High-Alert Emergency Medication Cautions Practice Questions

79 multiple-choice questions on High-alert cautions 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.

79 practice questions

1. A patient has an acute spinal cord injury with leg weakness. Regarding high-dose methylprednisolone in the field:

   1. A. It is not recommended
   2. B. It is given within 8 hours of injury
   3. C. It is given if the deficit is complete
   4. D. It is standard to prevent paralysis
   Show answer

   Answer: A. It is not recommended

   Current guidelines do not recommend high-dose methylprednisolone for acute spinal cord injury because evidence of benefit is weak and complications such as infection and GI bleeding increase. The old 8-hour window came from trials whose benefit did not hold up, it is not given based on deficit severity, and it is not standard care.

2. A patient in pulmonary edema reports a rash from a 'sulfa' antibiotic years ago. Regarding furosemide:

   1. A. Cross-reactivity is low; give and monitor
   2. B. Give half the usual dose and monitor closely
   3. C. Premedicate with diphenhydramine first
   4. D. Withhold it; it is the same drug
   Show answer

   Answer: A. Cross-reactivity is low; give and monitor

   Allergy to sulfonamide antibiotics carries little cross-reactivity with non-antibiotic sulfonamides such as furosemide, so it can generally be given with monitoring, per protocol. Furosemide is a different drug. Halving the dose undertreats the edema without making an allergy safer, and routine premedication is not needed for a remote rash.

3. Why should you wear gloves when applying or removing nitroglycerin paste?

   1. A. You can absorb it, causing headache
   2. B. The paste is a strong contact allergen
   3. C. The paste is caustic to your skin
   4. D. Gloves make the dose more accurate
   Show answer

   Answer: A. You can absorb it, causing headache

   Nitroglycerin is absorbed through intact skin, so a provider who touches the paste can develop headache, dizziness, or hypotension; wear gloves and remove old paste completely. It is not caustic or a common allergen, and gloves do not change dosing accuracy.

4. A patient taking apomorphine for Parkinson disease is nauseated. Why is ondansetron contraindicated?

   1. A. The pair can cause severe hypotension
   2. B. It worsens Parkinson tremor and rigidity
   3. C. It blocks apomorphine absorption
   4. D. It causes severe hyperglycemia
   Show answer

   Answer: A. The pair can cause severe hypotension

   The apomorphine and ondansetron labels contraindicate the combination because it has caused profound hypotension and loss of consciousness. The concern is not tremor, absorption, or hyperglycemia. Dopamine-blocking antiemetics are also avoided in Parkinson disease, so medical control may suggest another option.

5. Any medication given by infusion should be:

   1. A. Checked at the start and at handoff
   2. B. Rechecked when the patient complains
   3. C. Monitored with frequent reassessment
   4. D. Set once and left alone during transport
   Show answer

   Answer: C. Monitored with frequent reassessment

   Pumps fail, and lines infiltrate. Reassess both the patient and the rate. Checking at the start and handoff, or waiting for complaints, misses rate errors and infiltration in between.

6. Medical control orders phenytoin for a seizing adult during a long transfer. Why must it be infused no faster than 50 mg/min?

   1. A. Faster rates cause severe bronchospasm
   2. B. Faster rates cause severe hyperkalemia
   3. C. Faster rates cause hypotension, dysrhythmias
   4. D. Faster rates make the drug ineffective at once
   Show answer

   Answer: C. Faster rates cause hypotension, dysrhythmias

   The phenytoin label carries a boxed warning that rapid IV infusion (over 50 mg/min in adults) can cause hypotension and dangerous dysrhythmias, so cardiac and BP monitoring are needed. A faster rate does not make it ineffective, and bronchospasm and hyperkalemia are not the labeled rate-related risks.

7. Why do some drug labels print names in mixed case, such as hydrOXYzine and hydrALAZINE?

   1. A. To show which drug is a controlled substance
   2. B. To mark the brand-name product
   3. C. To show which drug is stronger
   4. D. To highlight differences in look-alike names
   Show answer

   Answer: D. To highlight differences in look-alike names

   'Tall Man' lettering capitalizes the letters that differ between look-alike names so they are easier to tell apart, a strategy promoted by the FDA and ISMP. It does not indicate strength, controlled status, or brand.

8. A newborn's weight is recorded as 3,200 g. What weight is entered for drug dosing?

   1. A. 3.2 kg
   2. B. 320 kg
   3. C. 32 kg
   4. D. 0.32 kg
   Show answer

   Answer: A. 3.2 kg

   There are 1,000 g in a kilogram, so 3,200 g = 3.2 kg. 32 kg and 0.32 kg are tenfold errors in each direction, and 320 kg is a hundredfold error. Recording weight in kilograms only reduces these errors.

9. A patient with a severe headache has used her sumatriptan injection and her ergotamine on the same day. What is the concern?

   1. A. Severe bradycardia and heart block
   2. B. Rebound headache within the hour
   3. C. The two drugs cancel each other out
   4. D. Added vasoconstriction, ischemia
   Show answer

   Answer: D. Added vasoconstriction, ischemia

   Triptans and ergot alkaloids both constrict blood vessels, and the labels warn against using them within 24 hours of each other because of prolonged vasospasm, including coronary ischemia. They do not cancel each other, and conduction block and immediate rebound headache are not the labeled danger.

