Metabolic, Toxicologic, and Other Agents Practice Questions

87 multiple-choice questions on Metabolic, toxicologic, and other agents 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.

87 practice questions

1. A patient says she took 'a bottle' of acetaminophen sometime today and feels fine. Which detail matters most to the receiving team?

   1. A. Whether she has vomited since
   2. B. The time of the ingestion
   3. C. Her pulse and blood pressure now
   4. D. What she ate before taking them
   Show answer

   Answer: B. The time of the ingestion

   The time of ingestion determines when a meaningful acetaminophen level can be drawn (at 4 hours or later for the nomogram) and how urgently acetylcysteine is needed, since it works best within 8 hours; bring the bottles and count the tablets. Vomiting, normal vital signs, and a recent meal do not rule out toxicity, because early acetaminophen poisoning often looks well; the ingestion time drives treatment.

2. Activated charcoal is contraindicated in patients with:

   1. A. Mild nausea without vomiting
   2. B. A recent ingestion of a tricyclic antidepressant
   3. C. Any overdose presenting after 30 minutes
   4. D. An unprotected airway or a caustic ingestion
   Show answer

   Answer: D. An unprotected airway or a caustic ingestion

   Aspiration of charcoal is serious. This includes a decreased level of consciousness.

3. A farm worker soaked in liquid pesticide has drooling, wheezing, and pinpoint pupils. Before loading him into the ambulance, what is essential?

   1. A. Load him first to save transport time
   2. B. Wrap him in a blanket, clothes on
   3. C. Remove his clothing; decontaminate
   4. D. Induce vomiting to remove poison
   Show answer

   Answer: C. Remove his clothing; decontaminate

   Organophosphates absorb through the skin and off-gas from clothing, so the crew wears protective equipment, removes contaminated clothing, and washes the skin before transport to protect the patient and the crew. Loading him unchanged or wrapping him keeps exposing everyone. Vomiting does nothing for a skin exposure and risks aspiration.

4. A worker splashed hydrofluoric acid on his hand and has severe pain with little visible damage. After irrigation, what is the specific topical treatment?

   1. A. Calcium gluconate gel
   2. B. Hydrocortisone cream
   3. C. Sodium bicarbonate paste
   4. D. Silver sulfadiazine cream
   Show answer

   Answer: A. Calcium gluconate gel

   Fluoride ions penetrate deeply and bind calcium, causing severe pain and tissue destruction (and dangerous hypocalcemia in large exposures); calcium gluconate gel binds the fluoride. Bicarbonate, silver sulfadiazine, and hydrocortisone do not bind fluoride.

5. A smoke-inhalation patient receiving hydroxocobalamin also needs other IV drugs. How should they be given?

   1. A. Through a separate IV line
   2. B. After a 24-hour wait
   3. C. Through the same line as the next push
   4. D. In the same line, mixed in the bag
   Show answer

   Answer: A. Through a separate IV line

   Hydroxocobalamin is physically incompatible with many drugs, so the label calls for a separate IV line. Mixing drugs in the same bag or line risks precipitation. Waiting 24 hours delays needed care. Pushing other drugs through the same line has the same incompatibility problem.

6. Calcium is the initial treatment for:

   1. A. Digoxin toxicity with hyperkalemia
   2. B. Hypoglycemia from a sulfonylurea overdose
   3. C. Opioid overdose with apnea
   4. D. CCB overdose and severe hyperkalemia
   Show answer

   Answer: D. CCB overdose and severe hyperkalemia

   In hyperkalemia it stabilizes the myocardium without lowering potassium. CCB = calcium channel blocker.

7. A patient in severe verapamil overdose is started on high-dose insulin therapy. Which two values need the closest monitoring?

   1. A. Calcium and magnesium
   2. B. Hemoglobin and platelets
   3. C. Sodium and chloride
   4. D. Glucose and potassium
   Show answer

   Answer: D. Glucose and potassium

   High-dose insulin (often 1 unit/kg, then an infusion) improves heart muscle function in calcium channel blocker and beta-blocker poisoning, but it drives glucose and potassium into cells, so dextrose is given and both are checked often. Sodium, chloride, hemoglobin, and platelets are not the main concerns. Calcium matters in this overdose but is not the main risk of insulin.

8. Medical control orders sodium bicarbonate 2 mEq/kg for a 75-kg patient. The syringes are 50 mEq each. How many syringes are needed?

   1. A. 2 syringes
   2. B. 3 syringes
   3. C. 1.5 syringes
   4. D. 15 syringes
   Show answer

   Answer: B. 3 syringes

   2 mEq/kg x 75 kg = 150 mEq; 150 divided by 50 mEq per syringe = 3 syringes. 2 syringes is only 100 mEq. 1.5 syringes is 75 mEq, or 1 mEq/kg. 15 syringes is a tenfold error.

9. Albuterol and insulin with dextrose are used in hyperkalemia to:

   1. A. Remove potassium through the kidneys
   2. B. Stabilize the myocardial cell membrane
   3. C. Bind potassium in the bloodstream
   4. D. Temporarily shift potassium into cells
   Show answer

   Answer: D. Temporarily shift potassium into cells

   Calcium stabilizes the heart; these shift potassium.

10. Tranexamic acid is used in trauma to:

    1. A. Reduce breakdown of formed clots
    2. B. Raise blood pressure by vasoconstriction
    3. C. Replace lost clotting factors and volume
    4. D. Reverse warfarin and other anticoagulants
    Show answer

    Answer: A. Reduce breakdown of formed clots

    It is most effective when given early after injury. It is used in significant hemorrhage.

11. Oxytocin may be used after delivery to:

    1. A. Stimulate labor in the field before delivery
    2. B. Contract the uterus to control bleeding
    3. C. Relieve uterine cramping pain after delivery
    4. D. Lower blood pressure in preeclampsia
    Show answer

    Answer: B. Contract the uterus to control bleeding

    Fundal massage is done alongside it. Uterine contraction controls postpartum hemorrhage.

