Routes of Administration Practice Questions

74 multiple-choice questions on Routes of administration for paramedic and EMT students, from Chapter 14 (Medication Administration). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

74 practice questions

1. The oral route is generally inappropriate in emergencies because:

   1. A. It is not permitted under most EMS protocols
   2. B. Oral drugs always cause severe gastric irritation
   3. C. Absorption is slow and unreliable, with aspiration risk
   4. D. Oral drugs are destroyed entirely by stomach acid
   Show answer

   Answer: C. Absorption is slow and unreliable, with aspiration risk

   Absorption is slow and unreliable, and a patient who vomits may aspirate. Aspirin and oral glucose are common exceptions.

2. When pushing a drug into a running IV line, why is it given through the injection port closest to the patient?

   1. A. The distal port filters out particulates
   2. B. Upper ports are reserved for blood products
   3. C. Less tubing to fill, so it arrives faster
   4. D. It slows the drug to prevent a rapid peak
   Show answer

   Answer: C. Less tubing to fill, so it arrives faster

   The port nearest the catheter leaves the least tubing (dead space) for the drug to cross, so the full dose reaches the vein promptly, especially when followed by a flush. Ports do not filter particulates, upper ports are not reserved for blood, and the nearest port speeds rather than slows delivery.

3. The buccal route places the medication:

   1. A. On the hard palate
   2. B. Under the tongue near the frenulum
   3. C. Between the cheek and gum
   4. D. Onto the back of the throat
   Show answer

   Answer: C. Between the cheek and gum

   Oral glucose gel is often given this way, in a patient who can protect their airway.

4. IV ketamine acts within about a minute. When it is given IM for severe agitation, onset is usually about:

   1. A. 30 to 60 seconds
   2. B. 30 to 45 minutes
   3. C. 60 to 90 minutes
   4. D. 3 to 5 minutes
   Show answer

   Answer: D. 3 to 5 minutes

   IM ketamine is absorbed quickly from well-perfused muscle and usually acts within about 3 to 5 minutes, which is why it is used when IV access is unsafe to obtain. 30 to 60 seconds matches IV onset, which IM absorption does not reach, and 30 to 45 or 60 to 90 minutes is closer to oral absorption than IM.

5. The intranasal route delivers medication:

   1. A. Directly into the lungs for local effect
   2. B. Into the stomach after the patient swallows it
   3. C. Across the nasal mucosa into the bloodstream
   4. D. Into the cerebrospinal fluid via the olfactory nerve
   Show answer

   Answer: C. Across the nasal mucosa into the bloodstream

   The vascular nasal mucosa gives rapid onset without a needle. Naloxone, midazolam, and fentanyl are commonly given this way.

6. When drawing up a drug for a mucosal atomizer, many protocols add about 0.1 mL because:

   1. A. Nasal absorption destroys part of the dose
   2. B. The drug must be diluted to atomize well
   3. C. Extra volume pushes the dose into the lungs
   4. D. The atomizer tip retains a small volume
   Show answer

   Answer: D. The atomizer tip retains a small volume

   The atomizer and its tip hold a small dead-space volume (about 0.1 mL), so that amount is added to deliver the full calculated dose. The nasal mucosa does not destroy part of the dose, the drug is atomized undiluted (the most concentrated form is preferred), and IN delivery is meant for the nasal mucosa, not the lungs.

7. Which statement describes the intramuscular route?

   1. A. It is preferred in cardiac arrest
   2. B. Its absorption is unreliable in shock
   3. C. It uses a 25-gauge, 3/8-inch needle in adults
   4. D. It has a faster onset than IV
   Show answer

   Answer: B. Its absorption is unreliable in shock

   Absorption from well-perfused muscle is moderate, but poor perfusion in shock makes IM absorption slow and unreliable. IV or IO access is preferred in cardiac arrest, IV onset is faster than IM, and adult IM injections use a needle of about 21 to 23 gauge and 1 to 1.5 inches rather than a 25-gauge, 3/8-inch subcutaneous needle. Epinephrine for anaphylaxis is given IM into the lateral thigh.

8. The subcutaneous route delivers medication:

   1. A. Into the muscle beneath the fascia
   2. B. Into a superficial vein of the arm
   3. C. Into the dermis just below the epidermis
   4. D. Into the fatty layer under the skin
   Show answer

   Answer: D. Into the fatty layer under the skin

   Absorption is slower than IM. Volume is limited to about 1 mL.

9. The intradermal route is used mainly for:

   1. A. Fluid administration in infants
   2. B. Skin tests and local anesthetic wheals
   3. C. All routine childhood vaccines
   4. D. Emergency drugs such as epinephrine
   Show answer

   Answer: B. Skin tests and local anesthetic wheals

   Examples include tuberculin skin testing. Volumes are very small.

