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Respiratory Emergency Medications Practice Questions

78 multiple-choice questions on Respiratory medications 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.

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78 practice questions

  1. Albuterol is typically nebulized at:

    1. A. 25 mg in 10 mL of saline
    2. B. 10 mg in 3 mL of saline
    3. C. 0.25 mg in 3 mL of saline
    4. D. 2.5 mg in 3 mL of saline
    Show answer

    Answer: D. 2.5 mg in 3 mL of saline

    It may be repeated or given continuously per protocol.

  2. A patient's anaphylaxis to a bee sting resolved completely after one IM epinephrine dose, and he now wants to refuse transport. What is the most important point to explain?

    1. A. Symptoms can return hours later, unprovoked
    2. B. A second phase is milder than the first one
    3. C. One epinephrine dose stops symptoms from returning
    4. D. Antihistamines at home replace epinephrine
    Show answer

    Answer: A. Symptoms can return hours later, unprovoked

    Biphasic anaphylaxis can recur hours later (commonly within 12 to 72 hours) without a new exposure, so observation is advised and a refusal must be informed, with an epinephrine auto-injector prescription and clear return precautions. Epinephrine's effect lasts only minutes. Antihistamines do not treat airway swelling or shock. A second phase can be as severe as or worse than the first.

  3. A patient in anaphylaxis needs IM epinephrine, but the bleeding risk is high and he takes apixaban. What is appropriate?

    1. A. Give IM epinephrine; risk is minor
    2. B. Give it IV push undiluted instead
    3. C. Give oral antihistamines instead
    4. D. Withhold epinephrine to avoid a hematoma
    Show answer

    Answer: A. Give IM epinephrine; risk is minor

    There is no absolute contraindication to epinephrine in anaphylaxis; a small IM hematoma from anticoagulation is minor compared with the risk of death, so give it in the anterolateral thigh and apply pressure. Undiluted IV push epinephrine risks dysrhythmias and hypertensive crisis. Antihistamines alone do not treat anaphylaxis.

  4. A patient with known hereditary angioedema has rapidly worsening lip and tongue swelling without hives. Epinephrine, diphenhydramine, and steroids help little. Which therapy targets the cause?

    1. A. Repeated nebulized albuterol
    2. B. A higher dose of diphenhydramine
    3. C. IV methylprednisolone 1 g
    4. D. Her C1-inhibitor or icatibant
    Show answer

    Answer: D. Her C1-inhibitor or icatibant

    Hereditary angioedema is caused by bradykinin excess from a C1-inhibitor deficiency, so the specific treatments are C1-inhibitor concentrate or a bradykinin-pathway drug such as icatibant (often carried by the patient), while the airway is closely watched. Antihistamines and steroids do not act on bradykinin. Albuterol treats lower-airway bronchospasm, not upper-airway swelling.

  5. Intramuscular epinephrine for anaphylaxis in an adult is dosed at:

    1. A. 3 mg of 1 mg/mL in the deltoid muscle
    2. B. 0.3 to 0.5 mg of 1 mg/mL in the thigh
    3. C. 0.01 mg of 0.1 mg/mL in the thigh
    4. D. 1 mg of 0.1 mg/mL by rapid IV push
    Show answer

    Answer: B. 0.3 to 0.5 mg of 1 mg/mL in the thigh

    That concentration was formerly labeled 1:1,000. It is given in the lateral thigh.

  6. Epinephrine is the first-line treatment for anaphylaxis because it:

    1. A. Works mainly by drying airway secretions
    2. B. Blocks histamine at both H1 and H2 receptors
    3. C. Reverses vasodilation, capillary leak, and bronchospasm
    4. D. Prevents biphasic reactions better than steroids
    Show answer

    Answer: C. Reverses vasodilation, capillary leak, and bronchospasm

    Antihistamines and steroids are adjuncts, not substitutes.

  7. Diphenhydramine in an allergic reaction:

    1. A. Replaces epinephrine when hypotension is mild
    2. B. Raises blood pressure through alpha effects
    3. C. Rapidly reverses upper airway obstruction
    4. D. Blocks H1 histamine receptors as an adjunct
    Show answer

    Answer: D. Blocks H1 histamine receptors as an adjunct

    Typical adult dose is 25 to 50 mg IV or IM.

  8. Magnesium sulfate in severe asthma is used because it:

    1. A. Reduces airway inflammation within minutes
    2. B. Dries secretions through anticholinergic action
    3. C. Blocks histamine release from airway mast cells
    4. D. Relaxes bronchial smooth muscle
    Show answer

    Answer: D. Relaxes bronchial smooth muscle

    It is typically given as 2 g IV over 10 to 20 minutes. It is used in refractory cases.

  9. Epinephrine given IM may be considered in severe asthma when:

    1. A. Air movement is poor despite nebulized therapy
    2. B. Wheezing is mild and the SpO2 is normal
    3. C. The patient is hypertensive and tachycardic
    4. D. The patient improves after the first albuterol
    Show answer

    Answer: A. Air movement is poor despite nebulized therapy

    Poor airflow limits delivery of inhaled medication.

  10. An adult with a moderate asthma attack is improving with albuterol and can swallow. Regarding the systemic steroid, which is accurate?

    1. A. IV steroids relieve the wheezing within minutes
    2. B. Steroids are withheld until the hospital
    3. C. IM steroids work better than oral steroids
    4. D. Oral prednisone works about as well as IV
    Show answer

    Answer: D. Oral prednisone works about as well as IV

    Oral corticosteroids are absorbed well and are about as effective as IV steroids when the patient can swallow; IV is used when the patient cannot. Neither route works within minutes, since the anti-inflammatory effect takes hours. Giving the steroid early, including prehospital, reduces relapse and admission. IM steroids are not more effective.