12. A man who drank windshield-washer fluid 12 hours ago now says his vision looks like a 'snowstorm.' What should you suspect?

    1. A. Ethanol intoxication
    2. B. Methanol poisoning
    3. C. Carbon monoxide poisoning
    4. D. Opioid toxicity
    Show answer

    Answer: B. Methanol poisoning

    Windshield-washer fluid often contains methanol, which is metabolized to formic acid that damages the optic nerve and causes acidosis; symptoms are often delayed many hours, and treatment includes fomepizole and dialysis. Ethanol, carbon monoxide, and opioids do not cause this delayed visual loss.

13. A toddler swallowed a small amount of oil of wintergreen. Why is this treated as a serious poisoning?

    1. A. It is a concentrated form of alcohol
    2. B. It is concentrated salicylate
    3. C. It is a strong caustic acid
    4. D. It mainly triggers allergy
    Show answer

    Answer: B. It is concentrated salicylate

    Oil of wintergreen is nearly pure methyl salicylate; one teaspoon contains salicylate equal to roughly 7 g of aspirin, which can be lethal to a small child. Its danger is salicylate toxicity, not alcohol content, caustic burns, or allergy.

14. A 3-year-old drank from several leftover cocktails and is drowsy. Which complication should you check for right away?

    1. A. Hypertension
    2. B. Hyperthermia
    3. C. Hypoglycemia
    4. D. Hyperkalemia
    Show answer

    Answer: C. Hypoglycemia

    Ethanol blocks glucose production by the liver, and young children have small glycogen stores, so alcohol ingestion commonly causes hypoglycemia, which can lead to seizures; check the glucose and give dextrose if low. Hyperkalemia, hypertension, and hyperthermia are not typical of childhood ethanol ingestion.

15. Medical control orders glucagon 5 mg IV for a beta-blocker overdose. You carry 1-mg kits. How many kits are needed, and which side effect should you prepare for?

    1. A. 1 kit; expect hypoglycemia
    2. B. 5 kits; expect vomiting
    3. C. 50 kits; expect diarrhea
    4. D. 10 kits; expect hives
    Show answer

    Answer: B. 5 kits; expect vomiting

    5 mg divided by 1 mg per kit = 5 kits; high-dose glucagon commonly causes vomiting, so protect the airway and consider an antiemetic. One kit is a fifth of the dose, and glucagon raises glucose rather than lowering it. 50 kits is a tenfold error. 10 kits is double the order, and hives are not typical.

16. Calcium chloride stabilized the ECG of a hyperkalemic patient, but 40 minutes later the peaked T waves and wide QRS return. What explains this?

    1. A. The calcium was given too slowly
    2. B. Calcium raised the potassium level
    3. C. Calcium lowered the potassium too far
    4. D. Calcium's effect is temporary
    Show answer

    Answer: D. Calcium's effect is temporary

    Calcium stabilizes the heart's cell membranes within minutes, but the effect lasts only about 30 to 60 minutes and it does not lower potassium, so ECG changes can return and the dose may be repeated while potassium-shifting and removal treatments are given. Calcium neither raises nor lowers potassium, and the rate of the push does not explain changes returning 40 minutes later.

17. Sodium bicarbonate indications include:

    1. A. Respiratory acidosis from COPD or hypoventilation
    2. B. TCA overdose, hyperkalemia, and salicylate poisoning
    3. C. Any metabolic acidosis, including lactic acidosis in shock
    4. D. Hyperventilation syndrome and respiratory alkalosis
    Show answer

    Answer: B. TCA overdose, hyperkalemia, and salicylate poisoning

    Bicarbonate is a specific antidote, not a routine resuscitation drug. In TCA overdose the trigger is a QRS >100 ms; some other sodium-channel blocker toxicities also qualify.

18. An adult exposed to a nerve agent has severe symptoms: trouble breathing, copious secretions, and twitching. Per the DuoDote label, how many auto-injectors are given at first?

    1. A. One, then wait 1 hour to reassess
    2. B. Half of one injector, then reassess
    3. C. Ten in rapid succession
    4. D. Three in rapid succession
    Show answer

    Answer: D. Three in rapid succession

    For severe symptoms, the DuoDote label calls for three auto-injectors in rapid succession (mild symptoms start with one), followed by more atropine as needed. Waiting an hour after one delays treatment of a lethal exposure. A partial dose is not possible with the device. Ten at once exceeds the labeled initial dose.

19. A patient with severe organophosphate poisoning needs RSI. Why is succinylcholine avoided?

    1. A. Its paralysis may last for hours
    2. B. It worsens the miosis significantly
    3. C. It fails to paralyze these patients
    4. D. It causes cyanide release
    Show answer

    Answer: A. Its paralysis may last for hours

    Succinylcholine is broken down by plasma cholinesterase, which organophosphates inhibit, so paralysis can last far longer than expected; a non-depolarizing agent such as rocuronium is preferred (often at higher doses). Succinylcholine does not release cyanide, change pupil size in a meaningful way, or fail to paralyze.

20. A woman at 28 weeks' gestation has carbon monoxide exposure with a headache and nausea. Why is she treated more aggressively?

    1. A. Fetal hemoglobin holds CO tightly
    2. B. Her pulse oximeter reads accurately
    3. C. CO does not cross the placenta well
    4. D. Pregnancy blocks oxygen therapy
    Show answer

    Answer: A. Fetal hemoglobin holds CO tightly

    Fetal hemoglobin binds CO more tightly and clears it more slowly than maternal hemoglobin, so fetal levels can be higher and last longer; high-flow oxygen is given and hyperbaric treatment is considered at lower thresholds. CO does cross the placenta. Pregnancy does not block oxygen therapy. Standard pulse oximetry cannot detect CO poisoning.

