Protocols, Guidelines, and Judgment Practice Questions

57 multiple-choice questions on Protocols, guidelines, and judgment for paramedic and EMT students, from Chapter 12 (Critical Thinking and Clinical Decision Making). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

57 practice questions

1. Protocols are most useful for:

   1. A. Every possible situation, without exception
   2. B. Rare presentations that providers seldom see
   3. C. Common presentations, ensuring consistent care
   4. D. Providing legal defense rather than guiding care
   Show answer

   Answer: C. Common presentations, ensuring consistent care

   They encode the usual best answer. Protocols provide consistent, evidence-based care for common presentations.

2. The limitation of protocols is that they:

   1. A. Cannot anticipate every combination of findings
   2. B. Are too detailed to apply in the field
   3. C. Are written by physicians rather than paramedics
   4. D. Change too often for providers to keep current
   Show answer

   Answer: A. Cannot anticipate every combination of findings

   Patients with several problems at once strain any algorithm. Comorbidities add further combinations no protocol can foresee.

3. Standing orders allow the paramedic to:

   1. A. Choose any treatment within their training and judgment
   2. B. Deviate from protocol whenever judgment suggests
   3. C. Act entirely outside any medical direction
   4. D. Act on written orders without calling a physician
   Show answer

   Answer: D. Act on written orders without calling a physician

   They are the medical director's orders in advance. The paramedic can act immediately without contacting a physician first.

4. When a patient's presentation falls outside protocol, the paramedic should:

   1. A. Use judgment and consult online medical control
   2. B. Provide transport only, with no interventions
   3. C. Consult only with their partner and proceed
   4. D. Apply the closest protocol exactly as written
   Show answer

   Answer: A. Use judgment and consult online medical control

   Physician consultation gives the decision solid footing.

5. Deviating from protocol requires:

   1. A. Only the paramedic's own clinical judgment
   2. B. A direct verbal request from the patient or family
   3. C. Written approval from a field supervisor
   4. D. Sound reasoning, medical control, and documentation
   Show answer

   Answer: D. Sound reasoning, medical control, and documentation

   An explained deviation is defensible; an unexplained one is not. Medical control contact is usually expected, and documentation must be clear.

6. Evidence-based guidelines improve care by:

   1. A. Shortening scene times on every call
   2. B. Replacing the need for clinical judgment
   3. C. Grounding protocols in research
   4. D. Reducing the documentation required per call
   Show answer

   Answer: C. Grounding protocols in research

   They still require clinical judgment to apply. Research, rather than tradition, drives the recommendations.

7. A protocol that conflicts with current evidence should be:

   1. A. Quietly ignored by individual providers
   2. B. Applied selectively when the provider agrees
   3. C. Followed without comment until it changes
   4. D. Raised through QI and medical direction
   Show answer

   Answer: D. Raised through QI and medical direction

   Changing the protocol helps every patient, not just yours. Use quality improvement (QI) and medical direction channels.

8. The paramedic's obligation when a protocol clearly does not fit a patient is to:

   1. A. Withhold treatment until a physician arrives
   2. B. Recognize the mismatch and seek direction
   3. C. Transport without providing any interventions
   4. D. Apply it anyway, since following it is protective
   Show answer

   Answer: B. Recognize the mismatch and seek direction

   Blind application is not a legal shield. Then act in the patient's interest.

9. Algorithms are best used as:

   1. A. Rigid decision trees to follow without deviation
   2. B. Documentation tools for completing the report
   3. C. Training aids used only in the classroom
   4. D. Decision support requiring judgment at each step
   Show answer

   Answer: D. Decision support requiring judgment at each step

   Each branch point assumes an accurate assessment.

10. Which situation most calls for online medical control?

    1. A. A routine chest pain call under standing orders
    2. B. An unusual or high-risk decision, or a deviation
    3. C. A minor injury requiring only basic wound care
    4. D. A stable interfacility transport without changes
    Show answer

    Answer: B. An unusual or high-risk decision, or a deviation

    Use the physician for the hard decisions, not the routine ones. Examples are an unusual presentation, a request to deviate, or a decision with significant risk either way.