10. During defibrillation of an intubated patient, what should be done with the oxygen source?

    1. A. Move it about 1 m from the chest
    2. B. Cover the bag with a damp towel
    3. C. Shut off the flow, leaving it on the chest
    4. D. Hold the bag against the chest
    Show answer

    Answer: A. Move it about 1 m from the chest

    Oxygen near the pads can fuel a fire from a spark, so free-flowing oxygen sources are moved at least about 1 m (3 feet) away during shocks; a sealed ventilator circuit can remain connected. Oxygen lingers around a bag left on the chest even after the flow stops, a towel does not keep oxygen away from the pads, and holding the bag on the chest adds to the risk.

11. On a cold morning, a vial of 20% mannitol in the ambulance contains crystals. What should be done?

    1. A. Shake it hard and give it right away
    2. B. Draw up the clear liquid above them
    3. C. Refrigerate it so the crystals settle
    4. D. Warm it until clear; use a filter
    Show answer

    Answer: D. Warm it until clear; use a filter

    Mannitol crystallizes at low temperatures; the label directs warming until the crystals dissolve and giving it through an in-line filter. Giving it with crystals risks particles entering the bloodstream. Drawing off the liquid leaves part of the drug in the crystals, so the dose is unknown, and cold makes crystallization worse.

12. The safest response when unsure about a dose or a drug is to:

    1. A. Give half the dose to stay on the safe side
    2. B. Stop and verify with a reference or partner
    3. C. Skip the drug without telling anyone
    4. D. Estimate the dose and proceed carefully
    Show answer

    Answer: B. Stop and verify with a reference or partner

    A brief pause is always cheaper than a medication error. Contact medical control if needed.

13. A man was bitten by a spider 2 days ago and now has a painful, darkening skin lesion with a pale center. A brown recluse is suspected. What is appropriate?

    1. A. Local wound care and follow-up
    2. B. Cut out the wound in the field
    3. C. Apply heat to draw out the venom
    4. D. Give steroids to stop the necrosis
    Show answer

    Answer: A. Local wound care and follow-up

    Brown recluse bites can cause local necrosis over days; care is supportive (clean the wound, cool compresses, elevation, tetanus status, pain control, and medical follow-up). Early excision worsens outcomes, heat increases tissue damage (cool compresses are used), and steroids have not been shown to stop the necrosis.

14. Which pair of drug names is a well-known look-alike, sound-alike risk in shock care?

    1. A. Dopamine and dobutamine
    2. B. Fentanyl and ketamine IV
    3. C. Norepinephrine and vasopressin
    4. D. Phenylephrine and atropine
    Show answer

    Answer: A. Dopamine and dobutamine

    Dopamine and dobutamine have similar names and are both catecholamine infusions dosed in mcg/kg/min, so ISMP lists them as a confused-name pair; read the full label and verify. Fentanyl and ketamine, norepinephrine and vasopressin, and phenylephrine and atropine do not share a confusable name pattern.

15. A postpartum woman with preeclampsia has heavy bleeding. Which uterotonic is contraindicated because of her hypertension?

    1. A. Methylergonovine
    2. B. Oxytocin infusion
    3. C. Tranexamic acid
    4. D. Firm fundal massage
    Show answer

    Answer: A. Methylergonovine

    Methylergonovine (Methergine) causes vasoconstriction and can trigger severe hypertension, stroke, or seizures, so it is contraindicated in hypertension and preeclampsia. Oxytocin and tranexamic acid can be used, and fundal massage is not a drug.

16. Insulin is a high-alert drug because:

    1. A. Dosing errors cause severe hypoglycemia
    2. B. It raises potassium quickly in overdose
    3. C. Oral forms are absorbed unpredictably
    4. D. Its effect reverses within minutes
    Show answer

    Answer: A. Dosing errors cause severe hypoglycemia

    Always use insulin syringes and spell out 'units'. Typical errors include units vs. mL confusion and tenfold mistakes. Insulin lowers rather than raises potassium, and its effect lasts hours, which is why a dosing error is so dangerous.

17. Heparin errors commonly involve:

    1. A. Giving a dose to the wrong patient
    2. B. Giving it IM instead of subcutaneously
    3. C. Using vials past their expiration date
    4. D. Confusing 1,000 and 10,000 units/mL vials
    Show answer

    Answer: D. Confusing 1,000 and 10,000 units/mL vials

    Read the concentration every time.

18. A unit stores succinylcholine at room temperature. Per the label, how long is it stable outside refrigeration?

    1. A. About 1 year
    2. B. About 24 hours
    3. C. It does not expire
    4. D. About 14 days
    Show answer

    Answer: D. About 14 days

    Succinylcholine is normally refrigerated, and the label allows about 14 days at room temperature, so units must track when vials leave refrigeration. One year overstates stability. 24 hours is far shorter than the label allows. Every drug has an expiration.

19. A patient has upper GI bleeding with vomiting blood. Regarding tranexamic acid, what did the large HALT-IT trial show?

    1. A. It cut deaths from GI bleeding by half
    2. B. No reduction in deaths, more clots
    3. C. It should be given in GI bleeds
    4. D. It works when given orally instead
    Show answer

    Answer: B. No reduction in deaths, more clots

    In HALT-IT, tranexamic acid did not reduce death from GI bleeding and was linked to more venous blood clots and seizures, so it is not routinely given for GI bleeding, unlike traumatic or postpartum hemorrhage. It did not halve deaths, and route was not the issue.

20. Combining IM olanzapine and a benzodiazepine within an hour can cause:

    1. A. Seizures from a lowered seizure threshold
    2. B. Malignant hyperthermia and rigidity
    3. C. Severe hypertension and tachycardia
    4. D. Oversedation and respiratory depression
    Show answer

    Answer: D. Oversedation and respiratory depression

    Avoid co-administration. Cardiorespiratory depression can occur.

