. It enlarges the bubble
    3. C. It blocks prescribed eye drops
    4. D. It dries the eye surface
    Show answer

    Answer: B. It enlarges the bubble

    Nitrous oxide diffuses into the intraocular gas bubble and expands it, which can sharply raise eye pressure and cause permanent vision loss; it is contraindicated for weeks after such surgery. Dryness, bleeding, and interaction with eye drops are not the concern.

25. In an ED trial of adults with arm or leg fractures, oral ibuprofen plus acetaminophen was compared with opioid combinations. What did it show?

    1. A. Opioids were 10 times more effective
    2. B. The combination caused more vomiting
    3. C. Ibuprofen plus acetaminophen gave no relief
    4. D. Similar pain relief at 2 hours
    Show answer

    Answer: D. Similar pain relief at 2 hours

    The trial found no meaningful difference in pain reduction at 2 hours between ibuprofen plus acetaminophen and three opioid combinations, supporting non-opioid options when appropriate. The combination did provide relief, opioids were not far more effective, and non-opioids cause less vomiting.

26. Midazolam onset and duration by IV route are:

    1. A. 10 min onset, 8–12 hr duration
    2. B. Immediate onset, about 24-hour duration
    3. C. 15 min onset, 4–6 hr duration
    4. D. 1–3 min onset, 30–60 min duration
    Show answer

    Answer: D. 1–3 min onset, 30–60 min duration

    Midazolam is short-acting compared with diazepam and lorazepam.

27. Diazepam duration is:

    1. A. Long (hours), with active metabolites
    2. B. Intermediate, about 30 to 60 minutes
    3. C. Ultra-short, measured in seconds
    4. D. Short, under 10 minutes, no metabolites
    Show answer

    Answer: A. Long (hours), with active metabolites

    Diazepam is lipid-soluble with prolonged effects.

28. Ondansetron adult dose is:

    1. A. 1 mg/kg IV, maximum 40 mg
    2. B. 40 mg IV/IM/ODT, single dose
    3. C. 4 mg IV/IM/ODT, may repeat
    4. D. 0.4 mg IV/IM/ODT, may repeat
    Show answer

    Answer: C. 4 mg IV/IM/ODT, may repeat

    Pediatric: 0.15 mg/kg (max 4 mg).

29. If IV promethazine must be given, how does its FDA labeling direct it to be given?

    1. A. Undiluted as a rapid push
    2. B. Mixed in a 1-L bag and run over 4 hours
    3. C. Into a hand vein to speed onset
    4. D. Diluted, slowly, via a running line
    Show answer

    Answer: D. Diluted, slowly, via a running line

    Promethazine can cause severe tissue injury and gangrene, so deep IM is preferred; if given IV, the 2023 labeling calls for dilution in 10 to 20 mL of saline and slow injection through a running IV line, stopping at once if the patient reports pain. A rapid undiluted push and small hand veins raise the risk of injury. A 4-hour infusion is not the labeled method.

30. Promethazine (Phenergan) is:

    1. A. A sedating phenothiazine antiemetic
    2. B. A 5-HT3 antagonist with no sedation
    3. C. A synthetic opioid used for nausea
    4. D. A corticosteroid used for vertigo
    Show answer

    Answer: A. A sedating phenothiazine antiemetic

    IV promethazine can cause severe tissue necrosis; give deep IM or diluted. It is also an antihistamine and carries tissue-injury risk if extravasated.

31. Metoclopramide (Reglan) acts by:

    1. A. Anticholinergic action that slows gastric emptying
    2. B. Selective 5-HT3 receptor blockade only
    3. C. Mu-opioid agonism that slows the gut
    4. D. Dopamine blockade and increased gastric motility
    Show answer

    Answer: D. Dopamine blockade and increased gastric motility

    Dose 10 mg IV slowly. It can cause dystonia.

32. Diphenhydramine as an antiemetic is useful for:

    1. A. Nausea of pregnancy as the only indication
    2. B. All types of nausea with equal effect
    3. C. Chemotherapy-induced nausea and vomiting
    4. D. Motion sickness and vertigo
    Show answer

    Answer: D. Motion sickness and vertigo

    Antihistamine antiemetics act on vestibular pathways. It is useful for vertigo-related nausea.