11. Local protocols vary between systems because:

    1. A. National standards are unclear or contradictory
    2. B. Directors adapt them to local resources
    3. C. Each state requires its systems to differ
    4. D. Disease patterns differ substantially by region
    Show answer

    Answer: B. Directors adapt them to local resources

    Know the protocols of the system you are credentialed in. Medical directors account for transport times and system capabilities.

12. The relationship between guidelines and the standard of care is that guidelines:

    1. A. Replace it whenever a guideline exists
    2. B. Are legally unrelated to it in any case
    3. C. Inform it, but reasonableness defines it
    4. D. Define it absolutely in every circumstance
    Show answer

    Answer: C. Inform it, but reasonableness defines it

    Following a guideline blindly in the wrong situation can still fall below the standard. The standard is what a reasonable paramedic would do in the circumstances.

13. Protocols in EMS are best understood as:

    1. A. Rigid orders that leave no room for judgment
    2. B. Optional suggestions that may be disregarded
    3. C. Physician-approved frameworks applied with judgment
    4. D. Hospital rules that apply equally to field providers
    Show answer

    Answer: C. Physician-approved frameworks applied with judgment

    Protocols set expected care; judgment determines fit, sequence, and when to consult.

14. Which is an example of offline (indirect) medical direction?

    1. A. A radio order for a specific drug and its dose
    2. B. Written protocols, training, and QI review
    3. C. A physician directing care by phone
    4. D. An on-scene physician giving orders
    Show answer

    Answer: B. Written protocols, training, and QI review

    Offline (indirect) medical direction includes protocols, standing orders, education, and quality review that the medical director provides before and after calls. Radio and phone orders are online (direct) medical direction, and an on-scene physician gives direct orders too, usually under local intervener rules.

15. You want to give a second dose of a sedative that exceeds your protocol's maximum for a combative patient. What is the best step?

    1. A. Give it, since the patient clearly needs more sedation
    2. B. Give it and document the reason afterward
    3. C. Contact online medical control before giving it
    4. D. Have your EMT partner make the decision
    Show answer

    Answer: C. Contact online medical control before giving it

    A dose beyond protocol limits is a deviation that requires online medical control. Documenting afterward does not authorize it, and the decision is outside an EMT's scope. Meanwhile, keep the scene safe and monitor the airway closely.

16. A protocol says 'administer aspirin for suspected ACS.' The patient has a true aspirin allergy. The paramedic should:

    1. A. Give it after premedicating with diphenhydramine
    2. B. Give half the usual aspirin dose
    3. C. Withhold aspirin and document why
    4. D. Give it anyway, since protocol is protocol
    Show answer

    Answer: C. Withhold aspirin and document why

    Protocols assume absence of contraindications; judgment recognizes exceptions. Document the contraindication and continue other ACS care.

17. Clinical guidelines differ from protocols in that guidelines:

    1. A. Apply only to physicians, not paramedics
    2. B. Offer evidence-based, more flexible advice
    3. C. Are legally binding on every provider
    4. D. Are stricter and leave less room for judgment
    Show answer

    Answer: B. Offer evidence-based, more flexible advice

    Guidelines present recommended practice; protocols are more prescriptive local directives. Guidelines are usually broader and more flexible than local protocols, not stricter.

18. A paramedic deviates from protocol in a way they believe benefits the patient. They must:

    1. A. Reverse it immediately and follow protocol
    2. B. Justify it, consult if possible, and document
    3. C. Document it if the patient worsens
    4. D. Wait for quality review to raise the issue first
    Show answer

    Answer: B. Justify it, consult if possible, and document

    Justified deviation requires rationale, consultation when feasible, and clear documentation. A deviation is documented with its reasoning whether or not the patient worsens, and the paramedic raises it rather than waiting for quality review to find it.