  11. CPAP is beneficial in pulmonary edema because it:

    1. A. Improves oxygenation and lowers preload and afterload
    2. B. Increases venous return to improve the cardiac output
    3. C. Acts as a bronchodilator to open small airways
    4. D. Lowers CO2 mainly by raising the respiratory rate
    Show answer

    Answer: A. Improves oxygenation and lowers preload and afterload

    It often works alongside nitroglycerin. It also reduces the work of breathing.

  12. Nitroglycerin in acute pulmonary edema is used to:

    1. A. Slow the heart rate to improve filling time
    2. B. Relax bronchial smooth muscle and ease wheezing
    3. C. Reduce preload and afterload, easing congestion
    4. D. Increase contractility to improve forward flow
    Show answer

    Answer: C. Reduce preload and afterload, easing congestion

    Blood pressure must be adequate before giving it.

  13. Furosemide in acute pulmonary edema:

    1. A. Is first-line for every pulmonary edema patient in the field
    2. B. Clears alveolar fluid within seconds of IV injection
    3. C. Has a limited role, since many are not fluid overloaded
    4. D. Is preferred over nitrates when the BP is very high
    Show answer

    Answer: C. Has a limited role, since many are not fluid overloaded

    Ventilatory support and nitrates matter more acutely.

  14. A 78-year-old with no lung disease history is wheezing, with crackles in both bases, JVD, a BP of 196/104, and an SpO2 of 86%. What treatment is most appropriate?

    1. A. Methylprednisolone 125 mg IV
    2. B. CPAP with nitroglycerin
    3. C. IM epinephrine 0.3 mg
    4. D. Albuterol and ipratropium alone
    Show answer

    Answer: B. CPAP with nitroglycerin

    Wheezing with crackles, JVD, and severe hypertension in a patient without lung disease suggests 'cardiac asthma' from acute pulmonary edema; CPAP and nitroglycerin treat the cause. Bronchodilators alone do not relieve the congestion. Steroids do not help pulmonary edema. Epinephrine raises afterload and myocardial oxygen demand, worsening heart failure.

  15. CPAP is started for a patient with acute pulmonary edema and an adequate BP. Per many protocols, what is the usual starting pressure?

    1. A. 15 cm H2O, held steady throughout
    2. B. 20 cm H2O, then lowered to 10
    3. C. 5 cm H2O, titrated to about 10
    4. D. 1 cm H2O, then raised hourly
    Show answer

    Answer: C. 5 cm H2O, titrated to about 10

    Prehospital CPAP commonly starts at about 5 cm H2O and is titrated up (often to 10) to effect while the BP is watched, since positive pressure lowers venous return. Starting at 15 to 20 cm H2O raises the risk of hypotension, gastric insufflation, and barotrauma. 1 cm H2O has no meaningful effect.

  16. To titrate naloxone in small doses, you add 0.4 mg (1 mL) to 9 mL of saline. What is the new concentration?

    1. A. 0.04 mg/mL
    2. B. 0.004 mg/mL
    3. C. 4 mg/mL
    4. D. 0.4 mg/mL
    Show answer

    Answer: A. 0.04 mg/mL

    0.4 mg in a total of 10 mL is 0.04 mg/mL, so each 1 mL delivers 0.04 mg, a common increment for patients with opioid dependence or after procedural opioids. 0.4 mg/mL is the undiluted vial. 0.004 mg/mL and 4 mg/mL are tenfold errors in either direction.

  17. A dialysis patient who makes almost no urine has missed two sessions and has pulmonary edema with a BP of 188/100. What is the main limitation of furosemide here?

    1. A. It is contraindicated when the BP is high
    2. B. It must be given IM in renal failure
    3. C. It works poorly without kidney function
    4. D. It causes dangerous immediate hyperkalemia
    Show answer

    Answer: C. It works poorly without kidney function

    Furosemide works by making the kidneys excrete sodium and water, so it has little effect in a patient who is nearly anuric; CPAP, nitroglycerin, and urgent dialysis are the effective treatments. It does not cause hyperkalemia (it tends to lower potassium). High BP is not a contraindication. It is given IV, not IM, in this setting.

  18. Why is morphine no longer routinely given for acute cardiogenic pulmonary edema?

    1. A. It is linked to more intubation and death
    2. B. It speeds up the heart rate dangerously
    3. C. It causes bronchospasm in most patients
    4. D. It raises the BP and the afterload sharply
    Show answer

    Answer: A. It is linked to more intubation and death

    Registry data linked morphine in acute decompensated heart failure to more mechanical ventilation, ICU admission, and death, likely from respiratory depression and vomiting, so current guidelines do not recommend it routinely; nitrates and CPAP are used instead. Morphine does not commonly cause bronchospasm, and it tends to lower BP and heart rate rather than raise them.

  19. Ipratropium dose (adult) nebulized is:

    1. A. 2.5 mg nebulized
    2. B. 0.05 mg nebulized
    3. C. 5 mg nebulized
    4. D. 0.5 mg nebulized
    Show answer

    Answer: D. 0.5 mg nebulized

    Ipratropium is typically given with the first albuterol doses. It is often combined with albuterol (DuoNeb).

  20. Ipratropium onset is:

    1. A. Slower than albuterol, but longer lasting
    2. B. Faster than albuterol, but shorter lasting
    3. C. Delayed by several hours, like steroids
    4. D. Immediate, lasting only a few minutes
    Show answer

    Answer: A. Slower than albuterol, but longer lasting

    Ipratropium complements albuterol's faster action. Onset is roughly 15 to 30 minutes.

  21. A patient in anaphylactic shock has received IM epinephrine and is lying supine. While moving her to the stretcher, how should she be positioned?