33. Prochlorperazine (Compazine) dose is:

    1. A. 5–10 mg IV/IM
    2. B. 100 mg IV/IM
    3. C. 0.5–1 mg IV/IM
    4. D. 50 mg IV/IM
    Show answer

    Answer: A. 5–10 mg IV/IM

    Phenothiazine; watch for dystonia and hypotension.

34. During an interfacility transfer on a dexmedetomidine infusion, which side effects should you expect to watch for?

    1. A. Hyperthermia and rigidity
    2. B. Seizures and hypertension
    3. C. Severe respiratory depression
    4. D. Bradycardia and hypotension
    Show answer

    Answer: D. Bradycardia and hypotension

    Dexmedetomidine is an alpha-2 agonist that lowers sympathetic tone, so bradycardia and hypotension are its most common effects; respiratory drive is largely preserved. It does not commonly cause seizures, hypertensive crises (except a transient rise with a rapid load), hyperthermia, or rigidity.

35. Opioid-induced respiratory depression is best detected by:

    1. A. Pulse oximetry, since SpO2 falls first
    2. B. Capnography, before SpO2 falls
    3. C. Blood pressure, since hypotension precedes apnea
    4. D. Heart rate, since bradycardia appears first
    Show answer

    Answer: B. Capnography, before SpO2 falls

    ETCO2 is an early warning; SpO2 lags, especially on oxygen. Rising ETCO2 and a falling respiratory rate appear before desaturation.

36. An 88-year-old with advanced dementia and a hip fracture cannot rate her pain. What is the best approach?

    1. A. Rely on the family to choose the dose
    2. B. Give the same dose as for a young adult
    3. C. Withhold analgesia since she can't rate pain
    4. D. Use an observational scale such as PAINAD
    Show answer

    Answer: D. Use an observational scale such as PAINAD

    Patients with advanced dementia feel pain but cannot self-report, so observational tools such as PAINAD (breathing, vocalizing, facial expression, body language, consolability) guide careful, titrated analgesia. Withholding treatment leads to undertreated pain and delirium. Family input helps but does not replace assessment. Older adults need lower starting doses.

37. A 40-kg adolescent needs IN fentanyl at 1.5 mcg/kg using 50 mcg/mL. What dose and volume per nostril are given?

    1. A. 60 mcg; 0.6 mL per nostril
    2. B. 6 mcg; 0.06 mL per nostril
    3. C. 60 mcg; 1.2 mL per nostril
    4. D. 600 mcg; 6 mL per nostril
    Show answer

    Answer: A. 60 mcg; 0.6 mL per nostril

    1.5 mcg/kg x 40 kg = 60 mcg, or 1.2 mL of 50 mcg/mL in total, split as 0.6 mL per nostril. Giving 1.2 mL per nostril doubles the dose. 600 mcg and 6 mcg are tenfold errors.

38. A child with fever has had vomiting and diarrhea for 3 days and has dry mucous membranes. Why is acetaminophen preferred over ibuprofen?

    1. A. Ibuprofen worsens the diarrhea
    2. B. Acetaminophen lowers the fever much faster
    3. C. NSAIDs can injure dehydrated kidneys
    4. D. Ibuprofen works too slowly
    Show answer

    Answer: C. NSAIDs can injure dehydrated kidneys

    NSAIDs reduce kidney blood flow, which a dehydrated child depends on, so acute kidney injury can result; acetaminophen is preferred until the child is rehydrated. Ibuprofen is not too slow and does not worsen diarrhea, and acetaminophen does not lower fever meaningfully faster; kidney risk is the reason.

39. A 15-kg child is to receive oral ibuprofen 10 mg/kg using the 100 mg/5 mL suspension. What volume is given?

    1. A. 15 mL
    2. B. 75 mL
    3. C. 0.75 mL
    4. D. 7.5 mL
    Show answer

    Answer: D. 7.5 mL

    10 mg/kg x 15 kg = 150 mg; the suspension is 20 mg/mL, so 150 / 20 = 7.5 mL. 0.75 mL and 75 mL are tenfold errors. 15 mL would be 300 mg, or 20 mg/kg.