19. Which best describes the role of evidence-based medicine in protocols?

    1. A. Evidence should replace clinical judgment
    2. B. Protocols should follow and update with evidence
    3. C. Evidence matters only in research settings
    4. D. Protocols are built on tradition rather than evidence
    Show answer

    Answer: B. Protocols should follow and update with evidence

    EBM anchors protocols to data rather than tradition.

20. An older protocol calls for oxygen for all chest pain. A patient with suspected ACS has an SpO2 of 98% on room air. What does current evidence support?

    1. A. High-flow oxygen by nonrebreather for everyone
    2. B. Oxygen by nasal cannula at 4 L/min for everyone
    3. C. No oxygen even if the SpO2 falls to 80 percent
    4. D. Oxygen only if the SpO2 falls below 90 percent
    Show answer

    Answer: D. Oxygen only if the SpO2 falls below 90 percent

    Trials such as AVOID and DETO2X found no benefit, and possible harm, from routine oxygen in normoxic ACS, so current guidelines give oxygen when SpO2 is below 90%. Hypoxia should still be treated. When a protocol lags the evidence, follow medical direction and raise it through QI.

21. A protocol requires 12-lead ECG for chest pain. A patient has 'indigestion' with diaphoresis. The paramedic should:

    1. A. Obtain a 12-lead for possible ACS
    2. B. Skip the 12-lead, since it isn't chest pain
    3. C. Defer the 12-lead to the hospital
    4. D. Give an antacid and reassess symptoms
    Show answer

    Answer: A. Obtain a 12-lead for possible ACS

    Judgment extends the protocol's intent to atypical presentations.

22. When protocol and physician online order conflict, the paramedic should:

    1. A. Clarify; online orders generally take precedence
    2. B. Disregard both and use personal judgment
    3. C. Let the patient choose which to follow
    4. D. Follow the written protocol without comment
    Show answer

    Answer: A. Clarify; online orders generally take precedence

    Online direction can modify protocol; the paramedic must confirm understanding and refuse only clearly dangerous orders. Online orders supersede offline protocols unless clearly harmful.

23. A paramedic receives an order that appears to be harmful to the patient. The correct action is:

    1. A. Question it; refuse if clearly harmful, and document
    2. B. Carry it out, since the physician is responsible
    3. C. End the radio contact and follow protocol
    4. D. Carry it out but document your disagreement afterward
    Show answer

    Answer: A. Question it; refuse if clearly harmful, and document

    Providers are accountable for their actions and must not carry out clearly dangerous orders.

24. Protocol adherence should be viewed as:

    1. A. Optional when the paramedic is experienced
    2. B. A minimum that still requires judgment
    3. C. Largely obsolete with modern training
    4. D. The entire scope of the paramedic's job
    Show answer

    Answer: B. A minimum that still requires judgment

    Protocols are the floor, not the ceiling, of clinical thinking.

25. The main benefit of standardized protocols is:

    1. A. Consistent, safe care across providers
    2. B. Lower cost as the primary outcome
    3. C. Eliminating the need for paramedic thinking
    4. D. Shorter calls with less time on scene
    Show answer

    Answer: A. Consistent, safe care across providers

    Standardization reduces variation and errors. Protocols create a shared expectation of care.

26. Which situation most clearly calls for medical control consultation?

    1. A. Pediatric dosing outside listed ranges
    2. B. Albuterol for wheezing under standing orders
    3. C. Aspirin for suspected ACS with no allergy
    4. D. Applying a pressure bandage to a wound
    Show answer

    Answer: A. Pediatric dosing outside listed ranges

    Dosing or treatment outside protocol boundaries requires physician input. Albuterol for wheezing and aspirin for suspected ACS are routine standing-order treatments that do not need a physician call.

27. A protocol lists adult doses only. For a 6-year-old, the paramedic should:

    1. A. Withhold all medications until arrival
    2. B. Use the adult dose for simplicity
    3. C. Give half the adult dose as an estimate
    4. D. Use weight-based dosing or medical control
    Show answer

    Answer: D. Use weight-based dosing or medical control

    Pediatric dosing is weight-based and must not be guessed.