21. Carbon monoxide poisoning is treated with:

    1. A. Hydroxocobalamin as the sole therapy
    2. B. Naloxone and supportive ventilation
    3. C. 100% oxygen, hyperbaric if severe
    4. D. Atropine titrated to dry secretions
    Show answer

    Answer: C. 100% oxygen, hyperbaric if severe

    Oxygen shortens CO half-life.

22. A 2-year-old swallowed a coin-sized button battery 1 hour ago and is breathing normally. Per poison center guidance, what may be given during transport?

    1. A. Honey 10 mL every 10 minutes
    2. B. Activated charcoal 1 g/kg
    3. C. Syrup of ipecac to vomit
    4. D. Nothing by mouth; it is unsafe
    Show answer

    Answer: A. Honey 10 mL every 10 minutes

    For a known or suspected button battery ingestion in a child 1 year or older within 12 hours, honey (10 mL every 10 minutes, up to 6 doses) coats the battery and slows esophageal burns, without delaying transport. Charcoal does not bind batteries and obscures endoscopy. Induced vomiting is not recommended. Honey is safe when the child can swallow.

23. A toddler drank liquid drain cleaner and is drooling. Which prehospital action is appropriate?

    1. A. Give activated charcoal 1 g/kg now
    2. B. Watch the airway; withhold charcoal
    3. C. Induce vomiting to clear the stomach
    4. D. Give vinegar to neutralize it
    Show answer

    Answer: B. Watch the airway; withhold charcoal

    Caustic ingestions are not treated with charcoal (it does not bind them and obscures endoscopy), induced vomiting (it re-exposes the esophagus), or neutralizing agents (they cause heat injury); the focus is the airway, because drooling and stridor can signal swelling, and rapid transport.

24. A toddler who chewed a grandparent's clonidine patch has pinpoint pupils, a heart rate of 70, and shallow breathing. What is accurate?

    1. A. Clonidine causes dilated pupils
    2. B. Atropine is the specific antidote
    3. C. It mimics opioids; naloxone is unreliable
    4. D. Clonidine poisoning causes a fast heart rate
    Show answer

    Answer: C. It mimics opioids; naloxone is unreliable

    Clonidine, a central alpha-2 agonist, causes miosis, bradycardia, hypotension, sedation, and apnea that mimic opioid toxicity; naloxone helps some children but inconsistently, so ventilation and supportive care come first. Clonidine does not dilate the pupils or speed the heart. Atropine may treat the bradycardia but is not a specific antidote.

25. Insulin in EMS is used for:

    1. A. Hypoglycemia in insulin-dependent diabetics
    2. B. DKA in every prehospital ALS system
    3. C. Hyperkalemia, given with dextrose
    4. D. Refractory nausea in diabetic patients
    Show answer

    Answer: C. Hyperkalemia, given with dextrose

    Insulin shifts potassium intracellularly; not used prehospital in most basic ALS systems. Some critical care protocols give 10 units regular insulin with 25 g dextrose.

26. A toddler ate several prenatal iron tablets. She vomited twice, and now, 8 hours later, seems better. What is accurate?

    1. A. A quiet phase can precede shock
    2. B. Iron is harmless in small children
    3. C. Give charcoal to bind the iron
    4. D. She has recovered; release her to the parents
    Show answer

    Answer: A. A quiet phase can precede shock

    Iron poisoning often has an early GI phase, then a deceptively quiet 'latent' phase before shock, acidosis, and liver failure, so a child who seems better still needs evaluation and possibly deferoxamine. Iron is a leading cause of pediatric poisoning deaths. Charcoal does not bind iron.

27. An 80-year-old with type 2 diabetes is confused, very dry, with a glucose reading of 'HI' (over 600) and no ketones. What is the priority prehospital treatment?

    1. A. Oral fluids, then observation
    2. B. Insulin 10 units IV push
    3. C. Isotonic fluid boluses
    4. D. D50 25 g IV push
    Show answer

    Answer: C. Isotonic fluid boluses

    This picture suggests hyperosmolar hyperglycemic state, with profound dehydration (often several liters), so isotonic fluid resuscitation is the priority; insulin is started later in the hospital after potassium is known. D50 would worsen hyperglycemia. A confused patient cannot safely drink enough to correct the deficit.

28. Hypertonic saline (3%) is used in:

    1. A. Hypovolemic shock as the first-line fluid
    2. B. DKA to correct pseudohyponatremia
    3. C. Herniating TBI and severe hyponatremia
    4. D. All head injuries with a GCS under 15
    Show answer

    Answer: C. Herniating TBI and severe hyponatremia

    Osmotic agents reduce ICP temporarily. Use per protocol for TBI with signs of herniation and for symptomatic hyponatremia.

29. Mannitol dose for increased ICP is:

    1. A. 0.5–1 g/kg IV
    2. B. 5 g/kg IV
    3. C. 0.1 g/kg IV
    4. D. 100 g IV for every adult
    Show answer

    Answer: A. 0.5–1 g/kg IV

    Osmotic diuretic; avoid in hypotension.

30. Oxytocin for postpartum hemorrhage is:

    1. A. 10 units IM, or 20–40 units in 1 L IV
    2. B. 10 units as a rapid undiluted IV push
    3. C. Contraindicated until hospital arrival
    4. D. 1 unit IM, repeated every 10 minutes
    Show answer

    Answer: A. 10 units IM, or 20–40 units in 1 L IV

    Given after delivery of the placenta; uterine massage first.

31. Oxytocin is contraindicated:

    1. A. Before all fetuses are delivered
    2. B. After the placenta has delivered
    3. C. For postpartum hemorrhage from atony
    4. D. When IV access is already established
    Show answer

    Answer: A. Before all fetuses are delivered

    Oxytocin contracts the uterus, so given before all babies are delivered (for example, an undiagnosed twin) it can trap the fetus and cause hypoxia or uterine rupture. Giving it after the placenta delivers is standard, postpartum hemorrhage from uterine atony is its main use, and an existing IV simply allows it to be infused IV.