40. Multimodal analgesia means:

    1. A. Rotating opioids to prevent tolerance
    2. B. Combining drugs with different mechanisms
    3. C. Giving repeated small doses of a single opioid
    4. D. Giving one drug by several different routes
    Show answer

    Answer: B. Combining drugs with different mechanisms

    Multimodal approaches improve pain control with fewer side effects. For example, acetaminophen + ketamine + an opioid can reduce the opioid dose.

41. Propofol for sedation is:

    1. A. A sedative-hypnotic that causes hypotension and apnea
    2. B. A benzodiazepine reversed by flumazenil
    3. C. A dissociative that preserves airway reflexes
    4. D. An opioid-sparing analgesic for fracture pain
    Show answer

    Answer: A. A sedative-hypnotic that causes hypotension and apnea

    Propofol has no analgesic effect. It is infused at 5–50 mcg/kg/min, mainly for intubated patients in transport.

42. Dexmedetomidine is:

    1. A. A synthetic opioid agonist with minimal respiratory effects
    2. B. A dopamine antagonist used mainly as an antiemetic
    3. C. An alpha-2 agonist with little respiratory depression
    4. D. A benzodiazepine with a very short half-life
    Show answer

    Answer: C. An alpha-2 agonist with little respiratory depression

    Causes bradycardia and hypotension. It is used mainly in critical care transport.

43. A trauma patient who is intoxicated with alcohol has severe fracture pain. What is the main caution with opioids?

    1. A. Alcohol blocks opioid effects
    2. B. Opioids raise blood alcohol
    3. C. Alcohol makes opioids toxic to the liver
    4. D. Added sedation, depressed breathing
    Show answer

    Answer: D. Added sedation, depressed breathing

    Alcohol and opioids both depress the CNS and breathing, so analgesia is still given but in smaller, titrated doses with close monitoring of ETCO2 and SpO2. Alcohol does not block opioids, opioids do not raise alcohol levels, and liver toxicity is not the acute concern.

44. Meperidine (Demerol) is rarely used because:

    1. A. It causes chest wall rigidity at low doses
    2. B. Normeperidine causes seizures; MAOI interactions
    3. C. It is available only as an oral tablet in the US
    4. D. It is too weak for moderate to severe pain
    Show answer

    Answer: B. Normeperidine causes seizures; MAOI interactions

    Meperidine has largely been replaced. Its metabolite normeperidine causes seizures, and it interacts dangerously with MAOIs.

45. A patient has a partial-thickness burn on the forearm from 5 minutes ago. Along with analgesia, which first-aid measure relieves pain and limits injury?

    1. A. Ice packed directly on the burn
    2. B. Ice-cold water for about an hour
    3. C. Running water for about 2 minutes
    4. D. Cool running water, about 20 min
    Show answer

    Answer: D. Cool running water, about 20 min

    Cooling a fresh burn with cool running water for about 20 minutes reduces pain and depth of injury; watch for hypothermia with large burns. Ice causes further tissue injury. Ice-cold water for an hour risks hypothermia and further tissue injury, and 2 minutes is too brief to stop the burning process.

46. Before more fentanyl for an angulated forearm fracture, which non-drug measure most reduces pain?

    1. A. Splinting, ice, and elevation
    2. B. Straightening the arm before splinting
    3. C. Splinting with the arm hanging low
    4. D. A tight elastic wrap over the break
    Show answer

    Answer: A. Splinting, ice, and elevation

    Immobilizing a fracture in a padded splint, with cold packs and elevation, reduces movement, spasm, and swelling, and it works together with analgesics. Straightening an angulated forearm in the field adds pain and is reserved for compromised distal circulation, a dependent arm swells more, and a tight wrap can impair circulation.