28. Why should paramedics understand the rationale behind protocols rather than just the steps?

    1. A. To skip steps that seem unnecessary
    2. B. To change doses when they seem too low
    3. C. To recall each step faster under stress
    4. D. To spot cases outside their assumptions
    Show answer

    Answer: D. To spot cases outside their assumptions

    Understanding why a protocol says what it does lets you apply it correctly and recognize a patient who falls outside its assumptions. Knowing the rationale does not license skipping steps or changing doses on your own, and faster recall under stress comes from practice rather than from understanding the reasons.

29. Clinical judgment is defined as:

    1. A. Following orders from online medical control exactly
    2. B. Educated guessing when data are incomplete
    3. C. Integrating knowledge, experience, and assessment
    4. D. A legal opinion about the standard of care
    Show answer

    Answer: C. Integrating knowledge, experience, and assessment

    Judgment is the synthesis skill that protocols cannot replace. The goal is patient-centered decisions.

30. A paramedic's scope of practice is set by:

    1. A. The receiving hospital's policies
    2. B. The paramedic's personal confidence and training
    3. C. The patient's consent and preferences
    4. D. State law and the medical director
    Show answer

    Answer: D. State law and the medical director

    Scope is legally defined; protocols operate within it.

31. Which statement about 'standard of care' is correct?

    1. A. A uniform national rule identical in every state
    2. B. A benchmark that applies only in hospitals
    3. C. Whatever the treating paramedic decides is best
    4. D. What a reasonable, similar provider would do
    Show answer

    Answer: D. What a reasonable, similar provider would do

    Standard of care is the legal benchmark for competent practice.

32. Documentation of protocol-based decisions should include:

    1. A. Supporting findings, intervention, and response
    2. B. Only the name and dose of medication given
    3. C. The paramedic's opinion of the protocol
    4. D. Nothing beyond the protocol number used
    Show answer

    Answer: A. Supporting findings, intervention, and response

    Documentation shows the reasoning chain that justified care.

33. Your chest pain protocol calls for nitroglycerin. The patient took tadalafil (Cialis) 12 hours ago and has BP 138/84. What is the best decision?

    1. A. Give nitroglycerin since BP is normal
    2. B. Give nitroglycerin only if pain is severe
    3. C. Give a double dose of nitroglycerin
    4. D. Withhold nitroglycerin due to tadalafil
    Show answer

    Answer: D. Withhold nitroglycerin due to tadalafil

    Nitrates are contraindicated within about 48 hours of tadalafil because of the risk of profound hypotension. Tadalafil is a phosphodiesterase-5 inhibitor.

34. Your protocol permits nitroglycerin for chest pain. The patient's 12-lead shows an inferior STEMI and BP is 96/60. What is the most appropriate action?

    1. A. Give nitroglycerin, as protocol allows for chest pain
    2. B. Give nitroglycerin and elevate the legs
    3. C. Withhold nitroglycerin and assess for RV infarct
    4. D. Give nitroglycerin every 2 minutes as tolerated
    Show answer

    Answer: C. Withhold nitroglycerin and assess for RV infarct

    Borderline BP with inferior STEMI suggests possible RV involvement; nitrates can cause severe hypotension, so judgment overrides a reflexive protocol step. Consider right-sided leads and cautious fluids per protocol.

35. A naloxone protocol states 'titrate to effect.' For a patient with opioid toxicity, the intended effect is:

    1. A. Pupils returning to normal size
    2. B. Full alertness and orientation
    3. C. Adequate spontaneous respirations
    4. D. The patient agreeing to transport
    Show answer

    Answer: C. Adequate spontaneous respirations

    Naloxone is titrated to restore adequate breathing; full reversal can cause withdrawal, agitation, and vomiting.

36. A patient meets every criterion on your protocol for termination of resuscitation, but the family arrives screaming and the scene becomes unsafe. What does good judgment suggest?