10. Before irrigating a chemical eye injury, tetracaine drops are ordered. Where should the drops be placed?

    1. A. Onto the center of the cornea
    2. B. Into the lower conjunctival sac
    3. C. Into the inner canthus, tip touching
    4. D. Onto the upper lid, eye closed
    Show answer

    Answer: B. Into the lower conjunctival sac

    Pull the lower lid down and drop the medication into the lower conjunctival sac without touching the tip to the eye; blinking spreads it. Drops aimed at the cornea trigger reflex blinking and are lost, touching the tip contaminates the bottle, and drops on a closed upper lid never reach the conjunctiva.

11. The transdermal route provides:

    1. A. Rapid onset for emergencies
    2. B. Precise minute-to-minute titration
    3. C. Immediate peak blood levels
    4. D. Slow, sustained absorption
    Show answer

    Answer: D. Slow, sustained absorption

    Absorption through the skin is slow and sustained. Remove nitroglycerin patches before defibrillation to avoid burns.

12. The intraosseous route is considered:

    1. A. Slower than IV for most emergency drugs
    2. B. Reserved only for pediatric patients
    3. C. Suitable for fluids but not medications
    4. D. Equivalent to IV for most drugs and fluids
    Show answer

    Answer: D. Equivalent to IV for most drugs and fluids

    It is the alternative when IV access fails in a critical patient.

13. Which route provides the fastest onset for most emergency medications?

    1. A. Oral
    2. B. Intramuscular
    3. C. Subcutaneous
    4. D. Intravenous
    Show answer

    Answer: D. Intravenous

    IO is essentially equivalent when IV access is not available.

14. Under the 2025 AHA adult guidelines, what is the recommended sequence for drug access in adult cardiac arrest?

    1. A. IV first; IO if IV fails or is not feasible
    2. B. IO first, before trying a peripheral IV line
    3. C. Endotracheal tube first, then IV or IO
    4. D. Central line first, then peripheral IV
    Show answer

    Answer: A. IV first; IO if IV fails or is not feasible

    The 2025 AHA adult ALS update recommends attempting IV access first for drug delivery in adult cardiac arrest, with IO access reasonable if IV attempts are unsuccessful or not feasible. IO before any IV attempt is not the recommended adult approach, endotracheal drug delivery was removed from the adult recommendations because absorption is unreliable, and central lines are not a first-line field route.

15. A patient with a gastrostomy tube needs an oral medication. Giving it through the tube is classified as:

    1. A. An enteral route
    2. B. A parenteral route
    3. C. A topical route
    4. D. A transdermal route
    Show answer

    Answer: A. An enteral route

    Anything delivered into the GI tract, including by nasogastric or gastrostomy tube, is enteral and is still subject to gut absorption and first-pass metabolism. Parenteral routes bypass the gut (IV, IO, IM, SC); topical and transdermal routes act on or through the skin.

16. Which preparation must not be given IV because its particles can embolize and cause cardiac arrest?

    1. A. A suspension labeled for IM use only
    2. B. A lipid emulsion such as propofol
    3. C. A solution labeled for IV or IM use
    4. D. A vesicant such as 10% calcium chloride
    Show answer

    Answer: A. A suspension labeled for IM use only

    Suspensions (cloudy particles in liquid) labeled for IM use only, such as penicillin G benzathine, can cause embolism and cardiac arrest if given IV; the boxed warning forbids IV use. Propofol is a lipid emulsion made for IV use, calcium chloride is a vesicant that is given IV through a secure vein, and a solution labeled for IV or IM use is safe in the vein.

17. A patient wearing a fentanyl patch has a fever of 104°F (40°C). What is the main concern?

    1. A. Fever destroys the drug in the patch
    2. B. Sweating washes the drug off the skin
    3. C. Heat speeds absorption from the patch
    4. D. Fever blocks opioid receptors in the brain
    Show answer

    Answer: C. Heat speeds absorption from the patch

    Fever, heating pads, and hot baths raise skin blood flow and drug release, which can push fentanyl levels into the toxic range; labeling warns about this, so watch breathing and consider removing the patch per protocol. Fever does not destroy the drug, sweating does not wash it out of the patch, and fever does not block opioid receptors.

18. Nasal glucagon powder is given to an unresponsive hypoglycemic patient. Does the patient need to inhale for it to work?

    1. A. Yes; it must be sniffed in deeply to work
    2. B. Yes; it is absorbed through the lungs
    3. C. No; it absorbs through the nasal mucosa
    4. D. No; it must first be mixed with saline
    Show answer

    Answer: C. No; it absorbs through the nasal mucosa

    Nasal glucagon is absorbed through the nasal mucosa, so it works in an unresponsive patient who is not breathing deeply; the patient does not need to sniff or inhale. It is not absorbed through the lungs, and it is a ready-to-use powder that is not mixed with saline.