    1. A. Sit her up to make transfer easier
    2. B. Keep her supine with the legs raised
    3. C. Seat her at 45 degrees, legs down
    4. D. Raise her head 30 degrees, legs flat
    Show answer

    Answer: B. Keep her supine with the legs raised

    In anaphylactic shock, venous return is already very low, and abruptly sitting or standing the patient has been linked to sudden cardiac arrest ('empty ventricle'); keep her supine with the legs raised (sitting up only if breathing requires it, and left side for pregnancy). Sitting her up, even partway with the legs down or the head raised, drops venous return.

  22. A COPD patient needs a precise, fixed oxygen concentration such as 28%. Which device delivers this best?

    1. A. Nasal cannula at 6 L/min
    2. B. Nonrebreather mask at 15 L/min
    3. C. Simple face mask at 6 L/min
    4. D. Venturi mask
    Show answer

    Answer: D. Venturi mask

    A Venturi (air-entrainment) mask delivers a set FiO2, such as 24%, 28%, or 35%, regardless of the patient's breathing pattern, which suits patients at risk of hypercapnia. A nonrebreather gives a high, variable FiO2. Simple masks and nasal cannulas deliver an FiO2 that varies with the patient's rate and depth of breathing.

  23. A patient with a severe asthma attack is very anxious and restless, and your partner suggests midazolam to calm her before more albuterol. What is best?

    1. A. Give haloperidol 5 mg IM to calm her
    2. B. Avoid sedation; treat the bronchospasm
    3. C. Give diphenhydramine 50 mg IV
    4. D. Give midazolam 2 mg IV, then albuterol
    Show answer

    Answer: B. Avoid sedation; treat the bronchospasm

    Anxiety and restlessness in severe asthma usually reflect hypoxia and air hunger; sedatives blunt the respiratory drive and can tip the patient into respiratory failure, so asthma guidelines advise against sedation outside of intubation. Treat the cause with bronchodilators, oxygen, steroids, and escalation as needed. Haloperidol and diphenhydramine are also sedating.

  24. Methylprednisolone adult dose is typically:

    1. A. 12.5 mg IV
    2. B. 1 g IV
    3. C. 125 mg IV
    4. D. 500 mg IV
    Show answer

    Answer: C. 125 mg IV

    Pediatric dose is 1–2 mg/kg.

  25. During an asthma attack, a patient used her fluticasone (Flovent) inhaler six times without relief. What should you explain?

    1. A. It must be nebulized to reach the lungs
    2. B. Six puffs is too few; give 12 more
    3. C. It works, but takes 5 minutes to act
    4. D. It is a controller, not a rescue drug
    Show answer

    Answer: D. It is a controller, not a rescue drug

    Fluticasone alone is an inhaled corticosteroid that controls inflammation over days to weeks; it does not relieve acute bronchospasm, so a short-acting bronchodilator (or a formoterol-containing reliever) is needed. It does not start working in 5 minutes. Nebulizing it would not make it a bronchodilator. Extra puffs add steroid exposure without rescue benefit.

  26. Racemic epinephrine for croup is given:

    1. A. Nebulized, 5 mL of 2.25% given undiluted
    2. B. IM, 0.5 mL of 2.25% in the thigh
    3. C. Nebulized, 0.5 mL of 2.25% in saline
    4. D. IV, 0.5 mL of 2.25% by slow push
    Show answer

    Answer: C. Nebulized, 0.5 mL of 2.25% in saline

    Nebulized epinephrine reduces stridor via mucosal vasoconstriction. The 0.5 mL is diluted in 3 mL of saline.

  27. Two minutes after IV naloxone, a patient with a heroin overdose is awake, but he coughs pink frothy sputum and his SpO2 is 84%. What is the most appropriate treatment?

    1. A. Albuterol 2.5 mg by nebulizer
    2. B. Positive pressure, such as CPAP
    3. C. Furosemide 40 mg IV for the fluid
    4. D. Another 2 mg of naloxone IV
    Show answer

    Answer: B. Positive pressure, such as CPAP

    Noncardiogenic pulmonary edema can follow opioid overdose or abrupt naloxone reversal; it is treated with oxygen and positive pressure (CPAP or assisted ventilation if needed). It is not volume overload, so furosemide does not help and may cause hypotension. More naloxone does not clear the fluid. Albuterol does not treat alveolar edema.

  28. A 9-month-old has hives and repeated vomiting minutes after a first taste of egg and is now unusually sleepy and floppy. How should this be interpreted?

    1. A. Possible anaphylaxis; give epinephrine
    2. B. Viral gastroenteritis with dehydration
    3. C. A food intolerance that needs fluids
    4. D. A mild reaction for oral antihistamines
    Show answer

    Answer: A. Possible anaphylaxis; give epinephrine

    Infants cannot describe symptoms, so anaphylaxis may appear as sudden irritability, vomiting, hives, and then drowsiness or floppiness (a sign of hypotension); skin plus GI or circulatory signs after a likely allergen call for IM epinephrine. A stomach virus or food intolerance does not cause hives minutes after a new food, and floppiness here suggests hypotension.

  29. CPAP in COPD/CHF exacerbation:

    1. A. Works mainly by lowering the respiratory rate
    2. B. Is contraindicated whenever nebulized drugs are needed
    3. C. Replaces the need for supplemental oxygen
    4. D. Reduces work of breathing; nebulizers can run in-line
    Show answer

    Answer: D. Reduces work of breathing; nebulizers can run in-line

    Many CPAP systems allow in-line nebulization. It also improves oxygenation.

