Ongoing Monitoring, Reassessment, and Transport of the Critical Patient Practice Questions

25 multiple-choice questions on Ongoing monitoring, reassessment, and transport of the critical patient for paramedic and EMT students, from Chapter 41 (Management and Resuscitation of the Critical Patient). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. A septic patient on norepinephrine has a BP of 84/54 mmHg. Using a MAP target of 65 mmHg, you should:

   1. A. Stop the norepinephrine infusion
   2. B. Titrate the norepinephrine up
   3. C. Leave the rate, since MAP is 69
   4. D. Give a 1-mg epinephrine IV bolus
   Show answer

   Answer: B. Titrate the norepinephrine up

   MAP is about the diastolic pressure plus one-third of the pulse pressure: 54 + (30 / 3) = 64 mmHg, just below target, so the infusion is increased slightly. Averaging systolic and diastolic gives 69 and falsely suggests the target is met. Stopping the infusion would drop the pressure further. A 1-mg IV bolus of epinephrine is a cardiac arrest dose and is dangerous in a patient with a pulse.

2. During a transfer, a patient's arterial line reads 128/70 mmHg while the cuff reads 96/58. You notice the transducer has slipped well below heart level. You should:

   1. A. Trust the arterial line, since cuffs often read low
   2. B. Wean the pressor based on the arterial value
   3. C. Remove the arterial line as unreliable
   4. D. Re-level the transducer at the heart and zero it
   Show answer

   Answer: D. Re-level the transducer at the heart and zero it

   An arterial transducer must sit at the level of the right atrium (the phlebostatic axis, about the fourth intercostal space at the mid-axillary line) and be zeroed there; one placed below the heart reads falsely high, by roughly 7 to 8 mmHg for every 10 cm. Assuming the cuff is wrong ignores an obvious setup error. Weaning a pressor on a falsely high reading could drop the real pressure dangerously. The line is accurate once leveled and zeroed.

3. After an acute spinal cord injury with neurogenic shock, many hospital guidelines target a MAP of about:

   1. A. 85 to 90 mmHg
   2. B. 50 to 55 mmHg
   3. C. 60 to 65 mmHg
   4. D. 120 to 130 mmHg
   Show answer

   Answer: A. 85 to 90 mmHg

   Raising the MAP after acute cord injury may improve perfusion of the injured cord and neurologic outcome. The 2013 AANS/CNS guideline recommends 85 to 90 mmHg for 7 days; the 2024 AO Spine/Praxis guideline suggests a floor of 75 to 80 mmHg and an upper target of 90 to 95 mmHg for 3 to 7 days, so 85 to 90 lies within both. A MAP of 50 to 55 is dangerously low, and 60 to 65 is the sepsis target, below what is advised after cord injury. A MAP of 120 to 130 is excessive and adds pressor risk without benefit.

4. A 65-year-old in septic shock has an automated BP of 88/52 mmHg, but her radial pulse is barely palpable. In profound hypotension, automated cuffs tend to:

   1. A. Underestimate the pressure by about half
   2. B. Read accurately at every pressure level
   3. C. Overestimate the pressure or fail to read
   4. D. Measure only the diastolic pressure
   Show answer

   Answer: C. Overestimate the pressure or fail to read

   Oscillometric cuffs are least accurate at low pressures and with dysrhythmias, often overreading or failing; manual pressure and palpated pulses help confirm the reading. Assuming the device is accurate in severe shock is a common pitfall.

5. Before a 90-minute transfer of a patient on a transport ventilator at 100% oxygen, the crew should:

   1. A. Bring one full D cylinder for the whole trip
   2. B. Estimate the oxygen needed and add a reserve
   3. C. Bring two full D cylinders as a standard load
   4. D. Lower the FiO2 to 60% to stretch the supply
   Show answer

   Answer: B. Estimate the oxygen needed and add a reserve

   A ventilator at 100% oxygen uses the patient's minute ventilation plus, for many pneumatic units, extra gas to drive the device, so the crew estimates the need for the whole trip and adds a reserve for delays; running out mid-transfer is a preventable emergency. A single D cylinder holds about 350 L and would not last, and a fixed load of two D cylinders (about 700 L) still falls short of the roughly 800 L or more needed for 90 minutes plus a reserve. Lowering the FiO2 to save gas would expose a patient who needs 100% oxygen to hypoxemia.

6. Your crew has just slid an intubated septic patient onto the stretcher when the monitor shows a flat ETCO2 line. Your first action is to:

   1. A. Replace the capnography sensor and wait
   2. B. Check the tube, circuit, and pulse
   3. C. Increase the ventilation rate to 30/min
   4. D. Extubate and place a supraglottic airway
   Show answer

   Answer: B. Check the tube, circuit, and pulse

   A flat line after a move means a displaced tube, disconnection, obstruction, or cardiac arrest until proven otherwise, so you check each quickly. Assuming a sensor fault delays recognition of a dislodged tube.