19. Oral medications have the slowest onset because:

    1. A. Their molecules are larger than IV drugs
    2. B. They pass through the gut and liver first
    3. C. The patient must chew them completely
    4. D. They are formulated at weaker strengths
    Show answer

    Answer: B. They pass through the gut and liver first

    They must dissolve, pass through the stomach, be absorbed in the intestine, and undergo first-pass metabolism. Oral onset is typically 30–60 minutes.

20. For a seizing child without IV access, current EMS guidelines usually favor which midazolam route over rectal diazepam?

    1. A. Oral tablet
    2. B. IM or intranasal
    3. C. Subcutaneous
    4. D. Transdermal patch
    Show answer

    Answer: B. IM or intranasal

    IM midazolam (the RAMPART trial) and IN midazolam stop seizures at least as quickly as IV access and are easier and more dignified than rectal diazepam, so model EMS guidelines favor them when there is no IV. A seizing child cannot swallow a tablet, subcutaneous absorption is slow and unreliable, and patches act over hours.

21. Ketamine 4 mg/kg IM is ordered for a 100-kg patient with severe agitation. Using 100 mg/mL, how should it be given?

    1. A. 4 mL into one deltoid
    2. B. 40 mL split among four sites
    3. C. 4 mL into a thigh muscle
    4. D. 0.4 mL into a thigh muscle
    Show answer

    Answer: C. 4 mL into a thigh muscle

    100 kg x 4 mg/kg = 400 mg, and 400 / 100 mg/mL = 4 mL. A large muscle such as the vastus lateralis accepts this volume (or it can be split between both thighs), while the deltoid holds only about 1 to 2 mL. 40 mL and 0.4 mL are decimal errors.

22. Terbutaline 0.25 mg SC is ordered for severe asthma. On hand: 1 mg/mL. Which volume and needle fit?

    1. A. 0.25 mL, 25-gauge, 5/8-inch needle
    2. B. 2.5 mL, 25-gauge, 5/8-inch needle
    3. C. 0.25 mL, 18-gauge, 1.5-inch needle
    4. D. 0.025 mL, 21-gauge, 1-inch needle
    Show answer

    Answer: A. 0.25 mL, 25-gauge, 5/8-inch needle

    0.25 mg / 1 mg/mL = 0.25 mL, given SC with a short, fine needle (about 25-gauge, 5/8 inch) into fatty tissue. 2.5 mL and 0.025 mL are decimal errors, and an 18-gauge, 1.5-inch needle is a drawing or IM needle that would place the drug in muscle.

23. The intravenous route provides:

    1. A. Slow onset with prolonged absorption
    2. B. Immediate onset and 100% bioavailability
    3. C. Unpredictable absorption in all patients
    4. D. Reduced bioavailability from first-pass metabolism
    Show answer

    Answer: B. Immediate onset and 100% bioavailability

    IV is the most rapid and predictable route.

24. Intraosseous administration delivers drugs:

    1. A. Into the muscle surrounding the bone
    2. B. Into the bone marrow cavity
    3. C. Into the periosteum around the bone
    4. D. Into the joint space beside the bone
    Show answer

    Answer: B. Into the bone marrow cavity

    The marrow drains into the central circulation at rates comparable to IV. IO is an alternative when IV access fails.

25. The intranasal route uses a mucosal atomizer because:

    1. A. Mist spreads over more absorptive mucosa
    2. B. It prevents sneezing and drug loss
    3. C. Atomizers are required by EMS regulations
    4. D. It delivers the drug into the lungs
    Show answer

    Answer: A. Mist spreads over more absorptive mucosa

    Atomized particles are absorbed rapidly across the nasal mucosa without needles. IN naloxone, midazolam, and fentanyl are common EMS uses.

26. A 4-mg naloxone nasal spray is a single-dose device. If a second dose is needed, it should be:

    1. A. Given by pressing the same device again
    2. B. Given with a new device in the other nostril
    3. C. Delayed for at least 30 minutes after the first
    4. D. Mixed with saline in the used device
    Show answer

    Answer: B. Given with a new device in the other nostril

    Each nasal spray device holds one dose; a repeat dose (every 2 to 3 minutes if needed) uses a new device, alternating nostrils. Pressing the used device again delivers nothing, waiting 30 minutes leaves a hypoxic patient untreated, and the device cannot be refilled or mixed.