47. Using 0.1 mg/kg, what is the maximum initial morphine dose for an 80-kg patient with a long-bone fracture?

    1. A. 80 mg IV
    2. B. 8 mg IV
    3. C. 0.8 mg IV
    4. D. 16 mg IV
    Show answer

    Answer: B. 8 mg IV

    Morphine is commonly dosed up to 0.1 mg/kg, often given in smaller increments and titrated.

48. A trauma patient has severe pain from a pelvic injury and a BP of 86/50. Which analgesic option is commonly preferred?

    1. A. Ketorolac 30 mg IV over 15 seconds
    2. B. Morphine 0.1 mg/kg IV push
    3. C. Ketamine 0.1 to 0.3 mg/kg IV
    4. D. Hydromorphone 2 mg IV push
    Show answer

    Answer: C. Ketamine 0.1 to 0.3 mg/kg IV

    Sub-dissociative ketamine provides analgesia while maintaining BP and respiratory drive. This low (sub-dissociative) ketamine dose is the usual choice in hypotensive trauma.

49. A patient with suspected kidney stones has stage 4 chronic kidney disease and takes warfarin. Regarding ketorolac:

    1. A. Give 15 mg IV after a 1-L fluid bolus to protect the kidney
    2. B. Give 30 mg IV, since NSAIDs are ideal for renal colic
    3. C. Give it orally only, which eliminates the bleeding risk
    4. D. Avoid it because of the renal impairment and anticoagulant use
    Show answer

    Answer: D. Avoid it because of the renal impairment and anticoagulant use

    NSAIDs can worsen renal function and increase bleeding risk, especially with anticoagulants.

50. A multisystem trauma patient may have internal bleeding. Why is ketorolac avoided?

    1. A. It has no analgesic effect for traumatic injuries
    2. B. It inhibits platelet function and may worsen bleeding
    3. C. It interacts with saline to form a precipitate
    4. D. It causes rapid respiratory depression in trauma
    Show answer

    Answer: B. It inhibits platelet function and may worsen bleeding

    NSAIDs impair platelet aggregation, which is undesirable when hemorrhage is possible.

51. A 40-kg adolescent needs IV acetaminophen. Using 15 mg/kg, what dose is appropriate?

    1. A. 600 mg IV
    2. B. 60 mg IV
    3. C. 1,500 mg IV
    4. D. 6,000 mg IV
    Show answer

    Answer: A. 600 mg IV

    IV acetaminophen is 15 mg/kg for patients under 50 kg and 1 g for larger adults.

52. A patient with chronic heavy alcohol use and cirrhosis asks for acetaminophen for pain. What is the main caution?

    1. A. Acetaminophen causes severe bleeding in cirrhosis
    2. B. Acetaminophen causes respiratory depression
    3. C. Liver disease increases the risk of hepatotoxicity
    4. D. Acetaminophen is ineffective in heavy drinkers
    Show answer

    Answer: C. Liver disease increases the risk of hepatotoxicity

    Acetaminophen is metabolized by the liver; dosing is reduced or avoided in significant hepatic disease.

53. A patient with chest trauma and decreased breath sounds on one side requests nitrous oxide. What is the best response?

    1. A. It is contraindicated; the gas expands air spaces
    2. B. It is safe once a vented chest seal is on
    3. C. It may be used if the patient holds the mask
    4. D. It is safe when it is mixed 30:70 with extra oxygen
    Show answer

    Answer: A. It is contraindicated; the gas expands air spaces

    Nitrous oxide diffuses into closed air spaces and can enlarge a pneumothorax. A chest seal does not stop the gas from enlarging an intrapleural air space, and diluting it with more oxygen does not remove the contraindication.

54. Why must a patient hold the nitrous oxide mask or mouthpiece themselves?

    1. A. The gas is inactive unless self-triggered
    2. B. It keeps the provider from inhaling the gas
    3. C. If oversedated, they drop it and the dose stops
    4. D. It ensures a tighter seal for better delivery
    Show answer

    Answer: C. If oversedated, they drop it and the dose stops

    Self-administration is a built-in safety mechanism against oversedation.

55. An 82-year-old with a hip fracture becomes drowsy with a respiratory rate of 8/min after 50 mcg of fentanyl. What is the best management?