32. Magnesium sulfate for preterm labor (tocolysis) is:

    1. A. Given orally, 400 mg every 6 hours
    2. B. 1 g IV push, repeated every hour
    3. C. Contraindicated in preterm labor
    4. D. 4–6 g IV load, then 1–2 g/hr
    Show answer

    Answer: D. 4–6 g IV load, then 1–2 g/hr

    Also provides fetal neuroprotection. This is a hospital or critical care therapy.

33. A woman at 30 weeks' gestation is having regular painful contractions. Regarding terbutaline in this setting, what is accurate?

    1. A. Prolonged use carries an FDA warning
    2. B. It is first-line for long-term use
    3. C. It is given IM every 10 minutes
    4. D. It reliably stops preterm labor for good
    Show answer

    Answer: A. Prolonged use carries an FDA warning

    The FDA's boxed warning states that injectable terbutaline should not be used for prolonged (beyond 48 to 72 hours) prevention or treatment of preterm labor because of serious maternal heart problems and death; in the field, transport to an obstetric center is the priority. It is not first-line for long-term use, is not given IM every 10 minutes, and does not reliably stop labor.

34. Rh immune globulin (RhoGAM) is relevant to EMS because:

    1. A. It controls postpartum hemorrhage in the field
    2. B. Bleeding Rh-negative mothers need it within 72 hours
    3. C. It is a tocolytic used for preterm labor
    4. D. Paramedics routinely give it after field deliveries
    Show answer

    Answer: B. Bleeding Rh-negative mothers need it within 72 hours

    Awareness supports appropriate handoff. It is given in the hospital; document and report Rh status.

35. A patient exposed to a nerve agent has had atropine and pralidoxime and now has a generalized seizure. Which drug is indicated?

    1. A. Physostigmine IV
    2. B. Naloxone 2 mg IV
    3. C. More pralidoxime, without other drugs
    4. D. A benzodiazepine
    Show answer

    Answer: D. A benzodiazepine

    Nerve agent seizures are treated with a benzodiazepine (midazolam IM is FDA-approved for this, and diazepam auto-injectors are also used), in addition to continued atropine. Pralidoxime does not stop seizures. Physostigmine is a cholinesterase inhibitor and would worsen the poisoning. Naloxone has no role.

36. A 6-year-old with congenital adrenal hyperplasia is vomiting and lethargic. What is the usual weight-based emergency hydrocortisone dose, IM or IV?

    1. A. 2 mg/kg, up to 100 mg
    2. B. 0.2 mg/kg, up to 10 mg
    3. C. 10 mg/kg, up to 500 mg
    4. D. 30 mg/kg, up to 1 g
    Show answer

    Answer: A. 2 mg/kg, up to 100 mg

    Adrenal crisis is treated with hydrocortisone about 2 mg/kg IM or IV, up to 100 mg; some references use age bands instead, which differ by scheme, so follow local protocol. 0.2 mg/kg up to 10 mg is far too little to cover the stress, while 10 mg/kg up to 500 mg and 30 mg/kg up to 1 g (a methylprednisolone-style megadose) far exceed stress-dose needs.

37. During a transfer, potassium chloride 10 mEq in 100 mL is ordered over 1 hour by a peripheral IV. What pump rate is set?

    1. A. 1,000 mL/h
    2. B. 50 mL/h
    3. C. 100 mL/h
    4. D. 10 mL/h
    Show answer

    Answer: C. 100 mL/h

    100 mL over 1 hour = 100 mL/h, which gives 10 mEq/h, a common maximum peripheral rate. 10 mL/h would take 10 hours. 1,000 mL/h would give the dose in 6 minutes, a dangerous rate. 50 mL/h would take 2 hours.

38. Diphenhydramine dose for allergic reaction is:

    1. A. 5 mg IV/IM/PO
    2. B. 100–200 mg IV/IM
    3. C. 0.1 mg/kg IV only
    4. D. 25–50 mg IV/IM/PO
    Show answer

    Answer: D. 25–50 mg IV/IM/PO

    Pediatric 1 mg/kg (max 50 mg).

39. A patient with methemoglobinemia from benzocaine takes sertraline. Which risk of methylene blue should be considered?

    1. A. Rebound hyperkalemia
    2. B. Acute opioid withdrawal
    3. C. Cyanide toxicity from the drug
    4. D. Serotonin syndrome
    Show answer

    Answer: D. Serotonin syndrome

    Methylene blue inhibits monoamine oxidase and can cause serotonin syndrome with serotonergic drugs such as SSRIs (FDA warning); it is also avoided in G6PD deficiency because it can cause hemolysis. It does not cause cyanide toxicity, hyperkalemia, or opioid withdrawal.

40. A patient on lithium recently began ibuprofen and has had vomiting and diarrhea. She now has a coarse tremor and confusion. What is most likely?

    1. A. Hypoglycemia from ibuprofen
    2. B. Opioid toxicity
    3. C. Serotonin syndrome
    4. D. Lithium toxicity
    Show answer

    Answer: D. Lithium toxicity

    Dehydration and NSAIDs reduce lithium clearance, so levels rise and cause tremor, confusion, ataxia, and vomiting; treatment is IV fluids and hospital care, sometimes dialysis (charcoal does not bind lithium). Serotonin syndrome needs serotonergic drugs. Ibuprofen does not cause hypoglycemia. Nothing suggests opioids.

41. N-acetylcysteine is the antidote for:

    1. A. Aspirin (salicylate) overdose
    2. B. Ibuprofen overdose
    3. C. Acetaminophen overdose
    4. D. Opioid overdose
    Show answer

    Answer: C. Acetaminophen overdose

    Most effective within 8 hours of ingestion.

42. Physostigmine is used for:

    1. A. Benzodiazepine overdose with coma
    2. B. Severe anticholinergic toxicity
    3. C. Organophosphate pesticide poisoning
    4. D. Opioid-induced respiratory depression
    Show answer

    Answer: B. Severe anticholinergic toxicity

    Reversible cholinesterase inhibitor; risk of bradycardia and seizures. It is used with caution.