27. The inhalation route is used for:

    1. A. Antibiotics for community-acquired pneumonia
    2. B. Opioid analgesics such as morphine sulfate
    3. C. Insulin for diabetic ketoacidosis care
    4. D. Bronchodilators such as albuterol
    Show answer

    Answer: D. Bronchodilators such as albuterol

    Oxygen and inhaled anesthetics are also given this way. Nebulized drugs act directly on airway smooth muscle.

28. When norepinephrine must run through a peripheral IV, which line is best?

    1. A. A small hand vein to limit the dose
    2. B. A line shared with a running blood product
    3. C. The IV with the slowest gravity flow
    4. D. A large proximal vein, checked often
    Show answer

    Answer: D. A large proximal vein, checked often

    Peripheral vasopressors are acceptable short-term through a well-functioning catheter in a large proximal vein (antecubital or upper arm), with frequent site checks, because extravasation can cause necrosis. Small hand veins raise extravasation risk, a blood line must carry only normal saline, and a sluggish line suggests a poorly positioned catheter.

29. Nitroglycerin 2% ointment is dosed by:

    1. A. Inches on a dose-measuring paper
    2. B. Number of drops onto the chest
    3. C. Milliliters drawn into a syringe
    4. D. Number of tablets crushed into it
    Show answer

    Answer: A. Inches on a dose-measuring paper

    Nitroglycerin 2% ointment is squeezed onto a ruled applicator paper and dosed in inches (1 inch is about 15 mg), then spread on the skin and covered; wear gloves so you do not absorb it. It is not dosed in drops, milliliters, or crushed tablets.

30. Large IV doses of furosemide are given slowly (no faster than about 4 mg/min) mainly to reduce the risk of:

    1. A. Hyperkalemia
    2. B. Bronchospasm
    3. C. Ototoxicity
    4. D. Seizures
    Show answer

    Answer: C. Ototoxicity

    Rapid injection of high-dose furosemide is linked to tinnitus and hearing loss (ototoxicity), so labeling limits the rate. Furosemide lowers potassium rather than raising it, and it does not cause bronchospasm or seizures.

31. The intracardiac route is:

    1. A. Standard in cardiac arrest
    2. B. Preferred for epinephrine in arrest
    3. C. Used mainly in pediatric arrest
    4. D. Obsolete in modern EMS
    Show answer

    Answer: D. Obsolete in modern EMS

    Intracardiac injection carries unacceptable risk.

32. A patient in anaphylactic shock stays hypotensive after two IM epinephrine doses and fluids. The usual next step is:

    1. A. A third dose given subcutaneously
    2. B. A titrated IV epinephrine infusion
    3. C. Oral diphenhydramine and observation
    4. D. An epinephrine dose by the ET route
    Show answer

    Answer: B. A titrated IV epinephrine infusion

    Refractory anaphylaxis (hypotension after two or more IM doses plus fluids) is treated with a titrated IV epinephrine infusion with cardiac monitoring, per protocol. Subcutaneous absorption is even worse in shock, oral antihistamines do not treat hypotension, and the ET route is not used for a patient with a pulse.

33. Calcium chloride and sodium bicarbonate are both given through one IV during an arrest. To prevent a precipitate, you should:

    1. A. Flush the line well between the two drugs
    2. B. Mix them in one syringe to save time
    3. C. Give them back to back with no flush
    4. D. Push the calcium into the bicarbonate bag
    Show answer

    Answer: A. Flush the line well between the two drugs

    Calcium and bicarbonate form insoluble calcium carbonate, which can block the line, so flush thoroughly between them (or use separate lines). Mixing them in a syringe, pushing them back to back, or adding calcium to a bicarbonate bag all produce the precipitate.

34. The umbilical vein route is used in:

    1. A. Newborn resuscitation
    2. B. Pregnant trauma patients
    3. C. Toddler dehydration
    4. D. Adult cardiac arrest
    Show answer

    Answer: A. Newborn resuscitation

    Umbilical vein catheterization provides neonatal vascular access.

35. Nebulized medications require:

    1. A. A syringe to inject the drug
    2. B. Gas flow of about 6 to 8 L/min
    3. C. Gas flow of about 1 to 2 L/min
    4. D. Gas flow of 15 L/min or more
    Show answer

    Answer: B. Gas flow of about 6 to 8 L/min

    Oxygen or air at about 6–8 L/min aerosolizes the solution. Nebulizers create a mist from the liquid drug.

36. Which epinephrine auto-injector strength fits a 22-kg child?

    1. A. 0.3 mg
    2. B. 0.15 mg
    3. C. 0.5 mg
    4. D. 0.01 mg
    Show answer

    Answer: B. 0.15 mg

    Auto-injectors are chosen by weight: 0.15 mg for about 15 to 30 kg and 0.3 mg for 30 kg or more (a 0.1-mg device exists for 7.5 to 15 kg). 0.3 mg is the adult device, 0.5 mg is the adult maximum for a drawn-up IM dose, and 0.01 mg is the per-kilogram dose, not a device strength.