    1. A. Ignore scene safety and follow protocol exactly
    2. B. Terminate resuscitation and leave immediately
    3. C. Prioritize crew safety and consult medical control
    4. D. Ask the family to decide whether to continue
    Show answer

    Answer: C. Prioritize crew safety and consult medical control

    Protocols don't account for every scene dynamic; safety and medical control guidance take priority. Continuing care during transport may be the safest option.

37. Your protocol lists adenosine for stable narrow-complex tachycardia. The rhythm is irregularly irregular at 170 with varying QRS widths, and the patient has a history of WPW. What is the best decision?

    1. A. Give adenosine as the protocol lists
    2. B. Give verapamil to control the rate
    3. C. Avoid AV nodal blockers and call medical control
    4. D. Give diltiazem to slow the rapid ventricular rate
    Show answer

    Answer: C. Avoid AV nodal blockers and call medical control

    In pre-excited atrial fibrillation, AV nodal blockers can accelerate conduction down the accessory pathway and precipitate VF. Consider procainamide or cardioversion per protocol.

38. Your spinal motion restriction protocol uses selective criteria. A 25-year-old fell from standing, is alert and sober, has no midline tenderness, no neuro deficits, and no distracting injury. The best decision is:

    1. A. Apply a collar and long backboard for the fall
    2. B. Use a scoop stretcher for all fall patients
    3. C. Spinal motion restriction is not indicated
    4. D. Request medical control before any movement
    Show answer

    Answer: C. Spinal motion restriction is not indicated

    Selective spinal criteria allow clinically cleared patients to forgo motion restriction.

39. A protocol says 'consider' a medication. What does this wording mean for the paramedic?

    1. A. The paramedic decides based on judgment
    2. B. The medication may be given only en route
    3. C. The medication must be given every time
    4. D. The medication requires a physician order first
    Show answer

    Answer: A. The paramedic decides based on judgment

    Words like 'consider' signal that the decision depends on the paramedic's assessment and judgment.

40. You are caring for a patient in cardiac arrest whose spouse produces a valid state-approved DNR form. What is the most appropriate action?

    1. A. Disregard the form since the spouse is upset
    2. B. Transport with CPR and let the hospital decide
    3. C. Start CPR until medical control confirms
    4. D. Honor the DNR and support the family
    Show answer

    Answer: D. Honor the DNR and support the family

    A valid DNR order should be honored; verifying its validity and documenting appropriately is part of protocol. Follow protocol for documentation.

41. A protocol allows you to treat and release a hypoglycemic diabetic who returns to normal mental status. Which finding should make you reconsider release?

    1. A. A responsible adult has agreed to stay with the patient
    2. B. The patient takes a long-acting oral sulfonylurea
    3. C. The patient ate a meal after treatment
    4. D. The patient's glucose is now 140 mg/dL
    Show answer

    Answer: B. The patient takes a long-acting oral sulfonylurea

    Sulfonylurea-induced hypoglycemia can recur for many hours, so release is generally inappropriate.

42. A paramedic followed a protocol word for word but missed an obvious contraindication. How is the standard of care judged?

    1. A. By whether the protocol was followed word for word
    2. B. By what a reasonable paramedic would have done
    3. C. By the patient's outcome alone, good or bad
    4. D. By what a physician would have done there
    Show answer

    Answer: B. By what a reasonable paramedic would have done

    The standard of care is what a reasonably prudent paramedic with similar training would do in similar circumstances. Protocols inform it but do not replace judgment, so following a protocol into an obvious contraindication can fall below the standard. Outcome alone does not define it, and paramedics are not held to a physician's standard.

43. A patient in stable SVT does not convert with vagal maneuvers or adenosine. Your protocol offers diltiazem, but the patient has severe heart failure with low ejection fraction. The best decision is:

    1. A. Avoid diltiazem and contact medical control
    2. B. Give two doses of diltiazem to ensure conversion
    3. C. Give the full diltiazem dose per protocol
    4. D. Give furosemide instead of an antiarrhythmic
    Show answer

    Answer: A. Avoid diltiazem and contact medical control

    Nondihydropyridine calcium channel blockers are negative inotropes and are generally avoided in decompensated heart failure with reduced EF.