21. A man bitten by a black widow spider has severe abdominal cramping and muscle spasms. Which treatment is commonly used?

    1. A. IV calcium gluconate
    2. B. Benzodiazepines and opioids
    3. C. Antibiotics for the bite site
    4. D. Ice and a pressure wrap
    Show answer

    Answer: B. Benzodiazepines and opioids

    Black widow envenomation causes painful muscle spasms that are treated with opioids for pain and benzodiazepines for spasm; antivenom is reserved for severe cases. IV calcium was used in the past but is not effective. Antibiotics are not needed for the envenomation itself, and ice and a pressure wrap do not relieve the systemic muscle spasms.

22. A patient with stable VT received amiodarone, and the VT persists. A partner suggests adding procainamide. What is the concern?

    1. A. Combining them adds QT and rhythm risk
    2. B. Procainamide raises the BP sharply with amiodarone
    3. C. The pair causes severe hyperkalemia
    4. D. The pair causes bronchospasm
    Show answer

    Answer: A. Combining them adds QT and rhythm risk

    Amiodarone and procainamide both prolong the QT interval and depress conduction, so ACLS advises against combining antiarrhythmics without expert consultation. Procainamide tends to lower BP rather than raise it, and hyperkalemia and bronchospasm are not the interaction risk.

23. An older patient with heart failure is on a lidocaine infusion during a long transfer. He now has perioral numbness, ringing in the ears, and confusion. What should you suspect?

    1. A. Opioid withdrawal
    2. B. An allergic reaction
    3. C. Early lidocaine toxicity
    4. D. A stroke needing thrombolysis
    Show answer

    Answer: C. Early lidocaine toxicity

    Perioral numbness, tinnitus, confusion, and later seizures are signs of lidocaine toxicity; heart failure, liver disease, and age reduce clearance. Stop or reduce the infusion and contact medical control. A stroke would not cause this cluster. Opioid withdrawal and allergy do not cause these findings.

24. A patient on dialysis with no urine output receives repeated magnesium sulfate during a long transfer. What is the main risk?

    1. A. Accumulation and magnesium toxicity
    2. B. Magnesium is cleared faster in dialysis
    3. C. Severe hypertension from the magnesium
    4. D. Magnesium is inactive in kidney failure
    Show answer

    Answer: A. Accumulation and magnesium toxicity

    Magnesium is removed by the kidneys, so it accumulates in kidney failure and can cause loss of reflexes, hypotension, and respiratory depression; doses are reduced and reflexes and breathing monitored. It is not cleared faster, does not cause hypertension, and is not inactive.

25. A swimmer in tropical waters was stung by a box jellyfish. What is applied to the sting first?

    1. A. Ice packed tightly on the skin
    2. B. Vinegar to inactivate stingers
    3. C. Urine on the sting
    4. D. Fresh water rubbed in firmly
    Show answer

    Answer: B. Vinegar to inactivate stingers

    Vinegar (4% to 6% acetic acid) inactivates the remaining nematocysts of box jellyfish; afterward, hot-water immersion helps the pain. Fresh water and rubbing can trigger more stingers to fire. Ice is less effective for pain, and urine is not recommended.

26. Why does the succinylcholine label warn against routine use in children?

    1. A. It cannot be dosed by weight
    2. B. It acts too slowly in small children
    3. C. It causes severe hypertension in infants
    4. D. Hyperkalemic arrest in hidden myopathy
    Show answer

    Answer: D. Hyperkalemic arrest in hidden myopathy

    Succinylcholine has a boxed warning for sudden hyperkalemic cardiac arrest in apparently healthy children with undiagnosed muscle diseases such as Duchenne dystrophy, so it is reserved for emergencies. It is fast-acting, not slow. Hypertension is not the problem, and it is dosed by weight.

27. A parent asks how to give a child liquid acetaminophen at home. Which advice best prevents dosing errors?

    1. A. Use a kitchen teaspoon
    2. B. Use a mL syringe or dosing cup
    3. C. Pour about half a cap
    4. D. Mix it into a full bottle of milk
    Show answer

    Answer: B. Use a mL syringe or dosing cup

    The AAP recommends dosing oral liquids in milliliters with a marked syringe or cup, because kitchen spoons vary and teaspoon-tablespoon confusion causes errors. Pouring an estimated amount is imprecise. Mixing into a bottle risks an incomplete dose.

28. Midazolam 5 mg/mL vs. 1 mg/mL concentration confusion leads to:

    1. A. Underdosing only, never overdosing
    2. B. An allergic reaction to the preservative
    3. C. No effect, since volume is the same
    4. D. A five-fold overdose or underdose
    Show answer

    Answer: D. A five-fold overdose or underdose

    Verify concentration before drawing up. The direction depends on which vial is used.

29. Fentanyl 50 mcg/mL vs. 'fentanyl 50 mg' confusion:

    1. A. Is a tenfold error that is rarely harmful
    2. B. Is common and clinically acceptable
    3. C. Is harmless, since the vial is labeled
    4. D. Is a thousandfold error; confirm units
    Show answer

    Answer: D. Is a thousandfold error; confirm units

    mcg vs. mg errors are lethal.

30. A toddler swallowed eye drops containing tetrahydrozoline (Visine). He is drowsy with small pupils and a heart rate of 70. What is the likely cause?