  30. A 20-kg child with severe asthma is to receive terbutaline 0.01 mg/kg SC. What dose is given?

    1. A. 0.02 mg SC
    2. B. 0.25 mg/kg SC
    3. C. 2 mg SC
    4. D. 0.2 mg SC
    Show answer

    Answer: D. 0.2 mg SC

    Pediatric SC terbutaline is commonly 0.01 mg/kg (maximum about 0.25 mg per dose), so 20 kg x 0.01 = 0.2 mg. 2 mg and 0.02 mg are tenfold errors. 0.25 mg/kg confuses the adult maximum dose with a per-kilogram dose and would be 5 mg.

  31. Ketamine in severe asthma is used because it:

    1. A. Bronchodilates and preserves respiratory drive
    2. B. Reliably lowers heart rate and blood pressure
    3. C. Blocks histamine release from mast cells
    4. D. Dries secretions through anticholinergic action
    Show answer

    Answer: A. Bronchodilates and preserves respiratory drive

    Ketamine releases catecholamines that bronchodilate, and it preserves respiratory drive and airway reflexes, which makes it a preferred induction agent for RSI in severe asthma. Its sympathomimetic effect raises rather than lowers heart rate and blood pressure, it is not a mast cell stabilizer, and it increases rather than dries secretions.

  32. Nebulized medication delivery is less effective when:

    1. A. Tidal volumes are very low or the patient is apneic
    2. B. The nebulizer is driven at 6 to 8 L/min of oxygen flow
    3. C. The mask fits snugly over the nose and mouth
    4. D. The patient is sitting upright during treatment
    Show answer

    Answer: A. Tidal volumes are very low or the patient is apneic

    Severe bronchospasm with minimal air movement reduces drug delivery; consider IM epinephrine.

  33. Continuous albuterol nebulization is dosed at:

    1. A. 2.5–5 mg/hr
    2. B. 10–15 mg/hr
    3. C. 0.5–1 mg/hr
    4. D. 40–50 mg/hr
    Show answer

    Answer: B. 10–15 mg/hr

    Used for severe asthma.

  34. Five minutes after IM epinephrine for anaphylaxis, a patient has new stridor and hoarseness, and the BP is 104/68. What is most appropriate?

    1. A. Give methylprednisolone 125 mg and recheck
    2. B. Repeat IM epinephrine; prepare the airway
    3. C. Insert a nasal airway and observe closely
    4. D. Give diphenhydramine and wait 30 minutes
    Show answer

    Answer: B. Repeat IM epinephrine; prepare the airway

    Worsening upper-airway swelling after one dose calls for a repeat IM epinephrine dose (every 5 to 15 minutes as needed), early preparation for a difficult airway, and rapid transport; nebulized epinephrine may be added. Antihistamines and steroids are too slow for airway edema. A nasal airway does not bypass laryngeal swelling and can provoke bleeding.

  35. H2 blockers (famotidine) in anaphylaxis:

    1. A. A cause of bronchospasm in asthmatics
    2. B. A replacement for repeat epinephrine
    3. C. An adjunct that may ease skin symptoms
    4. D. First-line therapy for airway swelling
    Show answer

    Answer: C. An adjunct that may ease skin symptoms

    H2 blockade is adjunctive only.

  36. A patient with a severe asthma attack asks why aminophylline is no longer used. What is accurate?

    1. A. It is a weak drug with no bronchodilation
    2. B. It is effective in children alone
    3. C. It causes immediate, severe bronchospasm
    4. D. It adds toxicity without better relief
    Show answer

    Answer: D. It adds toxicity without better relief

    Aminophylline (a theophylline) adds little bronchodilation beyond inhaled beta-agonists but has a narrow therapeutic range, causing vomiting, dysrhythmias, and seizures, so asthma guidelines do not recommend it for acute attacks. It is a bronchodilator, not inactive. Its problem is toxicity in all ages, not a pediatric-only effect, and it does not cause bronchospasm.

  37. Pediatric epinephrine for anaphylaxis is:

    1. A. 1 mg IM regardless of weight
    2. B. 0.1 mg/kg IM (max 0.3–0.5 mg)
    3. C. 0.01 mg/kg IM (max 0.3–0.5 mg)
    4. D. 0.001 mg/kg IM (max 0.3–0.5 mg)
    Show answer

    Answer: C. 0.01 mg/kg IM (max 0.3–0.5 mg)

    Auto-injectors: 0.15 mg for 15–30 kg, 0.3 mg for ≥30 kg.

  38. Epinephrine infusion for refractory anaphylaxis is:

    1. A. 1–10 mcg/min titrated
    2. B. 1 mg IV bolus repeated
    3. C. 100 mcg/min fixed rate
    4. D. 0.1 mg/kg/min titrated
    Show answer

    Answer: A. 1–10 mcg/min titrated

    Push-dose or infusion epinephrine for persistent hypotension after IM doses. Push-dose epinephrine (10 to 20 mcg) is an alternative.

  39. An adult with an acute asthma attack is receiving oxygen. Per GINA, what SpO2 target is used?

    1. A. 88% to 92%
    2. B. 93% to 95%
    3. C. 100%
    4. D. 85% to 88%
    Show answer

    Answer: B. 93% to 95%

    GINA advises titrating oxygen to an SpO2 of 93% to 95% in adults (94% to 98% in children); controlled oxygen gives better outcomes than high-flow 100%. 85% to 88% is too low. 88% to 92% is the target for patients at risk of hypercapnia, such as COPD.

  40. A 3-year-old has a barking cough and hoarseness but no stridor at rest and no retractions. Which treatment is appropriate?

    1. A. IV methylprednisolone 2 mg/kg
    2. B. Oral dexamethasone and comfort
    3. C. Nebulized albuterol every 20 min
    4. D. Nebulized epinephrine, repeated
    Show answer

    Answer: B. Oral dexamethasone and comfort

    Mild croup (no stridor at rest) is treated with a single dose of oral dexamethasone and keeping the child calm; nebulized epinephrine is reserved for stridor at rest or distress. IV steroids require a needle that upsets the child and offer no advantage. Albuterol treats lower-airway bronchospasm, not subglottic swelling.