43. A 60-kg patient has cardiac arrest from local anesthetic toxicity. Per ASRA, the 20% lipid emulsion bolus is 1.5 mL/kg for patients 70 kg or less. What volume is given?

    1. A. 9 mL
    2. B. 900 mL
    3. C. 150 mL
    4. D. 90 mL
    Show answer

    Answer: D. 90 mL

    1.5 mL/kg x 60 kg = 90 mL of 20% lipid emulsion over 2 to 3 minutes, followed by an infusion (patients over 70 kg receive 100 mL). 9 mL and 900 mL are tenfold errors. 150 mL is 2.5 mL/kg.

44. Octreotide is used for:

    1. A. Opioid-induced respiratory depression
    2. B. Insulin overdose from an insulin pump
    3. C. Beta blocker overdose with bradycardia
    4. D. Sulfonylurea-induced hypoglycemia
    Show answer

    Answer: D. Sulfonylurea-induced hypoglycemia

    Given in hospital after dextrose. It reduces insulin release.

45. Deferoxamine is the antidote for:

    1. A. Arsenic poisoning
    2. B. Mercury poisoning
    3. C. Lead poisoning
    4. D. Iron poisoning
    Show answer

    Answer: D. Iron poisoning

    Chelates iron.

46. Flumazenil, naloxone, and atropine are all examples of:

    1. A. Receptor antagonists used as antidotes
    2. B. Positive inotropes used in shock
    3. C. Receptor agonists used as antidotes
    4. D. Sedative-hypnotics used for agitation
    Show answer

    Answer: A. Receptor antagonists used as antidotes

    Each blocks a specific receptor to reverse toxicity.

47. Thiamine dose is:

    1. A. 10 mg IV/IM
    2. B. 1 mg/kg IV/IM
    3. C. 1 g IV/IM
    4. D. 100 mg IV/IM
    Show answer

    Answer: D. 100 mg IV/IM

    Given to malnourished or alcoholic patients.

48. In a hypertensive emergency without aortic dissection, how fast should the BP generally be lowered in the first hour?

    1. A. Leave it until the next day
    2. B. By no more than about 25%
    3. C. To normal within 10 minutes
    4. D. By at least 50% right away
    Show answer

    Answer: B. By no more than about 25%

    Guidelines advise lowering the BP by no more than about 25% in the first hour, then gradually, because rapid drops can cause stroke, MI, or kidney injury in patients adapted to high pressures; aortic dissection is an exception that needs faster control. Normalizing in minutes or halving it is too aggressive. Waiting a day leaves organ damage untreated.

49. Labetalol for hypertensive emergency is dosed:

    1. A. 1 mg IV push, repeated every 5 minutes
    2. B. 100 mg IV push as a single dose
    3. C. 0.1 mg/kg IV push, repeated every 30 min
    4. D. 10–20 mg IV over 2 min, doubled every 10 min
    Show answer

    Answer: D. 10–20 mg IV over 2 min, doubled every 10 min

    Combined alpha/beta blocker; avoid in asthma and heart failure.

50. An epinephrine infusion is mixed as 1 mg in 250 mL. What rate delivers 2 mcg/min?

    1. A. 3 mL/h
    2. B. 300 mL/h
    3. C. 30 mL/h
    4. D. 8 mL/h
    Show answer

    Answer: C. 30 mL/h

    1 mg in 250 mL = 4 mcg/mL; 2 mcg/min divided by 4 mcg/mL = 0.5 mL/min, or 30 mL/h. 3 mL/h and 300 mL/h are tenfold errors. 8 mL/h confuses the concentration with the rate and delivers only about 0.5 mcg/min.

51. Norepinephrine infusion starting dose is:

    1. A. 1 mcg/min fixed, never titrated
    2. B. 0.05–0.1 mcg/kg/min, titrated to MAP ≥65
    3. C. 1 mg/min, titrated to MAP ≥65
    4. D. 10 mcg/kg/min, titrated to SBP ≥90
    Show answer

    Answer: B. 0.05–0.1 mcg/kg/min, titrated to MAP ≥65

    First-line vasopressor in septic shock. This is about 2–4 mcg/min in adults.

52. A runner with exertional heat stroke has a core temperature of 41.8 C. A bystander asks about dantrolene. What is accurate?

    1. A. It is first-line for heat stroke
    2. B. It lowers the temperature in minutes
    3. C. It has no proven role; cool rapidly
    4. D. It replaces cold-water immersion
    Show answer

    Answer: C. It has no proven role; cool rapidly

    Dantrolene treats malignant hyperthermia but has not been shown to help heat stroke; rapid cooling, ideally cold-water immersion, is the treatment. It is not first-line, does not reliably lower temperature in heat stroke, and never replaces cooling.

53. Dobutamine is indicated in:

    1. A. Septic shock as the first-line pressor
    2. B. Cardiogenic shock with adequate BP
    3. C. Anaphylactic shock after epinephrine
    4. D. Hypovolemic shock before fluid resuscitation
    Show answer

    Answer: B. Cardiogenic shock with adequate BP

    Dobutamine may cause vasodilation and hypotension. It provides inotropic support at 2–20 mcg/kg/min.

54. Phenylephrine push-dose is:

    1. A. 0.1 mg/kg IV (1 mg/mL diluted in saline)
    2. B. 50–200 mcg IV (100 mcg/mL diluted)
    3. C. 1 mg IV push (10 mg/mL undiluted)
    4. D. 5–10 mg IV (10 mg/mL undiluted)
    Show answer

    Answer: B. 50–200 mcg IV (100 mcg/mL diluted)

    Pure alpha agonist; causes reflex bradycardia.