    1. A. Anticholinergic poisoning
    2. B. Acute opioid withdrawal
    3. C. Clonidine-like alpha-2 effects
    4. D. A harmless, nontoxic ingestion
    Show answer

    Answer: C. Clonidine-like alpha-2 effects

    Imidazolines such as tetrahydrozoline, swallowed by small children, act like clonidine, causing sedation, miosis, bradycardia, hypotension, and breathing problems; support breathing and transport. It is not harmless. Anticholinergic poisoning causes dilated pupils and a fast heart rate, and nothing suggests withdrawal.

31. A patient injected 100 units of long-acting insulin degludec and was given D10. What should you expect?

    1. A. Hyperglycemia as the insulin wears off
    2. B. No effect, because degludec is oral
    3. C. Hypoglycemia recurring for a day
    4. D. The glucose stays normal after one dose
    Show answer

    Answer: C. Hypoglycemia recurring for a day

    Long-acting insulins such as degludec act for a day or longer, so a large overdose causes recurrent hypoglycemia that needs repeated dextrose, infusions, and hospital observation. One dose of dextrose will not hold the glucose. Hyperglycemia is not expected, and degludec is injected.

32. A norepinephrine infusion runs into the only IV line, and a partner wants to push a saline flush through that line. What is the concern?

    1. A. There is no concern with this
    2. B. The flush dilutes the pressor dose
    3. C. It pushes a bolus of the pressor
    4. D. The flush clots the IV catheter
    Show answer

    Answer: C. It pushes a bolus of the pressor

    Flushing a line carrying a vasopressor pushes the drug already in the tubing into the patient as a bolus, which can cause a sudden spike in BP and dysrhythmias; give other drugs and flushes through a separate line. Saline does not meaningfully dilute the infusion or clot the catheter; the danger is the bolus.

33. In Arizona, a 3-year-old stung by a scorpion has roving eye movements, drooling, and restless thrashing. What is most likely?

    1. A. Opioid toxicity from a pill
    2. B. A febrile seizure in progress
    3. C. Bark scorpion envenomation
    4. D. A simple local reaction
    Show answer

    Answer: C. Bark scorpion envenomation

    The bark scorpion causes neurotoxicity in children, with roving eye movements, hypersalivation, and agitated limb movements; secretions threaten the airway, and an antivenom (Anascorp) is available at hospitals. A febrile seizure, a local reaction, and opioid toxicity do not cause this picture.

34. Why should liquid oral medications be drawn up in oral syringes that cannot connect to IV ports?

    1. A. They measure smaller volumes better
    2. B. They keep the drug sterile
    3. C. They make the oral dose more potent
    4. D. They block wrong-route IV use
    Show answer

    Answer: D. They block wrong-route IV use

    Oral syringes that cannot connect to IV lines prevent wrong-route errors, in which an oral liquid is injected IV with serious harm. Their purpose is not volume accuracy, sterility, or potency.

35. A partner plans to give tranexamic acid 1 g as a rapid IV push. What is the main concern?

    1. A. Rapid push causes bleeding
    2. B. Rapid push causes hypotension
    3. C. There is no concern
    4. D. Rapid push makes it ineffective
    Show answer

    Answer: B. Rapid push causes hypotension

    Rapid IV injection of tranexamic acid can cause hypotension, so it is given over about 10 minutes (no faster than about 100 mg/min). Speed does not make it ineffective or cause bleeding.

36. A hypoglycemic patient with a known pheochromocytoma has no IV access. Why is glucagon avoided?

    1. A. It interacts with adrenal steroids
    2. B. It causes severe bradycardia
    3. C. It can trigger a BP crisis
    4. D. It acts too slowly without an IV
    Show answer

    Answer: C. It can trigger a BP crisis

    Glucagon can stimulate catecholamine release from a pheochromocytoma, causing a hypertensive crisis, so its label lists pheochromocytoma as a contraindication; IO dextrose is used instead. Glucagon tends to raise rather than slow the heart rate, it works IM, and a steroid interaction is not the concern.

37. Which medication requires an independent double-check before administration in most agencies?

    1. A. Oral glucose gel for mild hypoglycemia
    2. B. A paralytic for intubation
    3. C. Chewable aspirin for suspected ACS
    4. D. Oxygen delivered by nonrebreather
    Show answer

    Answer: B. A paralytic for intubation

    A paralytic (neuromuscular blocker such as rocuronium) is a high-alert drug medication, along with opioids, insulin, and heparin, so most agencies require a two-provider check before giving it; weight-based pediatric doses are also double-checked. Oral glucose gel, chewable aspirin, and oxygen by nonrebreather are low-risk and do not usually need an independent check.

38. A patient with a suspected bowel obstruction is vomiting. Why is metoclopramide avoided?

    1. A. It sedates the patient too much for safe care
    2. B. It masks signs of a perforation
    3. C. It speeds the gut against the block
    4. D. It is too weak an antiemetic here
    Show answer

    Answer: C. It speeds the gut against the block

    Metoclopramide stimulates gut motility, which can worsen pain or cause perforation against a mechanical obstruction, so its label contraindicates use; another antiemetic such as ondansetron is chosen. It is not too weak, oversedation is not the labeled concern, and the risk is causing a perforation, not masking one.