37. Oral glucose is contraindicated when:

    1. A. The patient cannot protect the airway
    2. B. The patient has type 1 diabetes
    3. C. Blood glucose is below 60 mg/dL
    4. D. The patient took insulin in the last hour
    Show answer

    Answer: A. The patient cannot protect the airway

    The patient must be able to swallow and protect the airway. Aspiration risk prohibits oral administration in altered patients.

38. Which route of administration is the easiest to titrate to effect?

    1. A. IM
    2. B. Transdermal
    3. C. Oral
    4. D. IV
    Show answer

    Answer: D. IV

    IV allows small incremental doses with immediate effect.

39. The term 'bolus' means:

    1. A. A slow drip over several hours
    2. B. A tablet dissolved under the tongue
    3. C. A single large dose given at once
    4. D. A continuous weight-based infusion
    Show answer

    Answer: C. A single large dose given at once

    Bolus doses are given over seconds to minutes.

40. A continuous infusion is used when:

    1. A. A steady drug level is needed
    2. B. The patient is stable and alert
    3. C. The drug has a long half-life
    4. D. A single bolus dose will suffice
    Show answer

    Answer: A. A steady drug level is needed

    Examples include vasopressors and antiarrhythmics. Infusions maintain therapeutic levels of short-acting drugs.

41. The ophthalmic route delivers drugs:

    1. A. To the ear
    2. B. To the skin
    3. C. To the nose
    4. D. To the eye
    Show answer

    Answer: D. To the eye

    Example: tetracaine for eye irrigation.

42. The otic route delivers drugs to the:

    1. A. Nose
    2. B. Ear
    3. C. Skin
    4. D. Eye
    Show answer

    Answer: B. Ear

    Otic drops are rarely used in EMS.

43. To keep an intranasal dose small, which midazolam concentration is preferred?

    1. A. 1 mg/mL
    2. B. 0.5 mg/mL
    3. C. 0.1 mg/mL
    4. D. 5 mg/mL
    Show answer

    Answer: D. 5 mg/mL

    IN absorption works best with small volumes (about 1 mL or less per nostril), so the most concentrated product, 5 mg/mL, is used. The 1 mg/mL product needs five times the volume, and 0.5 or 0.1 mg/mL would need volumes far too large to absorb.

44. Which route has the highest risk of immediate severe adverse effects due to rapid onset?

    1. A. Transdermal
    2. B. Rectal
    3. C. IV
    4. D. Oral
    Show answer

    Answer: C. IV

    IV administration cannot be retrieved once given.

45. A combative patient with hyperactive delirium and severe agitation has no IV access. The most practical route for sedation is:

    1. A. IO line placed first, then the sedative given IO
    2. B. Oral solution given by medicine cup
    3. C. Intramuscular injection into a large muscle
    4. D. Rectal benzodiazepine gel given now
    Show answer

    Answer: C. Intramuscular injection into a large muscle

    IM injection into a large muscle is fast, does not need the patient's cooperation or vascular access, and reaches effect within minutes. An oral solution needs a cooperative patient who can swallow safely, placing an IO in a combative patient risks needlesticks and dislodgement while delaying sedation, and rectal gel is impractical and unreliable in a struggling adult. Monitor breathing and capnography after sedation.

46. For a 6-year-old with a forearm fracture and no IV, which analgesic is well supported and needle-free?

    1. A. Rectal morphine suppository
    2. B. Intranasal fentanyl spray
    3. C. Subcutaneous ketorolac
    4. D. Transdermal fentanyl patch
    Show answer

    Answer: B. Intranasal fentanyl spray

    IN fentanyl (about 1.5 mcg/kg) gives analgesia comparable to IV morphine in children within minutes, without a needle. Rectal morphine absorbs erratically, ketorolac is not given subcutaneously, and a fentanyl patch is for chronic pain in opioid-tolerant patients and takes hours to work.

47. Intranasal naloxone is less effective in a patient with:

    1. A. Heavy nasal bleeding or copious nasal secretions
    2. B. A history of opioid use disorder
    3. C. A respiratory rate of 8 breaths/min
    4. D. Pinpoint pupils and slow respirations
    Show answer

    Answer: A. Heavy nasal bleeding or copious nasal secretions

    Blood, mucus, or nasal trauma prevents mucosal contact and absorption.