    1. A. Support ventilation; consider small naloxone doses
    2. B. Give another 50 mcg because the pain is not controlled
    3. C. Give flumazenil 0.2 mg IV to reverse the fentanyl
    4. D. Lay flat and recheck vital signs in 15 minutes
    Show answer

    Answer: A. Support ventilation; consider small naloxone doses

    Older adults are more sensitive to opioids; respiratory depression is managed with ventilatory support and titrated naloxone. Stimulate the patient as well.

56. After ketamine 0.3 mg/kg IV for fracture pain, a patient has nystagmus and says he feels 'floaty,' with normal breathing and SpO2. What is appropriate?

    1. A. Give flumazenil for the nystagmus
    2. B. Give naloxone to reverse ketamine
    3. C. Intubate to protect the airway
    4. D. Reassure him; these are expected
    Show answer

    Answer: D. Reassure him; these are expected

    Nystagmus and mild perceptual changes are expected with sub-dissociative ketamine; reassure, keep the setting calm, and monitor. Naloxone and flumazenil do not reverse ketamine. Breathing is normal, so there is no reason to intubate.

57. A 30-year-old with normal kidney function, no bleeding risk, and severe renal colic needs pain relief. Which first-line option has fewer side effects than opioids?

    1. A. Codeine syrup by mouth, 30 mg
    2. B. Promethazine 25 mg IV
    3. C. An NSAID, such as ketorolac
    4. D. Oral diphenhydramine
    Show answer

    Answer: C. An NSAID, such as ketorolac

    NSAIDs reduce ureteral spasm and inflammation and relieve renal colic at least as well as opioids, with less vomiting and less need for rescue doses, so they are first-line when there is no contraindication. Codeine is weak and unpredictable. Promethazine and diphenhydramine are not analgesics.

58. A 30-kg child with a fracture has no IV. Protocol calls for IN ketamine 1 mg/kg. What dose is given?

    1. A. 3 mg IN
    2. B. 30 mg IN
    3. C. 10 mg IN
    4. D. 300 mg IN
    Show answer

    Answer: B. 30 mg IN

    1 mg/kg x 30 kg = 30 mg, split between the nostrils using a concentrated solution to keep the volume small. 300 mg and 3 mg are tenfold errors. 10 mg is about 0.33 mg/kg, below this protocol's dose.

59. Why is sub-dissociative ketamine commonly given slowly or as a short infusion?

    1. A. It is required to activate the drug
    2. B. It prevents ketamine from causing seizures
    3. C. It reduces dysphoria and emergence reactions
    4. D. It prevents severe bradycardia and asystole
    Show answer

    Answer: C. It reduces dysphoria and emergence reactions

    A rapid push of even a low ketamine dose is more likely to cause unpleasant psychoactive effects.

60. A 20-kg child has a painful burn and an IV in place. Using 0.1 mg/kg, what morphine dose is appropriate?

    1. A. 20 mg IV
    2. B. 0.2 mg IV
    3. C. 2 mg IV
    4. D. 10 mg IV
    Show answer

    Answer: C. 2 mg IV

    Pediatric morphine is commonly 0.05 to 0.1 mg/kg IV, titrated to effect.

61. A child with gastroenteritis is vomiting and mildly dehydrated. How does a single dose of ondansetron help?

    1. A. It relieves the abdominal cramps
    2. B. It prevents febrile seizures
    3. C. It allows oral rehydration
    4. D. It brings the fever down
    Show answer

    Answer: C. It allows oral rehydration

    In children with gastroenteritis, ondansetron reduces vomiting so oral rehydration succeeds, lowering the need for IV fluids and admission. It does not relieve cramping, lower fever, or prevent febrile seizures, and it can slightly increase diarrhea.