39. A patient on warfarin has life-threatening bleeding. Which reversal treatment does the hospital typically give?

    1. A. IV vitamin K and PCC
    2. B. Protamine sulfate
    3. C. Idarucizumab (Praxbind)
    4. D. Naloxone
    Show answer

    Answer: A. IV vitamin K and PCC

    Life-threatening warfarin bleeding is reversed with IV vitamin K plus four-factor prothrombin complex concentrate (PCC), which replaces clotting factors quickly. Protamine reverses heparin. Idarucizumab reverses dabigatran. Naloxone reverses opioids.

40. Ketamine in a patient with severe hypertension or active psychosis:

    1. A. Is preferred because it lowers BP
    2. B. Needs caution; it can worsen both conditions
    3. C. Should be given at double the usual dose
    4. D. Is harmless at any analgesic dose
    Show answer

    Answer: B. Needs caution; it can worsen both conditions

    Relative contraindications require judgment. Ketamine raises BP and can worsen psychosis.

41. Rocuronium without a confirmed airway plan is dangerous because:

    1. A. It cannot be reversed by any drug
    2. B. It causes dangerous hyperkalemia
    3. C. Paralysis lasts 30–60 minutes or longer
    4. D. It wears off within about 5 minutes
    Show answer

    Answer: C. Paralysis lasts 30–60 minutes or longer

    Always have a backup airway plan and rescue device ready. A failed airway means prolonged apnea unless sugammadex is available.

42. Storing look-alike vials (e.g., epinephrine 1 mg/mL and 0.1 mg/mL) together:

    1. A. Has no measurable effect on error rates
    2. B. Is required by most state regulations
    3. C. Is efficient and speeds drug retrieval
    4. D. Increases wrong-concentration errors
    Show answer

    Answer: D. Increases wrong-concentration errors

    Physical separation is a key safeguard. Separate and label them clearly.

43. A handwritten order reads 'insulin 10U.' Why does 'U' appear on the Joint Commission's banned-abbreviation list?

    1. A. It stands for an outdated unit
    2. B. It means 'under the skin'
    3. C. It is not a unit of insulin
    4. D. It can be misread as 0 or 4
    Show answer

    Answer: D. It can be misread as 0 or 4

    A handwritten 'U' can be mistaken for a 0 or 4, turning 10U into 100 or 104 units, a potentially fatal insulin overdose; write 'units.' It is not an outdated unit, does not mean subcutaneous, and units are the correct measure for insulin.

44. High-alert medication lists are published by:

    1. A. The United States Pharmacopeia (USP)
    2. B. The Drug Enforcement Administration (DEA)
    3. C. The Institute for Safe Medication Practices
    4. D. The Food and Drug Administration (FDA) only
    Show answer

    Answer: C. The Institute for Safe Medication Practices

    ISMP maintains the acute-care high-alert list.

45. A medication is drawn up but not labeled and set aside. The safest action is:

    1. A. Give half of it and watch the response
    2. B. Discard it and draw up a labeled dose
    3. C. Use it, since you remember what it is
    4. D. Ask your partner what it contains
    Show answer

    Answer: B. Discard it and draw up a labeled dose

    Unlabeled syringes must never be administered.

46. A child swallowed gasoline while siphoning and is now coughing. What is the main danger, and what should be avoided?

    1. A. Liver failure; give charcoal
    2. B. Hypoglycemia; give glucose gel
    3. C. Kidney failure; give fluids and wait
    4. D. Aspiration; do not induce vomiting
    Show answer

    Answer: D. Aspiration; do not induce vomiting

    Hydrocarbons such as gasoline cause chemical pneumonitis when aspirated, and coughing suggests aspiration; vomiting is not induced and charcoal is not given because both raise aspiration risk. Liver failure, hypoglycemia, and kidney failure are not the main early dangers.

47. The safest overall practice with any high-alert medication is:

    1. A. Rely on a single check by your partner alone
    2. B. Trust the color coding on the packaging
    3. C. Use layered checks and monitor the response
    4. D. Do one careful check while drawing it up
    Show answer

    Answer: C. Use layered checks and monitor the response

    Layered safeguards prevent the rare but catastrophic error. Verify the rights, state the drug, dose, and concentration aloud, and have a second provider confirm. A single check, whether yours while drawing up or a partner's alone, misses errors that layered checks and monitoring catch.

48. Why is the symbol 'µg' on the error-prone list?

    1. A. It can be misread as 'mg'
    2. B. It is a European unit of measure
    3. C. It refers to grams
    4. D. It is an outdated unit of weight
    Show answer

    Answer: A. It can be misread as 'mg'

    A handwritten 'µg' can be misread as 'mg,' a thousandfold overdose, so 'mcg' should be written out instead. Microgram is a current metric unit used worldwide, not an outdated or regional one, and it is a millionth of a gram rather than a gram.

49. A patient's chart lists heparin-induced thrombocytopenia (HIT). During a transfer, what is important?

    1. A. Avoid heparin, including flushes
    2. B. Switch to enoxaparin for clot prevention
    3. C. Give platelets if the count is low
    4. D. Use heparin flushes for the line
    Show answer

    Answer: A. Avoid heparin, including flushes

    In HIT, any heparin exposure, even small flushes or heparin-coated catheters, can trigger antibody-mediated clotting and low platelets, so heparin in every form is avoided and saline flushes are used. Enoxaparin cross-reacts with HIT antibodies, and platelet transfusion can fuel the clotting, so neither is used.

50. To make push-dose epinephrine, a provider mixes 1 mL of the 1 mg/mL concentration with 9 mL of saline. What is the error?