55. Vasopressin for shock is infused at:

    1. A. 40 units IV push, then 1 unit/min
    2. B. 1–2 units/min
    3. C. 0.3–0.4 units/min
    4. D. 0.03–0.04 units/min
    Show answer

    Answer: D. 0.03–0.04 units/min

    Non-titrated adjunct in septic shock. It is an adjunct to norepinephrine.

56. A dialysis patient who missed treatment has a pulse, a heart rate of 48, and a wide QRS with peaked T waves. Which drug should be given first?

    1. A. Amiodarone 150 mg IV over 10 minutes
    2. B. Calcium chloride 1 g IV slowly
    3. C. Furosemide 40 mg IV push
    4. D. Atropine 1 mg IV push, repeated
    Show answer

    Answer: B. Calcium chloride 1 g IV slowly

    Calcium stabilizes the cardiac membrane within minutes in hyperkalemia with ECG changes.

57. Why is nebulized albuterol given after calcium in a patient with hyperkalemia?

    1. A. Albuterol boosts calcium's membrane effect
    2. B. Albuterol removes potassium from the body
    3. C. Albuterol offsets the potassium calcium adds
    4. D. Calcium does not lower the potassium level
    Show answer

    Answer: D. Calcium does not lower the potassium level

    Albuterol shifts potassium into cells; neither calcium nor albuterol removes potassium from the body. Calcium only stabilizes the cardiac membrane. Albuterol does not strengthen calcium's membrane effect, and calcium does not add potassium.

58. For hyperkalemia, nebulized albuterol is commonly dosed at:

    1. A. 100 mg nebulized
    2. B. 10 to 20 mg nebulized
    3. C. 2.5 mg by MDI with spacer
    4. D. 0.25 mg nebulized
    Show answer

    Answer: B. 10 to 20 mg nebulized

    Doses for potassium shifting are several times higher than the usual bronchodilator dose.

59. A patient who overdosed on amitriptyline has a QRS of 140 ms and a BP of 82/50. Which treatment is indicated?

    1. A. Procainamide 20 mg/min IV until the QRS narrows
    2. B. Calcium chloride 1 g IV, repeated every 5 minutes
    3. C. Physostigmine 1 mg IV to reverse the toxicity
    4. D. Sodium bicarbonate 1 to 2 mEq/kg IV, repeated
    Show answer

    Answer: D. Sodium bicarbonate 1 to 2 mEq/kg IV, repeated

    Bicarbonate overcomes the sodium channel blockade of tricyclic antidepressants; class IA antidysrhythmics and physostigmine are avoided. Repeat to narrow the QRS.

60. A patient who overdosed on amlodipine has a BP of 70/40 and a heart rate of 60. Which treatments are appropriate?

    1. A. IV calcium, fluids, and vasopressors
    2. B. Atropine alone, then observe closely
    3. C. Naloxone and activated charcoal only
    4. D. Fluids alone, avoiding vasopressors
    Show answer

    Answer: A. IV calcium, fluids, and vasopressors

    Calcium channel blocker toxicity is treated with calcium, fluids, and vasopressors; the hospital may add high-dose insulin. Atropine alone rarely restores BP in calcium channel blocker shock, fluids without vasopressors are usually not enough, and naloxone and charcoal do not treat the shock.

61. A patient who overdosed on propranolol has a heart rate of 36 and a BP of 70/40, and atropine had no effect. Which drug is specifically indicated?

    1. A. Flumazenil 0.2 mg IV
    2. B. Glucagon 3 to 5 mg IV
    3. C. Diltiazem 20 mg IV
    4. D. Adenosine 12 mg IV
    Show answer

    Answer: B. Glucagon 3 to 5 mg IV

    Glucagon raises cAMP independently of beta receptors, improving heart rate and contractility in beta blocker toxicity.

62. A farm worker has pinpoint pupils, drooling, wheezing with copious bronchial secretions, and bradycardia. What is the most important drug therapy?

    1. A. Atropine 2 to 4 mg IV, repeated
    2. B. Albuterol 2.5 mg nebulized alone
    3. C. Naloxone 2 mg IV, repeated as needed
    4. D. Atropine 0.5 mg IV once, then reassess
    Show answer

    Answer: A. Atropine 2 to 4 mg IV, repeated

    Organophosphate poisoning often requires large, repeated atropine doses titrated to drying of respiratory secretions.

63. During atropine dosing for organophosphate poisoning, the heart rate reaches 118, but the patient still has wet crackles and copious secretions. What is appropriate?

    1. A. Give metoprolol, then give more atropine
    2. B. Switch to naloxone for the secretions
    3. C. Continue atropine until secretions dry
    4. D. Stop atropine because of the heart rate
    Show answer

    Answer: C. Continue atropine until secretions dry

    Tachycardia is not a reason to stop atropine in organophosphate poisoning (it may come from hypoxia or nicotinic effects); doses are repeated, often doubled, until the bronchial secretions dry and breathing improves. A beta blocker is not used. Naloxone does not reverse cholinergic effects.

64. A DuoDote or ATNAA auto-injector for nerve agent exposure contains:

    1. A. Atropine 0.5 mg and pralidoxime 60 mg
    2. B. Atropine 21 mg and pralidoxime 6 g
    3. C. Diazepam 10 mg and pralidoxime 600 mg
    4. D. Atropine 2.1 mg and pralidoxime 600 mg
    Show answer

    Answer: D. Atropine 2.1 mg and pralidoxime 600 mg

    Each dual-chamber auto-injector delivers 2.1 mg of atropine and 600 mg of pralidoxime chloride IM.

65. A house fire victim is confused and hypotensive with soot around the mouth. Which antidote is most appropriate?

    1. A. Hydroxocobalamin 5 g IV over 15 minutes
    2. B. Sodium bicarbonate 50 mEq IV push
    3. C. Naloxone 2 mg IV, repeated every 3 minutes
    4. D. Methylene blue 1 to 2 mg/kg IV over 5 minutes
    Show answer

    Answer: A. Hydroxocobalamin 5 g IV over 15 minutes

    Smoke inhalation often includes cyanide; hydroxocobalamin binds cyanide to form cyanocobalamin.