7. In a patient in shock with cold, mottled fingers, a fingerstick glucose may be inaccurate. A more reliable sample is:

   1. A. Venous blood drawn from the IV start
   2. B. A second fingerstick from the same hand
   3. C. Capillary blood from a warmed earlobe
   4. D. A urine dipstick for glucose
   Show answer

   Answer: A. Venous blood drawn from the IV start

   With peripheral vasoconstriction, capillary blood from a finger can give a glucose that differs from the true blood value, and guidance on meters in critically ill patients favors venous or arterial samples; a drop of venous blood obtained when the IV is started is practical in the field. Repeating the fingerstick on the same hand repeats the problem. An earlobe is still a capillary sample from a poorly perfused site. A urine dipstick reflects hours of glucose and cannot guide immediate treatment.

8. In a shocked patient, ETCO2 typically reads lower than the arterial PaCO2 because:

   1. A. Hyperventilation lowers exhaled CO2
   2. B. Lactic acid binds CO2 before it is exhaled
   3. C. Poorly perfused alveoli add dead space
   4. D. Shock lowers CO2 production to near zero
   Show answer

   Answer: C. Poorly perfused alveoli add dead space

   When pulmonary blood flow falls, ventilated but underperfused alveoli contribute gas with little CO2, widening the PaCO2-ETCO2 gap. Targeting a normal ETCO2 in a shocked patient can therefore hide a high PaCO2, which matters in head injury. Hyperventilation would lower both values rather than widen the gap between them, and buffering of lactic acid generates CO2 rather than trapping it. CO2 production falls somewhat in shock but does not approach zero.

9. A hypotensive head-injured patient with a GCS of 7 is being ventilated well with a bag-mask and OPA, with an SpO2 of 97%. The trauma center is 8 minutes away. The best airway plan is to:

   1. A. Perform RSI on scene before moving
   2. B. Wait on scene for an air crew to intubate
   3. C. Attempt blind nasal intubation first
   4. D. Keep bagging and transport now
   Show answer

   Answer: D. Keep bagging and transport now

   Hypoxia and hypotension during intubation worsen outcomes after brain injury, and peri-intubation hypotension is common in a patient who is already hypotensive. When bag-mask ventilation is keeping the saturation and ETCO2 on target and the trauma center is close, continuing it and transporting avoids those risks; RSI is a better choice when ventilation fails or the transport is long. Intubating a hypotensive patient on scene adds risk and delay. Waiting for an air crew delays definitive care. Blind nasal intubation is unreliable and is contraindicated with possible facial or basilar skull fractures.

10. During transport, a paralyzed, intubated patient's HR rises from 90 to 128 and BP from 110/70 to 160/96 mmHg with no other obvious cause. You should suspect:

    1. A. Worsening hypovolemia from ongoing bleeding
    2. B. A tension pneumothorax developing
    3. C. An expected effect of the paralytic
    4. D. Inadequate sedation, so he may be aware
    Show answer

    Answer: D. Inadequate sedation, so he may be aware

    A paralyzed patient cannot move or speak, so a sudden rise in heart rate and blood pressure is often the only sign of pain or awareness; give analgesia and sedation per protocol and reassess. Hypovolemia causes tachycardia with a falling, not rising, pressure. A tension pneumothorax causes hypotension and rising airway pressures. Rocuronium and similar drugs do not raise heart rate or blood pressure.

11. In most critically ill adults without COPD, oxygen should be titrated to an SpO2 of about:

    1. A. 88% to 92%
    2. B. 94% to 98%
    3. C. 82% to 86%
    4. D. 99% to 100%
    Show answer

    Answer: B. 94% to 98%

    Both hypoxemia and hyperoxia are harmful, so in acutely ill adults who are not at risk of hypercapnic respiratory failure, oxygen is titrated to a target of 94% to 98% (BTS); some guidelines set a slightly lower ceiling, but all advise against routinely keeping saturations at the top of the scale. A target of 88% to 92% is reserved for patients at risk of hypercapnic failure, such as those with COPD. A range of 82% to 86% is dangerously low. Keeping the saturation at 99% to 100% means giving excess oxygen with no benefit, and liberal oxygen has been linked to higher mortality.