    1. A. There is no error; this yields the usual 10 mcg/mL
    2. B. The result is 1,000 mcg/mL, a hundredfold error
    3. C. The result is 1 mcg/mL, one-tenth the intended strength
    4. D. The result is 100 mcg/mL, ten times the intended concentration
    Show answer

    Answer: D. The result is 100 mcg/mL, ten times the intended concentration

    Push-dose epinephrine at 10 mcg/mL is made from 1 mL of the 0.1 mg/mL concentration plus 9 mL of saline.

51. For a 15-kg child in cardiac arrest, a provider draws 1.5 mL from a 1 mg/mL epinephrine vial. What dose would be given?

    1. A. 0.015 mg, a tenfold underdose
    2. B. 15 mg, a hundredfold overdose
    3. C. 0.15 mg, the correct dose
    4. D. 1.5 mg, a tenfold overdose
    Show answer

    Answer: D. 1.5 mg, a tenfold overdose

    The correct dose is 0.15 mg, which is 1.5 mL of the 0.1 mg/mL concentration.

52. How should vials of neuromuscular blockers such as rocuronium be stored?

    1. A. Mixed with the sedatives
    2. B. In the glove box of the cab
    3. C. Apart, with a warning label
    4. D. With the saline flush syringes
    Show answer

    Answer: C. Apart, with a warning label

    ISMP recommends storing neuromuscular blockers separately, with auxiliary labels such as 'Warning: paralyzing agent,' because accidental use in a non-intubated patient causes respiratory arrest. Mixing them with sedatives or flushes invites mix-ups, and a glove box is not a controlled, temperature-appropriate location.

53. A patient's IV dextrose bag is labeled with another patient's name. What should you do?

    1. A. Cross out the name and hang it
    2. B. Use it if the bag is unopened
    3. C. Use it; dextrose is the same
    4. D. Replace it with a labeled bag
    Show answer

    Answer: D. Replace it with a labeled bag

    A mislabeled or wrong-patient fluid is removed and replaced, and the event reported, because the bag may contain additives or belong to another patient's order. Assuming the contents, crossing out the name, or relying on an unopened seal does not confirm what is in the bag or who it is for.

54. A patient who received ketamine for agitation is still agitated, and a provider wants to add a large dose of midazolam. What is the main risk?

    1. A. Worsened emergence agitation
    2. B. Additive respiratory depression
    3. C. Laryngospasm from the midazolam
    4. D. Severe rebound hypertension
    Show answer

    Answer: B. Additive respiratory depression

    Combining sedatives increases the risk of apnea and airway compromise; continuous capnography is essential. Midazolam tends to blunt emergence reactions rather than worsen them, and laryngospasm is a ketamine effect, not a midazolam one.

55. Sodium bicarbonate is pushed through an IV line, and epinephrine is given immediately afterward without a flush. What is the concern?

    1. A. The combination always causes immediate ventricular fibrillation
    2. B. There is no concern, because both drugs are compatible
    3. C. Epinephrine will convert bicarbonate into carbon dioxide gas
    4. D. Alkaline solutions can inactivate catecholamines in the line
    Show answer

    Answer: D. Alkaline solutions can inactivate catecholamines in the line

    Bicarbonate inactivates catecholamines and precipitates with calcium, so the line must be flushed between drugs.

56. Before leaving the home of an older patient, which step best supports medication safety at the hospital?

    1. A. Bring the prescription drugs alone
    2. B. Ask the family to look it up later
    3. C. Bring the bottles or a list
    4. D. Rely on the patient's memory
    Show answer

    Answer: C. Bring the bottles or a list

    Bringing the bottles or a current list (including over-the-counter drugs and supplements) lets the hospital reconcile medications and spot interactions or overdoses. Waiting for the family or trusting memory leads to omissions. Over-the-counter drugs and supplements also matter.

57. During a shortage, your agency stocks fentanyl 100 mcg/2 mL instead of 50 mcg/mL. What is required?

    1. A. Use the same volumes as before the change
    2. B. Double the usual volume drawn up
    3. C. Confirm the strength; recalculate
    4. D. Halve the usual volume
    Show answer

    Answer: C. Confirm the strength; recalculate

    Whenever a product's concentration or package differs, read the label and recalculate the volume for each dose; 100 mcg/2 mL equals 50 mcg/mL, but this must be confirmed rather than assumed. Using old volumes, doubling, or halving without checking invites errors.

58. Medical control orders fentanyl, and you are unsure whether you heard 15 mcg or 50 mcg. What should you do?

    1. A. Give 50 mcg because it is the usual adult dose
    2. B. Read back the order and clarify before giving
    3. C. Give 15 mcg because it is the smaller dose
    4. D. Split the difference and give about 30 mcg
    Show answer

    Answer: B. Read back the order and clarify before giving

    Fifteen and fifty are easily misheard; a closed-loop read-back with clarification prevents errors.

59. A patient taking methadone and haloperidol is vomiting. What is the concern with giving ondansetron?

    1. A. Ondansetron deeply sedates with methadone
    2. B. There is no interaction to be concerned about
    3. C. Ondansetron triggers opioid withdrawal here
    4. D. Additive QT prolongation and risk of torsades
    Show answer

    Answer: D. Additive QT prolongation and risk of torsades

    Methadone, haloperidol, and ondansetron all prolong the QT interval; consider an ECG and medical control. Ondansetron is not meaningfully sedating and does not block opioid receptors.

60. A family ate wild mushrooms for dinner and had no symptoms until severe vomiting and diarrhea began 10 hours later. Why is this worrying?