66. After hydroxocobalamin, a patient's skin and urine turn red. This finding is:

    1. A. An allergic reaction to the drug
    2. B. A sign of acute renal failure
    3. C. A sign of developing rhabdomyolysis
    4. D. An expected effect of the drug
    Show answer

    Answer: D. An expected effect of the drug

    Hydroxocobalamin is a deep red compound that discolors skin and urine and can interfere with some lab tests.

67. Using 70 mg/kg, what hydroxocobalamin dose is appropriate for a 20-kg child with suspected cyanide toxicity from smoke?

    1. A. 14 g IV
    2. B. 1.4 g IV
    3. C. 5 g IV
    4. D. 140 mg IV
    Show answer

    Answer: B. 1.4 g IV

    The pediatric hydroxocobalamin dose is 70 mg/kg, up to the adult dose of 5 g.

68. A patient with suspected carbon monoxide poisoning has an SpO2 reading of 99%. What is the best interpretation and action?

    1. A. The reading indicates cyanide; give hydroxocobalamin
    2. B. The reading confirms no poisoning; no oxygen is needed
    3. C. The reading is accurate; use a nasal cannula only
    4. D. The reading is unreliable; give 100% oxygen by nonrebreather
    Show answer

    Answer: D. The reading is unreliable; give 100% oxygen by nonrebreather

    Standard pulse oximetry cannot distinguish carboxyhemoglobin from oxyhemoglobin.

69. After heavy use of benzocaine throat spray, a patient is cyanotic with an SpO2 of 85% unresponsive to oxygen, and the blood looks chocolate-brown. What is the likely diagnosis and antidote?

    1. A. Opioid toxicity; naloxone
    2. B. Methemoglobinemia; methylene blue
    3. C. Cyanide toxicity; hydroxocobalamin
    4. D. Carbon monoxide; hyperbaric oxygen
    Show answer

    Answer: B. Methemoglobinemia; methylene blue

    Oxidizing agents such as benzocaine and dapsone cause methemoglobinemia, treated with methylene blue 1 to 2 mg/kg.

70. Which ingested substance is NOT well adsorbed by activated charcoal?

    1. A. Acetaminophen
    2. B. Lithium
    3. C. Carbamazepine
    4. D. Aspirin
    Show answer

    Answer: B. Lithium

    Charcoal poorly binds metals and ions such as lithium and iron, as well as alcohols.

71. Using 1 g/kg, what activated charcoal dose is appropriate for a 15-kg child with a recent toxic ingestion and an intact airway?

    1. A. 15 g PO
    2. B. 50 g PO
    3. C. 1.5 g PO
    4. D. 150 g PO
    Show answer

    Answer: A. 15 g PO

    Activated charcoal is commonly 1 g/kg, typically up to 50 g in adults, when indicated by protocol or poison control.

72. A patient with salicylate poisoning is tachypneic and vomiting with tinnitus. If the patient must be intubated, which is critical?

    1. A. Ventilate at 8 breaths/min to prevent alkalosis
    2. B. Maintain a high minute ventilation to avoid worsening acidosis
    3. C. Give a paralytic only, with no ventilator changes
    4. D. Avoid sodium bicarbonate because it worsens toxicity
    Show answer

    Answer: B. Maintain a high minute ventilation to avoid worsening acidosis

    These patients compensate with hyperventilation; normal ventilator rates allow acidosis to worsen and drive more salicylate into the brain.

73. A well-appearing toddler may have swallowed one of a grandparent's extended-release verapamil tablets an hour ago. Why is transport needed?

    1. A. Severe toxicity may appear later
    2. B. Symptoms would have begun by now
    3. C. He needs charcoal at home first
    4. D. A single tablet cannot cause toxicity
    Show answer

    Answer: A. Severe toxicity may appear later

    Some drugs, including calcium channel blockers, can cause serious toxicity in a toddler from one tablet, and extended-release forms can cause delayed bradycardia and hypotension many hours later, so observation is needed. A single tablet can be toxic, extended-release forms may cause no symptoms for many hours, and home charcoal is not a substitute for monitoring.

74. A patient on sertraline took tramadol and is now agitated and diaphoretic with hyperthermia and lower-extremity clonus. Which treatment is most appropriate?

    1. A. Haloperidol and physical restraint
    2. B. Physostigmine and atropine
    3. C. Naloxone and activated charcoal
    4. D. Benzodiazepines and active cooling
    Show answer

    Answer: D. Benzodiazepines and active cooling

    These findings suggest serotonin syndrome, which is managed with benzodiazepines, cooling, and stopping serotonergic drugs.

75. After a diphenhydramine overdose, a patient is hot, dry, flushed, agitated, and has dilated pupils. Which treatment is most appropriate prehospital?

    1. A. Flumazenil to reverse the sedation
    2. B. Atropine to reverse the toxidrome
    3. C. Haloperidol 10 mg IM for agitation
    4. D. Benzodiazepines for agitation and cooling
    Show answer

    Answer: D. Benzodiazepines for agitation and cooling

    Anticholinergic toxicity is managed supportively; antipsychotics are avoided, and a wide QRS may require bicarbonate.

76. A patient who overdosed on isoniazid has seizures that do not respond to benzodiazepines. Which antidote is specific?

    1. A. Pyridoxine (vitamin B6)
    2. B. Deferoxamine (chelator)
    3. C. Thiamine (vitamin B1)
    4. D. Fomepizole (ADH inhibitor)
    Show answer

    Answer: A. Pyridoxine (vitamin B6)

    Isoniazid depletes pyridoxine, reducing GABA synthesis; pyridoxine replaces it.

77. An 82-year-old has taken extra aspirin for arthritis for weeks. She is confused, breathing fast, and slightly febrile. What should you suspect?