44. You are dispatched to a seizure. On arrival, the patient has been seizing for 7 minutes. Your protocol lists midazolam IM. What is the best action?

    1. A. Obtain IV access first, even with delay
    2. B. Wait for the seizure to stop on its own
    3. C. Restrain the limbs to prevent injury
    4. D. Give IM midazolam without waiting for IV
    Show answer

    Answer: D. Give IM midazolam without waiting for IV

    Seizures lasting 5 minutes or more are treated as status epilepticus; IM midazolam is effective and avoids delay.

45. A physician on scene who identifies herself as an off-duty ED doctor wants to direct care. What should the paramedic do first?

    1. A. Hand over the patient to her and leave
    2. B. Follow the local intervener-physician protocol
    3. C. Follow all of her orders without question
    4. D. Ignore her and continue care as usual
    Show answer

    Answer: B. Follow the local intervener-physician protocol

    Most systems have protocols for on-scene physicians requiring identification and agreement to accompany the patient and assume responsibility. This includes verifying credentials and agreement with medical control.

46. Which factor best justifies requesting a protocol revision after repeated field problems?

    1. A. Another agency handles it differently
    2. B. A paramedic personally dislikes the protocol
    3. C. Evidence or QI data show poor outcomes
    4. D. The protocol is too long to memorize
    Show answer

    Answer: C. Evidence or QI data show poor outcomes

    Protocol changes should be driven by evidence and quality data rather than personal preference. Data showing the protocol does not fit common situations also justify revision.

47. A patient with chest pain says he is allergic to aspirin because it 'upsets his stomach.' How should this influence your decision?

    1. A. It's an intolerance; aspirin can still be given
    2. B. Give enteric-coated aspirin and have him swallow it whole
    3. C. Give clopidogrel in place of aspirin
    4. D. Withhold aspirin as a documented allergy
    Show answer

    Answer: A. It's an intolerance; aspirin can still be given

    Distinguishing intolerance from true allergy (hives, angioedema, bronchospasm) prevents withholding a beneficial medication. Aspirin can generally still be given per protocol. Enteric-coated aspirin swallowed whole acts too slowly, so chewable aspirin is preferred in ACS. Clopidogrel is an alternative for a true allergy, not for an intolerance, and is not a routine field substitute.

48. Your protocol requires transport of all patients who received naloxone, but the patient wants to refuse. He is alert, oriented, and understands the risks. What is the best approach?

    1. A. Give more naloxone to keep him alert
    2. B. Leave immediately without documenting
    3. C. Use the refusal process after confirming capacity
    4. D. Force him to go, because the protocol requires transport
    Show answer

    Answer: C. Use the refusal process after confirming capacity

    Adults with decision-making capacity can refuse; protocols typically specify how refusals are handled and documented. Explain risks and consult medical control if required.

49. Your trauma protocol calls for the nearest trauma center. You are 45 minutes from a Level I center and 8 minutes from a community hospital. Your patient has an obstructed airway you cannot secure. The best decision is:

    1. A. Continue to the trauma center with BVM only
    2. B. Drive to the trauma center as protocol directs
    3. C. Divert to the nearest hospital
    4. D. Wait on scene for an air medical crew
    Show answer

    Answer: C. Divert to the nearest hospital

    An uncontrolled airway is an immediate life threat; most protocols allow diversion to the nearest facility in this case. The goal of diversion is to secure the airway.

50. A protocol states that IV access should be obtained 'en route when possible' for a STEMI. The rationale is to:

    1. A. Allow fluids to be given during transport
    2. B. Reduce scene time and delays to reperfusion
    3. C. Avoid giving any medications on scene
    4. D. Meet billing documentation requirements
    Show answer

    Answer: B. Reduce scene time and delays to reperfusion

    Time to reperfusion drives STEMI outcomes, so nonessential procedures are performed en route.