  41. Furosemide adult dose is:

    1. A. 0.1 mg/kg IV, maximum 4 mg
    2. B. 400 mg IV (or 10× home dose)
    3. C. 40 mg IV (or 1–2× home dose)
    4. D. 4 mg IV (or 1–2× home dose)
    Show answer

    Answer: C. 40 mg IV (or 1–2× home dose)

    Monitor for hypotension and hypokalemia.

  42. A COPD patient in an exacerbation is alert, breathing 32/min with an ETCO2 of 64 mm Hg after bronchodilators. Which therapy reduces the need for intubation?

    1. A. High-flow 100% oxygen by nonrebreather
    2. B. Naloxone 2 mg IV to drive breathing
    3. C. Noninvasive ventilation (CPAP/BiPAP)
    4. D. A benzodiazepine for the anxiety
    Show answer

    Answer: C. Noninvasive ventilation (CPAP/BiPAP)

    In COPD with hypercapnic respiratory failure, noninvasive ventilation (CPAP or BiPAP) lowers the work of breathing and reduces intubation and death, provided the patient is alert and can protect the airway. Uncontrolled high-flow oxygen can raise CO2 further. Naloxone has no role without opioids. Sedatives depress the respiratory drive.

  43. Naloxone dose for opioid-induced respiratory depression is:

    1. A. 0.01 mg IV, titrated to full alertness
    2. B. 2 mg IV for every patient regardless of response
    3. C. 0.4–2 mg IV/IM/IN, titrated to ventilation
    4. D. 10 mg IV push to ensure full reversal
    Show answer

    Answer: C. 0.4–2 mg IV/IM/IN, titrated to ventilation

    Titrate to breathing, not full wakefulness, to avoid withdrawal. Chronic users may receive 0.04 to 0.4 mg increments.

  44. Intranasal naloxone dose is:

    1. A. 10 mg divided between nostrils
    2. B. 2–4 mg, depending on the device
    3. C. 0.1 mg in each nostril, repeated
    4. D. 0.4 mg, depending on the device
    Show answer

    Answer: B. 2–4 mg, depending on the device

    IN naloxone has slightly slower onset than IV.

  45. A patient with asthma says she uses her budesonide-formoterol (Symbicort) inhaler both daily and as her reliever. How should you interpret this?

    1. A. Formoterol causes the asthma attacks
    2. B. It is an accepted reliever under GINA
    3. C. She must stop it before albuterol
    4. D. It is a misuse; it is a controller drug
    Show answer

    Answer: B. It is an accepted reliever under GINA

    GINA's preferred approach uses low-dose budesonide-formoterol both as maintenance and as the as-needed reliever, because formoterol acts within minutes and the steroid reduces severe attacks. It is not a misuse. Formoterol is a bronchodilator and does not cause attacks. Albuterol can still be given in the field during a severe attack.

  46. Five minutes after IM epinephrine, an anaphylaxis patient is improving but is pale, tremulous, anxious, and has a heart rate of 118. What do these findings represent?

    1. A. A second allergic reaction
    2. B. Expected epinephrine effects
    3. C. An epinephrine overdose needing a beta blocker
    4. D. Early sepsis needing antibiotics
    Show answer

    Answer: B. Expected epinephrine effects

    Pallor, tremor, anxiety, and a fast heart rate are expected, transient effects of a therapeutic epinephrine dose and are not a reason to withhold later doses if anaphylaxis returns. They do not indicate a new allergic reaction. A beta blocker would blunt epinephrine and worsen anaphylaxis. Nothing here suggests infection.

  47. A 24-year-old asthmatic is tripoding, speaking in single words, with an SpO2 of 89%. Which initial bronchodilator therapy is most appropriate?

    1. A. Albuterol 0.25 mg nebulized once, then reassess
    2. B. Albuterol 2.5 mg with ipratropium 0.5 mg nebulized
    3. C. Ipratropium 0.5 mg alone, repeated every 5 minutes
    4. D. Methylprednisolone 125 mg IV as the only drug
    Show answer

    Answer: B. Albuterol 2.5 mg with ipratropium 0.5 mg nebulized

    Severe asthma is treated with a short-acting beta-2 agonist combined with ipratropium; steroids are added but act slowly.

  48. A patient found with pinpoint pupils is drowsy but rousable, breathing 14/min with good depth and an SpO2 of 96% on room air. What is the appropriate naloxone plan?

    1. A. No naloxone now; monitor breathing
    2. B. Give 4 mg IN to prevent decline
    3. C. Give 0.4 mg IM every 2 minutes now
    4. D. Give 2 mg IV to wake him up fully
    Show answer

    Answer: A. No naloxone now; monitor breathing

    Naloxone is given for inadequate breathing, not for drowsiness or pinpoint pupils alone; with adequate rate, depth, and oxygenation, monitor closely (including ETCO2) and be ready to ventilate and titrate naloxone if breathing falls. Full reversal risks acute withdrawal, vomiting, and agitation. Prophylactic or scheduled doses are not indicated when breathing is adequate.

  49. A 16-year-old asthmatic is drowsy and exhausted, no wheezes are heard, and the SpO2 is 84%. What is most appropriate?

    1. A. Give albuterol alone; the absent wheezes show improvement
    2. B. Assist ventilations and give IM epinephrine
    3. C. Withhold treatment because no wheezing is present
    4. D. Give oral prednisone and reassess in 20 minutes
    Show answer

    Answer: B. Assist ventilations and give IM epinephrine

    A silent chest with altered mentation signals near-arrest from minimal air movement; nebulized drugs cannot reach the lungs well.