48. Studies of oral glucose for hypoglycemia show that most of the glucose that raises blood sugar is absorbed from:

    1. A. The cheek lining while held in the mouth
    2. B. The tongue's surface within seconds
    3. C. The small bowel, after it is swallowed
    4. D. The lungs, as the gel is inhaled
    Show answer

    Answer: C. The small bowel, after it is swallowed

    Glucose is a water-soluble molecule that crosses the oral mucosa poorly; a Cochrane review found that swallowed glucose raised blood glucose more at 20 minutes than buccal glucose. Gel placed in the cheek works mainly as the patient swallows it, so give it only to a patient who can swallow and protect the airway. The cheek lining and tongue absorb little glucose, and gel should never reach the lungs.

49. Topical anesthetic cream (lidocaine-prilocaine) is rarely used before emergency IV starts in children because:

    1. A. It commonly triggers allergic reactions
    2. B. It is not approved for young children
    3. C. It needs about an hour to take effect
    4. D. It is poorly absorbed through intact skin
    Show answer

    Answer: C. It needs about an hour to take effect

    Lidocaine-prilocaine cream must sit under an occlusive dressing for at least an hour to numb the skin, too long for urgent access, though it suits planned procedures. Allergy to it is uncommon, it is labeled for infants and children, and it does absorb through intact skin, which is how it numbs.

50. Before defibrillating a patient who wears a nitroglycerin patch on the chest, you should:

    1. A. Place the pad directly over the patch
    2. B. Remove the patch and wipe the skin
    3. C. Leave it, since patches are not conductive
    4. D. Cut the patch in half to reduce the dose
    Show answer

    Answer: B. Remove the patch and wipe the skin

    Pads placed over a medication patch can block current delivery and cause skin burns, so remove the patch and wipe off residual drug before placing the pad. Pads should not go over the patch, the patch can still interfere and burn even if it is not a conductor, and cutting it does not solve the problem.

51. Which factor most limits subcutaneous absorption in a patient in shock?

    1. A. A larger needle gauge being used for injection
    2. B. Faster liver metabolism of the absorbed drug
    3. C. Increased muscle mass at the injection site
    4. D. Vasoconstriction reducing skin blood flow
    Show answer

    Answer: D. Vasoconstriction reducing skin blood flow

    Shock shunts blood away from skin and subcutaneous tissue, making absorption unpredictable.

52. A patient in cardiac arrest has no IV. After two failed IV attempts, the next route should be:

    1. A. Subcutaneous
    2. B. Intramuscular
    3. C. Endotracheal
    4. D. Intraosseous
    Show answer

    Answer: D. Intraosseous

    IO access is preferred over ET administration because drug delivery and effect are more reliable.

53. A patient uses an albuterol metered-dose inhaler with a spacer. Between puffs, she should:

    1. A. Wait about a minute and shake it again
    2. B. Take both puffs in one breath
    3. C. Rinse the spacer with water first
    4. D. Hold her breath for 2 full minutes each time
    Show answer

    Answer: A. Wait about a minute and shake it again

    Waiting about a minute between puffs and shaking the canister again gives a full, evenly mixed second dose. Two puffs in one breath deposit less drug in the airways, rinsing the spacer between puffs leaves it wet and is unnecessary, and a breath-hold of about 10 seconds, not 2 minutes, is enough.

54. A patient with a severe asthma attack can only take shallow breaths. What limits nebulized therapy?

    1. A. Nebulizers cannot be run with supplemental oxygen
    2. B. Bronchospasm chemically inactivates the drug in the airway
    3. C. Albuterol needs a breath hold to activate
    4. D. Low tidal volume limits drug reaching lower airways
    Show answer

    Answer: D. Low tidal volume limits drug reaching lower airways

    Inhaled drug delivery depends on adequate airflow; consider assisted ventilation or IM epinephrine. Bronchospasm does not inactivate albuterol, the drug needs no breath hold to work, and nebulizers run well on supplemental oxygen.

55. Why should an IV drug be pushed slowly when the label warns of rapid-push effects?

    1. A. IV drugs reach peak concentration almost immediately
    2. B. IV drugs cannot be stopped once injected
    3. C. IV drugs are metabolized more slowly than oral ones
    4. D. IV drugs must first be absorbed from the vein wall
    Show answer

    Answer: A. IV drugs reach peak concentration almost immediately

    There is no absorption phase with IV drugs, so push rate controls the peak concentration.

56. For adenosine, the best peripheral IV site is:

    1. A. A vein on the back of the hand
    2. B. A vein in the foot
    3. C. A small wrist vein
    4. D. An antecubital vein
    Show answer

    Answer: D. An antecubital vein

    Adenosine lasts only seconds, so it is pushed rapidly into a large proximal vein, preferably antecubital, followed at once by a 20-mL saline flush. Hand, foot, and small wrist veins lengthen the trip to the heart, so more of the drug is broken down before it arrives.