62. Why is promethazine contraindicated in a 20-month-old with vomiting?

    1. A. It is ineffective for nausea in infants and toddlers
    2. B. It causes severe hypoglycemia in toddlers
    3. C. Fatal respiratory depression risk under age 2
    4. D. Its dose cannot be adjusted for weight
    Show answer

    Answer: C. Fatal respiratory depression risk under age 2

    Promethazine carries a boxed warning against use in children younger than 2 because of fatal respiratory depression. It is effective as an antiemetic and is weight-dosed in older children, and hypoglycemia is not the reason for the warning.

63. After 10 mg of IV metoclopramide, a patient feels intensely restless and cannot sit still. This is most likely:

    1. A. Akathisia; stop the drug, consider diphenhydramine
    2. B. Anaphylaxis; give IM epinephrine and IV fluids
    3. C. Serotonin syndrome; give cyproheptadine orally
    4. D. Hypoglycemia; give dextrose and recheck glucose
    Show answer

    Answer: A. Akathisia; stop the drug, consider diphenhydramine

    Dopamine antagonists can cause akathisia, especially with rapid IV push. Slow or stop the drug.

64. A 78-year-old needs sedation before synchronized cardioversion. How should midazolam commonly be given?

    1. A. A 10-mg bolus to ensure complete amnesia
    2. B. Small titrated doses, such as 1 mg
    3. C. 0.3 mg/kg IV push over 10 seconds
    4. D. IM only, to avoid the hypotension of IV dosing
    Show answer

    Answer: B. Small titrated doses, such as 1 mg

    Older adults are more sensitive to benzodiazepines, so smaller titrated doses are used. Watch BP and breathing closely.

65. A post-intubation fentanyl infusion is ordered at 50 mcg/h. The bag contains 1,000 mcg in 100 mL. What rate is set?

    1. A. 10 mL/h
    2. B. 5 mL/h
    3. C. 50 mL/h
    4. D. 0.5 mL/h
    Show answer

    Answer: B. 5 mL/h

    1,000 mcg in 100 mL = 10 mcg/mL, so 50 mcg/h divided by 10 mcg/mL = 5 mL/h. 50 mL/h would deliver 500 mcg/h. 0.5 mL/h is a tenfold underdose. 10 mL/h would deliver 100 mcg/h.

66. A septic patient with a BP of 86/50 needs RSI. Which induction agent is most appropriate?

    1. A. Ketamine 1 mg/kg IV
    2. B. Propofol 2 mg/kg IV
    3. C. Midazolam 0.3 mg/kg IV
    4. D. Fentanyl 5 mcg/kg IV
    Show answer

    Answer: A. Ketamine 1 mg/kg IV

    Ketamine maintains sympathetic tone and BP; propofol and high-dose midazolam commonly cause hypotension.

67. A dialysis patient with peaked T waves needs RSI. Which paralytic is preferred?

    1. A. Rocuronium
    2. B. Succinylcholine
    3. C. Vecuronium at 0.01 mg/kg
    4. D. No paralytic at all
    Show answer

    Answer: A. Rocuronium

    Succinylcholine raises serum potassium and can cause dysrhythmias in patients with hyperkalemia.

68. Etomidate 0.3 mg/kg is ordered for RSI in a 90-kg patient. What dose is given?

    1. A. 270 mg IV
    2. B. 2.7 mg IV
    3. C. 27 mg IV
    4. D. 30 mg/kg IV
    Show answer

    Answer: C. 27 mg IV

    0.3 mg/kg x 90 kg = 27 mg, given as a single IV push before the paralytic. 270 mg and 2.7 mg are tenfold errors. 30 mg/kg confuses a usual adult total dose with a per-kilogram dose and would be a massive overdose.

69. Using 1 to 1.2 mg/kg, what rocuronium dose is appropriate for RSI in a 70-kg patient?

    1. A. 700 to 840 mg IV
    2. B. 7 to 8 mg IV
    3. C. 70 to 84 mg IV
    4. D. 1 to 1.2 mg IV
    Show answer

    Answer: C. 70 to 84 mg IV

    RSI-dose rocuronium is 1 to 1.2 mg/kg, which provides paralysis lasting roughly 30 to 60 minutes or more.