  50. A patient with a mild asthma attack, speaking in full sentences with an SpO2 of 97%, responds well to one albuterol treatment. Is adding ipratropium indicated?

    1. A. No, it is contraindicated with albuterol use
    2. B. Not routinely; it helps in severe attacks
    3. C. Yes, it must accompany each albuterol dose
    4. D. Yes, it replaces the need for steroids
    Show answer

    Answer: B. Not routinely; it helps in severe attacks

    Adding ipratropium to albuterol reduces admissions mainly in moderate to severe exacerbations; it adds little in a mild attack that responds to albuterol alone. It is not required with every dose, does not replace steroids, and is commonly combined with albuterol (DuoNeb), so it is not contraindicated.

  51. Per many protocols, terbutaline for a severe asthma exacerbation in an adult is given as:

    1. A. 0.25 mg SC
    2. B. 2.5 mg IV push
    3. C. 0.025 mg IM
    4. D. 25 mg nebulized
    Show answer

    Answer: A. 0.25 mg SC

    Terbutaline is a beta-2 agonist commonly given 0.25 mg SC, repeatable per protocol.

  52. After three albuterol treatments, an asthmatic is breathing better but is tremulous and anxious with a heart rate of 132. These findings most likely represent:

    1. A. Albuterol overdose needing naloxone
    2. B. Worsening asthma needing a beta blocker
    3. C. An allergic reaction to albuterol
    4. D. Expected beta-adrenergic side effects
    Show answer

    Answer: D. Expected beta-adrenergic side effects

    Tremor, anxiety, and tachycardia are common albuterol effects; continue monitoring the patient.

  53. A 10-year-old with severe asthma is still in distress after three albuterol treatments, ipratropium, and a systemic steroid. Which drug is commonly added next?

    1. A. IV magnesium sulfate
    2. B. Oral montelukast 10 mg
    3. C. Inhaled fluticasone
    4. D. IV aminophylline infusion
    Show answer

    Answer: A. IV magnesium sulfate

    IV magnesium sulfate (commonly 25 to 50 mg/kg, maximum 2 g, over 15 to 20 minutes) relaxes bronchial smooth muscle and is recommended for severe exacerbations that fail initial therapy. Aminophylline is no longer recommended because of toxicity. Montelukast and inhaled fluticasone are controller drugs with no role in rescue.

  54. Ipratropium should be used with caution in a patient with:

    1. A. Hypothyroidism
    2. B. Type 2 diabetes
    3. C. Narrow-angle glaucoma
    4. D. Controlled hypertension
    Show answer

    Answer: C. Narrow-angle glaucoma

    As an anticholinergic, ipratropium can dilate the pupil and worsen narrow-angle glaucoma, especially if mist reaches the eyes.

  55. Why are corticosteroids given early in an asthma exacerbation even though they will not help during transport?

    1. A. Their onset takes hours, and early dosing reduces relapse and admission
    2. B. They work within minutes and replace the need for albuterol
    3. C. They are needed to activate the albuterol beta-2 receptors
    4. D. They prevent albuterol-induced tachycardia during transport
    Show answer

    Answer: A. Their onset takes hours, and early dosing reduces relapse and admission

    Steroids reduce airway inflammation over several hours; giving them early improves later outcomes.

  56. A 22-kg child is having a moderate to severe asthma attack. Using 2 mg/kg, a common protocol dose, what is the methylprednisolone dose?

    1. A. 220 mg IV
    2. B. 125 mg IV
    3. C. 44 mg IV
    4. D. 4.4 mg IV
    Show answer

    Answer: C. 44 mg IV

    Pediatric methylprednisolone is commonly 1 to 2 mg/kg (often to a maximum of 125 mg); 22 kg x 2 = 44 mg.

  57. A 15-kg 2-year-old has a barking cough without stridor at rest. Using 0.6 mg/kg, what dexamethasone dose is appropriate?

    1. A. 15 mg IV push
    2. B. 90 mg PO or IM
    3. C. 9 mg PO or IM
    4. D. 0.9 mg PO or IM
    Show answer

    Answer: C. 9 mg PO or IM

    Dexamethasone 0.6 mg/kg is a common croup dose (lower doses are also used), so 15 kg x 0.6 = 9 mg.

  58. A child with croup has stridor at rest and intercostal retractions. Which medication is most appropriate?

    1. A. Nebulized albuterol
    2. B. Intravenous furosemide
    3. C. Nebulized epinephrine
    4. D. Intramuscular diphenhydramine
    Show answer

    Answer: C. Nebulized epinephrine

    Nebulized epinephrine (racemic or L-epinephrine) reduces subglottic edema through alpha-mediated vasoconstriction.

  59. A child with croup improves after nebulized epinephrine. Why is continued observation or transport needed?

    1. A. The effect wears off in about 2 hours and symptoms may return
    2. B. Nebulized epinephrine can cause a delayed rise in BP for hours
    3. C. The child needs a second dose every 15 minutes
    4. D. Rebound tachycardia from the epinephrine peaks at 4 hours
    Show answer

    Answer: A. The effect wears off in about 2 hours and symptoms may return

    Nebulized epinephrine is short-acting, so symptoms can return once it wears off; dexamethasone is given for sustained effect. Nebulized epinephrine's cardiovascular effects fade with the drug rather than appearing hours later, and observation is for returning stridor.

  60. If racemic epinephrine is unavailable for croup with stridor at rest, many protocols substitute:

    1. A. IM epinephrine 0.1 mg/mL at 1 mg
    2. B. Nebulized L-epinephrine 1 mg/mL
    3. C. Subcutaneous terbutaline 2.5 mg
    4. D. IV epinephrine 0.1 mg/mL push
    Show answer

    Answer: B. Nebulized L-epinephrine 1 mg/mL

    L-epinephrine 1 mg/mL, commonly up to 5 mL nebulized, is as effective as racemic epinephrine for croup.