57. A patient with nausea cannot keep anything down and has no IV. Which route for ondansetron is appropriate?

    1. A. Transdermal patch behind the ear
    2. B. IM or orally disintegrating tablet
    3. C. Nebulized solution through a mask
    4. D. Swallowed tablet with a glass of water
    Show answer

    Answer: B. IM or orally disintegrating tablet

    Ondansetron is available as IM and ODT forms; ODT absorbs largely through the oral mucosa and GI tract without needing swallowed water.

58. Transdermal nitroglycerin patches are not used for acute chest pain in the field because:

    1. A. Patches are unsafe to combine with aspirin
    2. B. Patches raise the risk of reflex bradycardia
    3. C. Patches are absorbed faster than sublingual tablets
    4. D. Onset is slow and the dose cannot be titrated
    Show answer

    Answer: D. Onset is slow and the dose cannot be titrated

    Transdermal delivery provides slow, steady absorption suited to maintenance, not acute titration. Patches are not unsafe with aspirin, a nitrate's usual reflex rate effect is tachycardia rather than bradycardia, and absorption through skin is slower than sublingual, not faster.

59. When removing a patient's medication patch, why should you wear gloves and fold it with the sticky sides together?

    1. A. Skin oils can inactivate the leftover drug
    2. B. Residual drug can absorb through your skin
    3. C. Folding stops the patch from drying out
    4. D. The adhesive can trigger a latex allergy
    Show answer

    Answer: B. Residual drug can absorb through your skin

    Used patches still hold a substantial amount of drug (a used fentanyl patch can retain much of its original dose), so handle them with gloves and fold the sticky sides together before disposal to prevent exposure and misuse. Skin oils do not inactivate the drug, folding is done to prevent exposure and diversion rather than to preserve the patch, and latex allergy is not the reason for gloves here.

60. Magnesium 2 g for severe asthma is given over about 15 to 20 minutes rather than by rapid IV push, mainly because a rapid push can cause:

    1. A. Hypotension
    2. B. Hyperglycemia
    3. C. Bronchospasm
    4. D. Seizures
    Show answer

    Answer: A. Hypotension

    Rapid IV magnesium causes vasodilation with flushing, hypotension, and sometimes bradycardia, so it is infused over 15 to 20 minutes. Magnesium does not raise glucose, it relaxes rather than constricts bronchial smooth muscle, and it is used to stop (eclamptic) seizures, not cause them.

61. Diltiazem 0.25 mg/kg IV is pushed over about 2 minutes, unlike adenosine. Pushing it rapidly mainly risks:

    1. A. Hyperkalemia
    2. B. Hypotension
    3. C. Hypoglycemia
    4. D. Tachycardia
    Show answer

    Answer: B. Hypotension

    Diltiazem relaxes vascular smooth muscle and slows AV conduction, so a rapid push can drop blood pressure sharply; labeling calls for a 2-minute push. It does not raise potassium or lower glucose, and it slows rather than speeds the heart rate.

62. If anaphylaxis symptoms persist after IM epinephrine, the dose may be repeated after about:

    1. A. 30 to 60 seconds
    2. B. 5 to 15 minutes
    3. C. 60 to 90 minutes
    4. D. 3 to 4 hours
    Show answer

    Answer: B. 5 to 15 minutes

    IM epinephrine may be repeated every 5 to 15 minutes if symptoms persist or recur. 30 to 60 seconds is too soon for the first dose to peak, and waiting 60 minutes or several hours leaves a progressing reaction untreated.

63. A medication's onset of action depends heavily on route. Which order lists typical onset from fastest to slowest?

    1. A. IV, intramuscular, subcutaneous, oral
    2. B. Subcutaneous, oral, IV, intramuscular
    3. C. Intramuscular, IV, oral, subcutaneous
    4. D. Oral, subcutaneous, intramuscular, IV
    Show answer

    Answer: A. IV, intramuscular, subcutaneous, oral

    IV is immediate; IM absorbs faster than SC due to greater blood flow; oral is slowest.

64. Rectal diazepam is absorbed through the rectal mucosa partly bypassing the liver because:

    1. A. The rectum has no venous blood supply
    2. B. Lower rectal veins drain systemically
    3. C. The drug is inactivated before absorption
    4. D. Rectal veins drain only into the portal system
    Show answer

    Answer: B. Lower rectal veins drain systemically

    Lower rectal veins drain systemically, so first-pass metabolism is partly avoided.

65. A patient with a tracheostomy needs an inhaled bronchodilator. How is it best delivered?

    1. A. Nebulizer mask placed over the nose only
    2. B. Nebulizer mask placed over the mouth and nose
    3. C. Nebulizer on a trach collar or in-line
    4. D. MDI sprayed into the mouth with a spacer
    Show answer

    Answer: C. Nebulizer on a trach collar or in-line

    Inhaled drugs must reach the airway via the stoma, either by trach collar or in-line with ventilation.