    1. A. It proves a simple viral illness
    2. B. It suggests amatoxin poisoning
    3. C. It means food allergy, not poisoning
    4. D. Delayed symptoms mean a mild case
    Show answer

    Answer: B. It suggests amatoxin poisoning

    Mushrooms that cause symptoms only after 6 or more hours, such as Amanita phalloides, contain amatoxins that cause delayed liver failure, so all who ate them need evaluation; bring a sample. Early-onset symptoms are usually less dangerous. Delayed GI illness after wild mushrooms is not assumed to be viral or allergic.

61. A toddler bit into a laundry detergent pod and is drooling, vomiting, and drowsy. What is the priority?

    1. A. Induce vomiting to clear the gel
    2. B. Airway and breathing, transport
    3. C. Give activated charcoal
    4. D. Give milk and observe at home
    Show answer

    Answer: B. Airway and breathing, transport

    Concentrated detergent pods can cause airway injury, aspiration, and CNS depression in young children, so airway and breathing come first, with transport; rinse any eye exposure. Inducing vomiting and charcoal raise aspiration risk. Home observation is unsafe with these symptoms.

62. A 70-kg 15-year-old is in VF. Using 5 mg/kg, the amiodarone dose would be 350 mg. What dose should be given?

    1. A. 300 mg, the adult maximum single dose
    2. B. 150 mg, the stable VT dose over 10 min
    3. C. 350 mg, as calculated by weight
    4. D. 700 mg, the 10 mg/kg pediatric dose
    Show answer

    Answer: A. 300 mg, the adult maximum single dose

    The pediatric amiodarone single dose should not exceed the adult dose of 300 mg.

63. A 70-kg adolescent has stable SVT. Using 0.1 mg/kg, the first adenosine dose would be 7 mg. What dose should be given?

    1. A. 6 mg, the maximum first dose
    2. B. 7 mg, as calculated by weight
    3. C. 12 mg, to ensure conversion
    4. D. 3 mg, half the adult dose
    Show answer

    Answer: A. 6 mg, the maximum first dose

    The pediatric first adenosine dose is 0.1 mg/kg up to a maximum of 6 mg.

64. A bystander injected the diluent from a glucagon emergency kit without mixing it with the powder. What happened?

    1. A. A double dose was given
    2. B. No glucagon was given
    3. C. Half a dose was given
    4. D. The full dose was given
    Show answer

    Answer: B. No glucagon was given

    In powder-and-diluent glucagon kits, the active drug is the powder; injecting the diluent alone delivers no glucagon. Ready-to-use autoinjectors and nasal forms avoid this step. The patient received no dose, not a full, double, or half dose.

65. A diabetic patient receives methylprednisolone 125 mg for asthma. What should you anticipate?

    1. A. Hypoglycemia
    2. B. A steady fall in the heart rate
    3. C. A rise in blood glucose
    4. D. Rapid deep sedation
    Show answer

    Answer: C. A rise in blood glucose

    Corticosteroids raise blood glucose over hours, particularly in diabetics, so the glucose is rechecked and the receiving team informed. They do not cause hypoglycemia, slow the heart, or sedate.

66. A patient with hypertrophic obstructive cardiomyopathy has chest pain. Why is nitroglycerin used with great caution?

    1. A. It causes coronary spasm
    2. B. Less preload worsens obstruction
    3. C. It raises the afterload sharply in HCM
    4. D. It causes reflex bradycardia
    Show answer

    Answer: B. Less preload worsens obstruction

    In obstructive HCM, reducing preload and afterload narrows the outflow tract further and can cause severe hypotension or syncope, so nitrates and other vasodilators are used cautiously or avoided. Nitroglycerin lowers rather than raises afterload, its reflex rate effect is tachycardia, and it does not cause coronary spasm.

67. A norepinephrine infusion is run by gravity without a pump or flow controller. What is the main risk?

    1. A. Inadvertent free flow causing a dangerous bolus
    2. B. The infusion will never reach therapeutic levels
    3. C. Gravity flow runs too slowly to raise the BP
    4. D. It requires a more concentrated bag
    Show answer

    Answer: A. Inadvertent free flow causing a dangerous bolus

    Vasoactive infusions require controlled delivery to avoid surges in BP and dysrhythmias. Gravity flow is not too slow or a reason to change the concentration; the problem is uncontrolled flow.

68. A worker collapsed in a manure pit, and a coworker who smelled 'rotten eggs' before it faded also collapsed. What should you do?

    1. A. Enter after the smell fades
    2. B. Lower a rope and climb in
    3. C. Do not enter without SCBA
    4. D. Enter fast with a surgical mask
    Show answer

    Answer: C. Do not enter without SCBA

    Hydrogen sulfide smells like rotten eggs at low levels, but at high levels it paralyzes the sense of smell and causes sudden collapse; would-be rescuers often become victims, so entry requires trained rescuers with SCBA. A mask gives no protection, and a fading smell signals danger, not safety.

69. Five minutes after IV ondansetron, a patient develops hives and itching. What should be done?

    1. A. Continue it and add diphenhydramine
    2. B. Give epinephrine 0.5 mg IM now
    3. C. Slow the next dose over 15 minutes
    4. D. Stop the drug, treat, and document
    Show answer

    Answer: D. Stop the drug, treat, and document

    A suspected drug reaction is managed by stopping the drug, treating as needed (and watching for anaphylaxis), documenting it, and reporting it so the allergy is recorded. Continuing or slowing the drug keeps exposing the patient to it, and IM epinephrine is reserved for signs of anaphylaxis rather than isolated hives.