  61. A 4-month-old with bronchiolitis has nasal congestion, wheezing, and an SpO2 of 91%. Which initial approach is most appropriate?

    1. A. Nebulized epinephrine every 20 minutes
    2. B. Suction the nares and give oxygen as needed
    3. C. Dexamethasone 0.6 mg/kg IM before transport
    4. D. Continuous albuterol nebulization at 10 mg/hr
    Show answer

    Answer: B. Suction the nares and give oxygen as needed

    Bronchodilators and steroids are not routinely helpful in bronchiolitis; supportive care with suctioning and oxygen is the mainstay.

  62. A COPD patient with an SpO2 of 86% becomes increasingly drowsy after being placed on a nonrebreather at 15 L/min. What is the best adjustment?

    1. A. Titrate oxygen to an SpO2 of 88% to 92% and monitor ETCO2
    2. B. Increase to high-flow oxygen at 25 L/min immediately
    3. C. Give naloxone to reverse the oxygen-induced drowsiness
    4. D. Stop all oxygen until the patient becomes more alert
    Show answer

    Answer: A. Titrate oxygen to an SpO2 of 88% to 92% and monitor ETCO2

    Excess oxygen can worsen hypercapnia in some COPD patients; controlled oxygen with capnography monitoring is preferred.

  63. A 68-year-old has a COPD exacerbation with wheezing and increased sputum. Which combination is commonly given?

    1. A. Furosemide 40 mg IV and nitroglycerin SL
    2. B. Albuterol/ipratropium nebulizer and a corticosteroid
    3. C. Diphenhydramine 50 mg IV as sole therapy
    4. D. Epinephrine 1 mg IV and albuterol by MDI
    Show answer

    Answer: B. Albuterol/ipratropium nebulizer and a corticosteroid

    COPD exacerbations are treated with inhaled bronchodilators, systemic steroids, and controlled oxygen.

  64. Why is IM epinephrine used cautiously for bronchospasm in a 72-year-old with coronary artery disease?

    1. A. It may provoke myocardial ischemia and dysrhythmias
    2. B. It is ineffective in patients older than 65 years
    3. C. It must be given IV rather than IM in older adults
    4. D. It causes severe bronchospasm in the elderly
    Show answer

    Answer: A. It may provoke myocardial ischemia and dysrhythmias

    Epinephrine's beta-1 and alpha effects raise myocardial oxygen demand; this concern does not apply to true anaphylaxis, where it remains first-line.

  65. A CHF patient on CPAP becomes hypotensive at 78/40 and begins vomiting. What should be done?

    1. A. Discontinue CPAP and protect the airway
    2. B. Give nitroglycerin to improve forward flow
    3. C. Continue CPAP and give furosemide
    4. D. Increase CPAP pressure to 15 cm H2O
    Show answer

    Answer: A. Discontinue CPAP and protect the airway

    Hypotension and vomiting are contraindications to CPAP because of aspiration risk and reduced venous return.

  66. A patient has flash pulmonary edema with a BP of 210/120 and severe distress. Which treatments are first-line?

    1. A. Nitroglycerin and CPAP
    2. B. Albuterol and ipratropium
    3. C. Furosemide alone, then reassess
    4. D. Morphine and a fluid bolus
    Show answer

    Answer: A. Nitroglycerin and CPAP

    Hypertensive acute pulmonary edema responds best to vasodilation with nitrates and positive pressure ventilation.

  67. An elderly patient has crackles, fever, and a cough, and pneumonia is as likely as heart failure. What is the main concern with giving furosemide?

    1. A. Furosemide reliably causes bronchospasm in pneumonia
    2. B. Furosemide loses its effect when the patient has a fever
    3. C. Diuresis can worsen dehydration and hypotension if it is not CHF
    4. D. Furosemide pushes the potassium up to dangerous levels within minutes
    Show answer

    Answer: C. Diuresis can worsen dehydration and hypotension if it is not CHF

    Prehospital misdiagnosis is common; giving a diuretic to a patient with pneumonia or sepsis can cause harm. Fever does not block furosemide, and it lowers rather than raises potassium; the danger in a pneumonia or septic patient is volume loss.

  68. A 35-year-old stung by a bee has hives, wheezing, and a BP of 82/50. What is the first drug?

    1. A. Epinephrine 1 mg IV of 0.1 mg/mL by push
    2. B. Diphenhydramine 50 mg IV push over 1 minute
    3. C. Methylprednisolone 125 mg IV over 2 minutes
    4. D. Epinephrine 0.5 mg IM of 1 mg/mL in the thigh
    Show answer

    Answer: D. Epinephrine 0.5 mg IM of 1 mg/mL in the thigh

    IM epinephrine (0.3 to 0.5 mg in adults) is first-line for anaphylaxis; antihistamines and steroids are adjuncts.

  69. Five minutes after IM epinephrine, an anaphylaxis patient is still hypotensive and wheezing. What is the next step?

    1. A. Repeat IM epinephrine and give a fluid bolus
    2. B. Give epinephrine 1 mg IV push of 0.1 mg/mL
    3. C. Wait 30 minutes before another dose
    4. D. Give diphenhydramine and stop epinephrine
    Show answer

    Answer: A. Repeat IM epinephrine and give a fluid bolus

    IM epinephrine can be repeated every 5 to 15 minutes; refractory cases may need an epinephrine infusion.

  70. An adult in anaphylaxis remains hypotensive after two IM epinephrine doses. Along with continued epinephrine, what fluid therapy is appropriate?