66. A patient on a bag-valve mask needs albuterol. The correct setup is:

    1. A. Pausing ventilation while the nebulizer runs
    2. B. Nebulizer in-line between the mask and bag
    3. C. Spraying an inhaler into the bag reservoir
    4. D. Giving albuterol IM until breathing improves
    Show answer

    Answer: B. Nebulizer in-line between the mask and bag

    In-line nebulization lets drug delivery continue during assisted ventilation.

67. Why are IM injections avoided in patients who may receive fibrinolytics?

    1. A. IM drugs inactivate fibrinolytic agents
    2. B. IM sites become infected after lysis
    3. C. IM drugs trigger reperfusion dysrhythmias
    4. D. They can cause bleeding and hematomas
    Show answer

    Answer: D. They can cause bleeding and hematomas

    Puncture of muscle in anticoagulated or lytic patients can cause significant bleeding. IM injections do not inactivate fibrinolytics, become infected because of lysis, or trigger reperfusion dysrhythmias; the concern is bleeding into the muscle.

68. The term 'parenteral' most precisely means:

    1. A. Only routes that pass through the liver
    2. B. Only the intravenous and intraosseous routes
    3. C. Any route outside the gastrointestinal tract
    4. D. Any route that uses a needle and syringe
    Show answer

    Answer: C. Any route outside the gastrointestinal tract

    Parenteral routes bypass the GI tract; they include IV, IO, IM, SC, inhalation, and others.

69. To atomize an intranasal dose properly, the syringe plunger should be:

    1. A. Pushed slowly over a full minute
    2. B. Dripped in slowly while the patient sniffs
    3. C. Pushed briskly to create a fine mist
    4. D. Pressed partway, then left in place
    Show answer

    Answer: C. Pushed briskly to create a fine mist

    A brisk push forces the liquid through the atomizer tip as a fine mist that coats the nasal mucosa. A slow push or dripping lets the drug run down the throat as liquid, and stopping partway delivers an incomplete dose.

70. Which medication is commonly given by the sublingual route in EMS?

    1. A. Glucagon
    2. B. Diphenhydramine
    3. C. Nitroglycerin
    4. D. Albuterol
    Show answer

    Answer: C. Nitroglycerin

    Nitroglycerin tablets and spray are given under the tongue for rapid absorption.

71. A child refuses to open her mouth for oral ibuprofen and has a mild fever only. The best option is to:

    1. A. Start an IV so the fever reducer can be given IV
    2. B. Have a parent hold her jaw open
    3. C. Squirt it quickly toward her throat
    4. D. Don't force it; reoffer or try another route
    Show answer

    Answer: D. Don't force it; reoffer or try another route

    Follow protocol for alternative routes. Holding the jaw open or squirting liquid toward the throat forces the dose and risks aspiration, and an IV is not justified for a mild fever.

72. In an adult asthma attack, about how many puffs of albuterol by MDI with spacer roughly match one 2.5-mg nebulizer treatment?

    1. A. 1 to 2 puffs
    2. B. 20 to 25 puffs
    3. C. 4 to 8 puffs
    4. D. 40 to 50 puffs
    Show answer

    Answer: C. 4 to 8 puffs

    Asthma guidelines treat 4 to 8 puffs of albuterol by MDI with a spacer as roughly equivalent to a 2.5-mg nebulizer treatment for an exacerbation. 1 to 2 puffs is a routine maintenance dose, and 20 or more puffs would be an excessive dose at one time.

73. A 3-year-old with mild dehydration from gastroenteritis is alert and drinking. The preferred rehydration route is:

    1. A. Small, frequent oral fluid sips
    2. B. A 20 mL/kg IV bolus before transport
    3. C. An IO line in the proximal tibia
    4. D. Subcutaneous saline into the abdomen
    Show answer

    Answer: A. Small, frequent oral fluid sips

    For mild to moderate dehydration in an alert child, oral rehydration in small, frequent amounts works as well as IV fluids with less distress. An IV bolus is for moderate to severe dehydration or shock, IO access is for critical patients when IV fails, and subcutaneous fluid is not a field rehydration method.

74. A patient receiving an inhaled medication via metered-dose inhaler should be coached to:

    1. A. Inhale rapidly and exhale right after the puff
    2. B. Inhale slowly with the puff, then hold
    3. C. Spray the dose onto the tongue and swallow it
    4. D. Breathe in through the nose during the puff
    Show answer

    Answer: B. Inhale slowly with the puff, then hold

    Coach the patient to exhale fully first. Slow deep inhalation and a breath-hold improve drug deposition in the lower airways.