70. An infusion is ordered at 30 mL/h, but the pump is set to 30 mL/min. How much faster is the drug delivered?

    1. A. 2 times faster
    2. B. 10 times faster
    3. C. 60 times faster
    4. D. 30 times faster
    Show answer

    Answer: C. 60 times faster

    There are 60 minutes in an hour, so 30 mL/min is 1,800 mL/h, 60 times the ordered 30 mL/h; clear unit labels and an independent pump check prevent this. 2, 10, and 30 times all understate the size of the error.

71. A handwritten order reads "midazolam 1.0 mg." What error can a trailing zero cause?

    1. A. It may be misread as 0.1 mg, a tenfold underdose
    2. B. It may be read as a 1-mL volume instead of a dose
    3. C. It may be misread as 10 mg, a tenfold overdose
    4. D. No error; trailing zeros are recommended for clarity
    Show answer

    Answer: C. It may be misread as 10 mg, a tenfold overdose

    Trailing zeros are prohibited because the decimal point can be missed.

72. A protocol lists a dose as ".5 mg." What is the safer way to write this dose?

    1. A. 0.5 mg, with a leading zero
    2. B. 5 mg, with the decimal removed
    3. C. 1/2 mg, using a fraction
    4. D. .50 mg, with a trailing zero
    Show answer

    Answer: A. 0.5 mg, with a leading zero

    A leading zero keeps the decimal point from being missed and the dose read as 5 mg.

73. A patient with a head injury and severe pain receives an opioid. Why is careful titration with ETCO2 monitoring important?

    1. A. Hypoventilation raises CO2 and ICP
    2. B. ETCO2 shows the opioid level
    3. C. Opioids lower the ICP
    4. D. Opioids cause seizures in head injury
    Show answer

    Answer: A. Hypoventilation raises CO2 and ICP

    Opioid-induced hypoventilation raises CO2, which dilates cerebral vessels and raises intracranial pressure, worsening secondary brain injury, so doses are titrated while watching ETCO2. Opioids do not lower ICP or cause seizures in this setting, and ETCO2 does not measure drug levels.

74. When a pediatric dose is calculated under stress, which practice most reduces error?

    1. A. Rounding the dose up to the nearest whole milliliter
    2. B. Having a second provider calculate it independently and compare
    3. C. Using the adult dose and halving it for all children
    4. D. Estimating the weight from the child's age without a tape
    Show answer

    Answer: B. Having a second provider calculate it independently and compare

    Independent double-checks catch calculation and decimal errors before administration.

75. Two patients in the same home both use insulin pens. Can one pen be used for both if the needle is changed?

    1. A. Yes, if the pen is wiped with alcohol
    2. B. Yes, in an emergency
    3. C. No; pens are for one patient only
    4. D. Yes, if the needle is changed
    Show answer

    Answer: C. No; pens are for one patient only

    Insulin pens must never be shared, even with a new needle, because blood can flow back into the cartridge and spread bloodborne infections. Changing the needle or wiping the pen does not remove this risk, and an emergency does not change it.

76. An adult in DKA has a pH of 7.18. Regarding sodium bicarbonate:

    1. A. It is not routinely recommended
    2. B. Give it routinely to fix the acidosis
    3. C. Give it instead of fluids
    4. D. Give it before checking glucose
    Show answer

    Answer: A. It is not routinely recommended

    Bicarbonate is generally not given in DKA unless the acidosis is extreme (pH below about 7.0), because fluids and insulin correct the acidosis and bicarbonate can worsen hypokalemia and other problems. It does not replace fluids, and the glucose check is not tied to it.

77. A patient took Percocet and an over-the-counter cold medicine and then extra Tylenol for pain. What is the main risk?

    1. A. Aspirin toxicity from the Percocet
    2. B. Acetaminophen overdose
    3. C. Opioid withdrawal from the Percocet
    4. D. Bleeding from the extra Tylenol
    Show answer

    Answer: B. Acetaminophen overdose

    Acetaminophen is in many combination products (Percocet, many cold remedies), so patients can exceed the daily maximum without realizing it and risk liver injury; ask about every product. The opioid is not being stopped, so withdrawal is not expected. Percocet contains acetaminophen, not aspirin, and acetaminophen does not cause bleeding at usual doses.

78. A teen chewed oleander leaves and now has vomiting, a heart rate of 40, and a potassium of 6.2. Which hospital antidote may be used?

    1. A. Digoxin Fab
    2. B. Flumazenil 0.2 mg
    3. C. Fomepizole IV
    4. D. Naloxone 2 mg IV
    Show answer

    Answer: A. Digoxin Fab

    Oleander contains cardiac glycosides that act like digoxin, causing vomiting, bradycardia, heart block, and hyperkalemia; digoxin immune Fab can bind them. Naloxone, flumazenil, and fomepizole treat opioid, benzodiazepine, and toxic alcohol poisoning.

79. A wader was stung on the ankle by a stingray and has severe pain. Which first-aid measure best relieves the pain?

    1. A. Hot water immersion
    2. B. Vinegar poured on the wound
    3. C. A tight tourniquet above it
    4. D. Ice packs on the wound itself
    Show answer

    Answer: A. Hot water immersion

    Stingray venom is heat-labile, so immersing the wound in water as hot as the patient can tolerate (without scalding) for 30 to 90 minutes relieves pain; the wound also needs irrigation and a check for a retained barb. Ice does not help this venom. Vinegar is for certain jellyfish. Tourniquets cause harm.