    1. A. Opioid overdose from her pain pills
    2. B. Normal aging changes in the elderly
    3. C. Chronic salicylate toxicity
    4. D. Progressing dementia
    Show answer

    Answer: C. Chronic salicylate toxicity

    Chronic salicylate toxicity in older adults causes confusion, rapid breathing, fever, and nausea, and it is often mistaken for sepsis or dementia; it carries a high mortality, so ask about aspirin and other salicylate products. Dementia and normal aging do not cause rapid breathing and fever. Opioid overdose slows breathing.

78. A 30-kg child in DKA is tachycardic with delayed capillary refill. Per many protocols, what initial fluid is appropriate?

    1. A. 60 mL/kg NS as rapidly as possible, then reassess
    2. B. D5W at 20 mL/kg to prevent hypoglycemia
    3. C. No fluids until insulin has been started
    4. D. 10 to 20 mL/kg NS (300 to 600 mL), then reassess
    Show answer

    Answer: D. 10 to 20 mL/kg NS (300 to 600 mL), then reassess

    Pediatric DKA fluids are given in measured boluses because of concern for cerebral edema.

79. An adult in DKA has a BP of 92/60 and signs of dehydration. Which prehospital therapy is appropriate?

    1. A. Insulin 10 units IV push before any fluid
    2. B. D50 25 g IV to correct the ketosis
    3. C. A 1-L NS bolus; insulin is not given prehospital
    4. D. Sodium bicarbonate 1 mEq/kg IV push, repeated
    Show answer

    Answer: C. A 1-L NS bolus; insulin is not given prehospital

    Volume replacement is the key prehospital treatment; insulin is managed in the hospital with potassium monitoring.

80. A patient with Addison disease has been vomiting and has a BP of 74/40. The family has the patient's emergency medication. Which drug and dose are appropriate?

    1. A. Methylprednisolone 10 mg PO
    2. B. Dexamethasone 0.1 mg IV push
    3. C. Prednisone 5 mg by mouth
    4. D. Hydrocortisone 100 mg IV or IM
    Show answer

    Answer: D. Hydrocortisone 100 mg IV or IM

    Adrenal crisis requires a stress dose of hydrocortisone, commonly 100 mg in adults, plus fluids.

81. A trauma patient injured 4 hours ago is in hemorrhagic shock. Regarding tranexamic acid:

    1. A. Not indicated; benefit is limited to within 3 hours
    2. B. Give 2 g IV push; timing does not matter
    3. C. Give 1 g over 10 minutes; any time is fine
    4. D. Give it only if more than 6 hours have passed
    Show answer

    Answer: A. Not indicated; benefit is limited to within 3 hours

    TXA given more than 3 hours after injury showed no benefit and possible harm in CRASH-2.

82. A hiker was bitten on the hand by a rattlesnake, and the hand is swelling. Which field care is appropriate?

    1. A. Immobilize, remove rings, transport
    2. B. Elevate the hand above the heart
    3. C. Apply a pressure-immobilization wrap
    4. D. Apply ice and a tight tourniquet
    Show answer

    Answer: A. Immobilize, remove rings, transport

    For pit viper bites, keep the patient calm, immobilize the limb near heart level, remove rings and watches before swelling, and transport for antivenom. Raising the hand above the heart is not advised, a pressure-immobilization wrap suits some elapid bites but can worsen local tissue injury from a pit viper, and ice and tourniquets do not help.

83. After delivery of the placenta, the uterus feels boggy and bleeding is heavy. What is the most appropriate treatment?

    1. A. Fundal massage and oxytocin 10 units IM
    2. B. Oxytocin 100 units IV push and transport
    3. C. Methylergonovine 10 mg IV push
    4. D. Magnesium sulfate 4 g IV over 20 minutes
    Show answer

    Answer: A. Fundal massage and oxytocin 10 units IM

    Uterine atony is treated with fundal massage and oxytocin, commonly 10 units IM or diluted in IV fluid.

84. A woman has heavy postpartum hemorrhage 1 hour after delivery. Per many protocols, which additional drug may be given?

    1. A. Ketorolac 30 mg IV
    2. B. Magnesium 2 g IV
    3. C. Tranexamic acid 1 g IV
    4. D. Heparin 5,000 units IV
    Show answer

    Answer: C. Tranexamic acid 1 g IV

    The WOMAN trial showed reduced bleeding deaths with TXA given within 3 hours of birth.

85. A patient with heat stroke has a core temperature of 41.5 C (106.7 F). What role do antipyretics such as acetaminophen play?

    1. A. None; rapid cooling is the treatment
    2. B. They are first-line before cooling
    3. C. They help once cooling has begun
    4. D. They lower the reset hypothalamic set point
    Show answer

    Answer: A. None; rapid cooling is the treatment

    Heat stroke is not caused by a hypothalamic set-point change, so antipyretics are ineffective. Because the set point is normal in heat stroke, antipyretics add nothing even after cooling starts, and they can stress an injured liver.

86. A septic patient remains hypotensive with a MAP of 58 after 30 mL/kg of crystalloid. Which vasopressor is generally first-line?

    1. A. Dobutamine
    2. B. Norepinephrine
    3. C. Phenylephrine
    4. D. Dopamine
    Show answer

    Answer: B. Norepinephrine

    Surviving Sepsis guidelines recommend norepinephrine as the first-line vasopressor, targeting a MAP of 65 mm Hg.

87. A patient has been trapped under a collapsed wall for 6 hours with a crushed leg. Before release, many protocols call for:

    1. A. Furosemide to protect the kidneys
    2. B. Withholding fluids until after extrication
    3. C. IV potassium to prevent muscle weakness
    4. D. IV fluids and readiness to treat hyperkalemia
    Show answer

    Answer: D. IV fluids and readiness to treat hyperkalemia

    Release of a crushed limb can cause sudden hyperkalemia and acidosis; pre-release fluids plus calcium, bicarbonate, or albuterol may be used.