51. A medical control physician orders a medication dose that is ten times higher than usual. The correct response is to:

    1. A. Refuse further contact with that physician
    2. B. Give half the ordered dose as a compromise
    3. C. Give the dose because it was ordered
    4. D. Read it back and question it before giving it
    Show answer

    Answer: D. Read it back and question it before giving it

    Questioning orders that appear unsafe protects the patient; closed-loop clarification often reveals a miscommunication.

52. Which describes the proper role of evidence-based guidelines such as those of the American Heart Association?

    1. A. They automatically override local protocols
    2. B. They shape the local protocols you follow
    3. C. They apply only to in-hospital care
    4. D. They replace the need for medical direction
    Show answer

    Answer: B. They shape the local protocols you follow

    National guidelines shape local protocols, but paramedics practice under their medical director's protocols. Paramedics follow those protocols under medical direction.

53. A patient refuses to be placed on a backboard but agrees to transport. He is alert with mild neck pain and no deficits. The best decision is:

    1. A. Use a collar and stretcher and document
    2. B. Refuse transport unless he accepts a board
    3. C. Place him on a backboard despite refusal
    4. D. Cancel the call since he refused care
    Show answer

    Answer: A. Use a collar and stretcher and document

    Modern spinal care emphasizes motion restriction rather than rigid boards; respecting patient wishes while minimizing risk is appropriate. Use the least restrictive spinal motion restriction the patient accepts.

54. A protocol requires an advanced airway for all cardiac arrests. BVM ventilation is effective, and the paramedic has failed two intubation attempts. What is the best decision?

    1. A. Continue BVM or place a supraglottic airway
    2. B. Keep attempting intubation until successful
    3. C. Terminate resuscitation after failed intubation
    4. D. Stop ventilation and focus only on compressions
    Show answer

    Answer: A. Continue BVM or place a supraglottic airway

    Effective ventilation and high-quality CPR matter more than intubation; supraglottic airways or BVM are acceptable alternatives. Minimize CPR interruptions throughout.

55. A patient with a known peanut allergy reports she ate peanuts and now has throat tightness. Your protocol allows IM epinephrine. Her BP is 162/90 and she is 70 years old. What is the best decision?

    1. A. Give diphenhydramine alone and monitor
    2. B. Wait for hives before giving epinephrine
    3. C. Give IM epinephrine without delay
    4. D. Withhold epinephrine due to age and hypertension
    Show answer

    Answer: C. Give IM epinephrine without delay

    Epinephrine is first-line treatment for anaphylaxis, and age or hypertension are not absolute contraindications. There is no absolute contraindication to epinephrine in anaphylaxis.

56. Your protocol permits CPAP for dyspnea from pulmonary edema. Which finding should lead you to avoid CPAP?

    1. A. Hypertension with a BP of 190/110
    2. B. Unable to follow commands and vomiting
    3. C. Crackles throughout both lung fields
    4. D. An SpO2 of 88% on room air
    Show answer

    Answer: B. Unable to follow commands and vomiting

    CPAP requires a patient who can protect the airway; altered mental status and vomiting increase aspiration risk.

57. A patient with an LVAD is unresponsive with no palpable pulse, but the device is humming. Your arrest protocol does not mention LVADs. What is best?

    1. A. Start chest compressions immediately, per the protocol
    2. B. Assess perfusion and the device; call the VAD team
    3. C. Declare death, since there is no palpable pulse
    4. D. Defibrillate at once, since no pulse is felt
    Show answer

    Answer: B. Assess perfusion and the device; call the VAD team

    Protocols cannot anticipate every case. LVAD patients often have no palpable pulse, so assess perfusion by mental status, skin, Doppler MAP, and ETCO2, check the device alarms, and call the VAD coordinator listed on the device. AHA guidance supports compressions if perfusion is absent, but not reflexively on a missing pulse alone. Defibrillation is for a shockable rhythm in a patient without perfusion, not for a missing pulse alone, which is expected with a continuous-flow LVAD.