12. The BP cuff is cycling every 3 minutes on the same arm as the IV running norepinephrine. Why is this a problem?

    1. A. The cuff reads falsely high from the drug
    2. B. It makes the pump lower its set rate
    3. C. Each inflation briefly stops the drug's flow
    4. D. Cuff inflation makes the infusion run faster
    Show answer

    Answer: C. Each inflation briefly stops the drug's flow

    Each cuff inflation occludes the vein, so the infusion stops (and backs up or triggers an occlusion alarm) and then delivers a small surge when the cuff deflates; with a short-acting pressor this causes swings in blood pressure. Put the cuff on the other arm. The drug does not make the cuff read falsely high, and the pump does not change its programmed rate; it simply cannot push against the occluded vein. Inflation slows or stops, rather than speeds, the infusion.

13. In addition to timed reassessments, you should repeat the primary assessment after:

    1. A. Every intervention or patient move
    2. B. The initial set of vital signs
    3. C. Arrival at the receiving facility
    4. D. The end of the full secondary survey
    Show answer

    Answer: A. Every intervention or patient move

    Interventions and moves can dislodge tubes and lines or change the patient's condition, so you reassess the airway, breathing, and circulation after each. The initial vital signs are just the first data point, not a trigger for reassessment. Waiting until arrival misses problems that could have been corrected en route. The secondary survey is often never completed in a critical patient, so it cannot be the trigger.

14. A 72-year-old woman has an inferior STEMI with cardiogenic shock. The nearest hospital, 10 minutes away, has no cath lab. A PCI center with mechanical circulatory support is 25 minutes away. The best destination is:

    1. A. The PCI center with circulatory support
    2. B. The nearest hospital for initial stabilization
    3. C. Whichever hospital the patient prefers
    4. D. The nearest facility for fibrinolytics
    Show answer

    Answer: A. The PCI center with circulatory support

    Cardiogenic shock from STEMI is best treated with emergency revascularization, so direct transport to a PCI-capable center is recommended when it can be reached quickly. Fibrinolytics are less effective in shock and are reserved for long delays to PCI.

15. A hemodynamically stable STEMI patient is 150 minutes by ground from the nearest PCI center, and a non-PCI hospital is 15 minutes away. Under AHA guidance, the best plan is usually:

    1. A. Go directly to the PCI center despite the delay
    2. B. Go to the closer hospital and wait for symptoms to settle
    3. C. Request air transport only if pain persists past an hour
    4. D. Go to the closer hospital for fibrinolytics, then transfer
    Show answer

    Answer: D. Go to the closer hospital for fibrinolytics, then transfer

    When PCI cannot be achieved within about 120 minutes of first contact, fibrinolysis at the nearest capable hospital followed by transfer is recommended for eligible patients. Cardiogenic shock is the exception, favoring direct transport for PCI.

16. A febrile 70-year-old with pneumonia has HR 118, RR 20, BP 118/70 mmHg, normal mentation, and mottled knees. Her qSOFA score is 0. You should:

    1. A. Rule out sepsis because qSOFA is negative
    2. B. Repeat the qSOFA in an hour before acting
    3. C. Still treat and report possible sepsis
    4. D. Treat her as a low-risk viral illness
    Show answer

    Answer: C. Still treat and report possible sepsis

    The 2021 Surviving Sepsis guideline recommends against using qSOFA alone as a screening tool, because it misses many septic patients; a suspected infection with tachycardia and mottling suggests poor perfusion and warrants sepsis care and notification. A negative qSOFA does not rule out sepsis. Waiting an hour delays antibiotics and fluids. Calling it a low-risk viral illness ignores signs of hypoperfusion.

17. Right after you switch a patient from the ICU ventilator to your transport ventilator, the most important step is to:

    1. A. Set the transport vent to its default mode
    2. B. Confirm chest rise, ETCO2, and SpO2
    3. C. Raise the FiO2 to 100% and move on
    4. D. Rely on the SpO2 trend for the first minutes
    Show answer

    Answer: B. Confirm chest rise, ETCO2, and SpO2

    Transfers between ventilators are a common time for disconnection, wrong settings, and lost PEEP, so the crew immediately confirms that the chest rises, the ETCO2 waveform and value match the previous ones, and the saturation holds. A default mode may not match the patient's prescribed settings, raising the oxygen does not show that the patient is being ventilated, and the SpO2 falls only minutes after a disconnection or loss of PEEP, so it is too slow to rely on by itself.

18. A rural crew has a hypotensive patient with a pelvic fracture 90 minutes by ground from the trauma center. A helicopter can reach a landing zone near them in 15 minutes and fly 25. The best decision is to:

    1. A. Drive the full 90 minutes to avoid the cost of air
    2. B. Wait on scene for the helicopter before any treatment
    3. C. Take him to a clinic first for a pelvic x-ray
    4. D. Request air transport and start toward a landing zone
    Show answer

    Answer: D. Request air transport and start toward a landing zone

    Air transport is justified when it substantially shortens the time to definitive care, as here, and treatment continues while the crew moves toward the landing zone. Waiting idle on scene or detouring for imaging delays surgical bleeding control.