70. During etomidate induction, the patient has brief jerking movements of the extremities. This is most likely:

    1. A. An allergic reaction needing epinephrine
    2. B. A generalized seizure needing midazolam
    3. C. A sign of inadequate paralytic dose
    4. D. Myoclonus, a common transient effect
    Show answer

    Answer: D. Myoclonus, a common transient effect

    Etomidate frequently causes myoclonus, which is not seizure activity.

71. A patient on daily buprenorphine for opioid use disorder has a femur fracture. Why may usual fentanyl doses work poorly?

    1. A. Buprenorphine binds receptors very tightly
    2. B. Buprenorphine speeds fentanyl breakdown
    3. C. Fentanyl causes withdrawal in these patients
    4. D. Buprenorphine is an opioid antagonist
    Show answer

    Answer: A. Buprenorphine binds receptors very tightly

    Buprenorphine is a high-affinity partial agonist that occupies most mu receptors, so full agonists may need higher titrated doses; multimodal analgesia such as ketamine helps, and buprenorphine is usually continued. It does not speed fentanyl metabolism, fentanyl does not cause withdrawal here, and buprenorphine is not a pure antagonist.

72. A conscious 20-kg child has a tibial IO. Protocol calls for preservative-free lidocaine 0.5 mg/kg before the flush. What dose is given?

    1. A. 100 mg IO
    2. B. 1 mg IO
    3. C. 40 mg IO
    4. D. 10 mg IO
    Show answer

    Answer: D. 10 mg IO

    0.5 mg/kg x 20 kg = 10 mg (the pediatric dose is capped at the 40-mg adult dose). 1 mg is too little to help. 40 mg is the adult dose. 100 mg is 5 mg/kg, a toxic dose for this child.

73. A daily cannabis user has weeks of cyclic vomiting relieved by hot showers, and ondansetron failed. Which drug has shown benefit in trials?

    1. A. More ondansetron, at 16 mg IV
    2. B. Morphine, titrated to the effect
    3. C. Diphenhydramine 50 mg IV push
    4. D. Haloperidol, by medical order
    Show answer

    Answer: D. Haloperidol, by medical order

    Cannabinoid hyperemesis syndrome often responds poorly to ondansetron; in a randomized trial, haloperidol worked better, and topical capsaicin is another option, with stopping cannabis as the cure. Larger ondansetron doses add QT risk without benefit. Opioids can worsen nausea. Diphenhydramine has little evidence here.

74. A patient took 2 g of acetaminophen at home 4 hours ago for back pain. Before more acetaminophen, the paramedic should consider:

    1. A. A limit of 1 g in each 24-hour period
    2. B. The usual adult maximum of 4 g per day
    3. C. The usual adult maximum of 8 g per day
    4. D. Giving NAC before any more acetaminophen
    Show answer

    Answer: B. The usual adult maximum of 4 g per day

    Home doses count toward the total daily limit to avoid hepatotoxicity. A 1-g daily cap is far below the usual limit and 8 g is double it; 2 g already taken leaves about 2 g for the rest of the day.

75. Ten minutes after fentanyl 100 mcg IV, a patient with a dislocated shoulder rates pain 7/10 with stable vital signs and normal breathing. What is appropriate?

    1. A. Switch immediately to IV ketorolac 60 mg
    2. B. Repeat a titrated dose per protocol and reassess
    3. C. Do nothing; one dose is the maximum allowed
    4. D. Give naloxone to reset the opioid receptors
    Show answer

    Answer: B. Repeat a titrated dose per protocol and reassess

    Analgesia is titrated to effect with repeated assessment of pain and vital signs.

76. A patient with sickle cell disease is in a severe pain crisis. What is the most appropriate prehospital approach?

    1. A. Give oral ibuprofen alone and reassess in an hour
    2. B. Withhold analgesia to avoid masking a diagnosis
    3. C. Give naloxone to rule out opioid-seeking behavior
    4. D. Prompt opioid analgesia, fluids, and oxygen if hypoxic
    Show answer

    Answer: D. Prompt opioid analgesia, fluids, and oxygen if hypoxic

    Vaso-occlusive crises require timely, adequate analgesia; undertreatment is a common problem.