    1. A. 100 mL of 3% saline as a slow push
    2. B. 250 mL of D5W infused over 1 hour
    3. C. No fluid, since it worsens airway swelling
    4. D. 1–2 L of isotonic crystalloid, rapidly
    Show answer

    Answer: D. 1–2 L of isotonic crystalloid, rapidly

    Anaphylactic shock involves vasodilation and large fluid shifts, so adults commonly need 1 to 2 L of isotonic crystalloid given rapidly (children 10 to 20 mL/kg), with an epinephrine infusion if hypotension persists. D5W provides little volume. Withholding fluid leaves the patient underfilled. Hypertonic saline is not used for anaphylaxis.

  71. An asthmatic used her albuterol inhaler about 20 times before you arrived. She is still wheezing with poor air movement and has a heart rate of 136. What is best?

    1. A. Give metoprolol to slow the heart rate
    2. B. Give oral prednisone alone and observe
    3. C. Nebulize albuterol with ipratropium
    4. D. Withhold albuterol because of the rate
    Show answer

    Answer: C. Nebulize albuterol with ipratropium

    A fast heart rate in severe asthma is driven largely by hypoxia and distress; it usually improves as bronchospasm is relieved, so it is not a reason to withhold albuterol. Give nebulized albuterol with ipratropium (and steroids), escalating as needed. A beta blocker would worsen bronchospasm. Oral steroids alone act too slowly.

  72. After IM epinephrine, an anaphylaxis patient's BP and skin have improved, but she still has mild wheezing. Which adjunct is reasonable?

    1. A. IV furosemide
    2. B. Inhaled fluticasone
    3. C. IV magnesium sulfate
    4. D. Nebulized albuterol
    Show answer

    Answer: D. Nebulized albuterol

    Inhaled albuterol is a useful adjunct for bronchospasm that persists after epinephrine in anaphylaxis, but it never replaces epinephrine. Furosemide has no role, an inhaled controller steroid does not relieve acute bronchospasm, and IV magnesium is reserved for severe, refractory bronchospasm rather than mild wheezing.

  73. A patient has isolated hives and itching after a new medication, with normal vital signs and no respiratory or GI symptoms. Commonly, the appropriate drug is:

    1. A. IM epinephrine 0.5 mg, repeated every 5 minutes
    2. B. An epinephrine infusion at 2 to 10 mcg/min
    3. C. Diphenhydramine; IM epinephrine is not required now
    4. D. Methylprednisolone 125 mg IV as the only drug
    Show answer

    Answer: C. Diphenhydramine; IM epinephrine is not required now

    A localized allergic reaction without systemic involvement is not anaphylaxis; monitor closely for progression.

  74. After a nebulized ipratropium-albuterol treatment through a loose mask, an alert patient has one dilated pupil that reacts poorly and no other neurologic findings. What is the most likely cause?

    1. A. An acute stroke needing a stroke alert
    2. B. Drug mist reaching the eye
    3. C. Increased pressure from a brain bleed
    4. D. Albuterol-induced hypoglycemia
    Show answer

    Answer: B. Drug mist reaching the eye

    Ipratropium is an anticholinergic; mist escaping from a loose mask into one eye can dilate that pupil (pharmacologic anisocoria) in an otherwise normal, alert patient. A stroke or herniation causing a blown pupil comes with a decreased level of consciousness or other deficits. Albuterol does not cause hypoglycemia (it tends to raise glucose) and does not dilate one pupil.

  75. A woman at 30 weeks' gestation has hives, wheezing, and a BP of 84/50 after a shellfish meal. What is the first drug?

    1. A. Ranitidine 50 mg IV
    2. B. Diphenhydramine 50 mg IV
    3. C. Epinephrine 0.5 mg IM
    4. D. Methylprednisolone 125 mg IV
    Show answer

    Answer: C. Epinephrine 0.5 mg IM

    Anaphylaxis in pregnancy is treated like anaphylaxis in anyone: IM epinephrine first, along with left lateral positioning and fluids, because maternal hypotension threatens the fetus far more than epinephrine does. Diphenhydramine, steroids, and H2 blockers are adjuncts that do not reverse shock or bronchospasm.

  76. During a magnesium infusion for asthma, the patient becomes flushed and the BP drops from 120/78 to 96/60. What is the most appropriate action?

    1. A. Stop and give IM epinephrine for anaphylaxis
    2. B. Slow the infusion; flushing and hypotension are rate-related
    3. C. Speed up the infusion to finish the dose sooner
    4. D. Give calcium chloride 1 g IV push immediately
    Show answer

    Answer: B. Slow the infusion; flushing and hypotension are rate-related

    Rapid magnesium administration causes vasodilation, flushing, and hypotension.

  77. A premixed ipratropium-albuterol unit-dose vial (DuoNeb) contains:

    1. A. Ipratropium 0.5 mg and levalbuterol 10 mg (as base)
    2. B. Ipratropium 5 mg and albuterol 25 mg (as base)
    3. C. Ipratropium 0.5 mg and albuterol 2.5 mg (as base)
    4. D. Ipratropium 0.05 mg and albuterol 0.25 mg (as base)
    Show answer

    Answer: C. Ipratropium 0.5 mg and albuterol 2.5 mg (as base)

    The 3-mL vial contains 0.5 mg ipratropium and 3 mg albuterol sulfate, equivalent to 2.5 mg albuterol base.

  78. A pregnant woman at 30 weeks has a moderate asthma attack. How should bronchodilator therapy be handled?

    1. A. Withhold albuterol until after delivery to protect the fetus
    2. B. Use half doses of albuterol to limit fetal exposure
    3. C. Treat as usual; maternal hypoxia poses more fetal risk
    4. D. Avoid supplemental oxygen to prevent fetal toxicity
    Show answer

    Answer: C. Treat as usual; maternal hypoxia poses more fetal risk

    Standard asthma treatment is used in pregnancy because uncontrolled maternal hypoxia threatens the fetus far more than the drugs.

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