19. A sending hospital's norepinephrine bag contains 8 mg in 250 mL, but your pump's library default is 4 mg in 250 mL. You should:

    1. A. Program the pump for the bag's real strength
    2. B. Use the library default since it is standard
    3. C. Double the pump rate to make up the difference
    4. D. Run the rate the hospital used unchecked
    Show answer

    Answer: A. Program the pump for the bag's real strength

    Rates in mcg/min are converted to mL/h using the concentration, so the pump must be set for the bag actually hanging (8 mg in 250 mL, or 32 mcg/mL); using the 16 mcg/mL default would deliver twice the intended dose. Doubling the rate gets the correction backward: the bag is already twice as strong, so the patient would receive four times the intended dose. The hospital's rate may be right, but it must be checked against the order and concentration before you take over.

20. A paramedic is asked to transport a patient on norepinephrine and a heparin drip. Neither infusion is in the paramedic's protocols. The best action is to:

    1. A. Transport and stop both infusions during the trip
    2. B. Arrange a critical care team or a qualified nurse
    3. C. Transport and run them without any monitoring
    4. D. Ask the family to monitor the infusions en route
    Show answer

    Answer: B. Arrange a critical care team or a qualified nurse

    Care during transport must stay within the provider's scope, so infusions outside protocol require a critical care team or an accompanying nurse. Stopping a vasopressor in a dependent patient can cause rapid hypotension.

21. Before moving a critical patient from the bed to the ambulance, you should first:

    1. A. Let the lines hang free to avoid pulling
    2. B. Pause the pressor infusion until loaded
    3. C. Secure the tube, lines, and monitor cables
    4. D. Deflate the ET cuff to limit tracheal injury
    Show answer

    Answer: C. Secure the tube, lines, and monitor cables

    Moving a patient is the highest-risk moment for dislodging the endotracheal tube and IV lines, so everything is secured and monitored continuously during the move. Loose lines catch on rails and get pulled out, pausing a pressor drops the pressure within minutes, and deflating the cuff risks aspiration and loss of ventilation.

22. During transport of a patient sedated with ketamine who is breathing on his own with oxygen, which monitor detects hypoventilation earliest?

    1. A. Pulse oximetry on a fingertip probe
    2. B. Automated blood pressure every 3 minutes
    3. C. Continuous three-lead ECG monitoring
    4. D. Waveform capnography by nasal cannula
    Show answer

    Answer: D. Waveform capnography by nasal cannula

    Capnography shows a rising ETCO2, a falling rate, or a flat line within a breath or two of hypoventilation or apnea. Pulse oximetry falls late, especially when supplemental oxygen fills the lungs with an oxygen reserve. Blood pressure and the ECG change only after hypoxia or hypercapnia has become severe.

23. A 60-year-old in septic shock with a pH of 7.10 is on a norepinephrine infusion. Continuous ECG monitoring is most important to detect:

    1. A. Dysrhythmias from ischemia or acidosis
    2. B. The patient's exact blood pressure trend
    3. C. Changes in the patient's oxygen saturation
    4. D. The volume of fluid given during the transport
    Show answer

    Answer: A. Dysrhythmias from ischemia or acidosis

    Shock causes ischemia, acidosis, and electrolyte shifts that trigger dysrhythmias, and vasopressors add to the risk. The ECG does not measure pressure or saturation, which require separate monitoring.

24. Recording each set of vital signs with its time during a long transport mainly:

    1. A. Replaces the need for a verbal handover report
    2. B. Shows trends the receiving team can act on
    3. C. Is needed mainly for billing purposes
    4. D. Lets the crew reassess less often
    Show answer

    Answer: B. Shows trends the receiving team can act on

    A single set of vital signs shows little; timed sets show whether the patient is improving or worsening and how they responded to each treatment, which guides the receiving team's next steps. Written records support but do not replace a verbal handover. Billing is not the clinical purpose of timed vital signs. Recording does not reduce the need for reassessment.

25. When handing over a patient on a norepinephrine infusion, the most important infusion details to give are the:

    1. A. Total volume infused since the start
    2. B. Time the bag was mixed by the hospital pharmacy
    3. C. Dose, line used, and recent dose changes
    4. D. The mixing diluent, saline or D5W
    Show answer

    Answer: C. Dose, line used, and recent dose changes

    The receiving team needs to know how much drug the patient is getting, which line it runs through (so it is not flushed or interrupted), and how the dose has been changing, which shows the trend of the shock. The total volume infused, the time the bag was made, and whether it was mixed in saline or D5W may be recorded, but they do not change the patient's care at handover.