# Help with questions??



## lalaneedstopass (Oct 30, 2008)

Alright, so it's been like 2 months since I've taken the test last and I finally feel more than ready to take this... well almost. I've gone through all my text books multiple times and test books but I still have some questions. 

I took a practice test on learningexpress.com and have just a couple questions on ones I got wrong. For instance:

Question 1: After delivering a 3rd shock on the AED you check the pulse?
I thought after any shock you immediately do 2 minutes of CPR then check for a pulse since a pulse usually does not appear after any shock.

Question 2: If you do direct pressure on a laceration and the bleeding is not stopped you remove the gauze to make sure you have put pressure on the right area??
I thought that you never ever remove a gauze unless on an occlusive dressing preventing the cause of a pneumothorax. And simply just apply another guaze and apply pressure point and elevate. 

Question 3: If a pt. has many fractures and is apparant they are going into shock and is breathing inadequately you immobilize and transport immediately??
I thought that you would want to assess the ABC's then immobilize and transport.

Also, some other questions I haven't found completely accurate answers on.

First, in my textbook and in class it said that in order to be a significant MOI falls in adults are falls greater than 20 feet or 2 times the pts. height. Then in some test books the answers were 15 feet or 3 times the pts. height. So which one is it?

Second, what exactly is the ventilation rate for newborns? All I've found is the rates for infants, children, and adults.

Third, what are the rates to deliver breaths by ventilation? Do I basically just focus on well an apneic pt w/ pulse gets 10-12 breaths therefore 60/12=5 so 1 breath every 5 seconds... A child gets 12-20 breaths therefore 60/20=3 so 1 breath every 3 seconds... Okay I think I just answered my own question.. But correct me if I'm wrong.

Thanks


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## Code 3 (Oct 30, 2008)

> Question 1: After delivering a 3rd shock on the AED you check the pulse?
> 
> I thought after any shock you immediately do 2 minutes of CPR then check for a pulse since a pulse usually does not appear after any shock.



After the first set of (3) stacked shocks, you check the patient's pulse. You do not check for a pulse inbetween each shock of the first stack.



> Question 2: If you do direct pressure on a laceration and the bleeding is not stopped you remove the gauze to make sure you have put pressure on the right area??



Per the "Bleeding Control" testable skill in my county, you are to manage wounds the following way:


Apply direct pressure
Elevate the extremity
*If continued bleeding, apply additional dressings on top*
If further bleeding, locate and apply pressure to arterial pressure point
Bandage the wound



> Question 3: If a pt. has many fractures and is apparant they are going into shock and is breathing inadequately you immobilize and transport immediately??
> 
> I thought that you would want to assess the ABC's then immobilize and transport.




Position patient supine with legs elevated 8-12 inches
Apply high concentration of 02
Cover patient with a blanket
Immediate/Rapid transport

Keep in mind that in Patient Assessment: Trauma, you consider stabilization of C-spine in the first steps prior to ABC's. During your initial assessment, you will determine any apparent life threats, such as shock, and treat them accordingly. The management of secondary fractures should be handled at the very end of the assessment and only if time permits.




> Also, some other questions I haven't found completely accurate answers on.
> 
> First, in my textbook and in class it said that in order to be a significant MOI falls in adults are falls greater than 20 feet or 2 times the pts. height. Then in some test books the answers were 15 feet or 3 times the pts. height. So which one is it?



The general rule is 15 feet for adults and 10 feet for children. In falls greater than 20 feet, the internal organs have a higher chance of injury due to decceleration forces.



> Second, what exactly is the ventilation rate for newborns? All I've found is the rates for infants, children, and adults.



Newborns (0-30 days): 1-1.5 seconds
Infants: 2-3 seconds
Children: 3-5 seconds
Adults: 5-6 seconds

I hope this helps and I'm sure others will chime in with more information.


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## jrm818 (Oct 30, 2008)

Code 3 said:


> After the first set of (3) stacked shocks, you check the patient's pulse. You do not check for a pulse inbetween each shock of the first stack.



Most AED's have been reprogrammed to get away from giving stacked shocks.  I think the OP is referring to the 3rd shock with intervals of CPR between each.  Likely the quiz the OP was talking about was outdated in terms of checking a pulse...the procedures change so much a lot of tests like that don't keep up...




Code 3 said:


> Position patient supine with legs elevated 8-12 inches
> Apply high concentration of 02
> Cover patient with a blanket
> Immediate/Rapid transport
> ...



Breathing takes precedence over C-spine precautions.  If possible you protect the C-spine, but if the question says they are breathing "inadequately," that needs to be fixed ASAP.  As far as the world of quiz questions go, ABC's THEN C-spine THEN other fractures.  In the real world with multiple rescuers you can hold cspine while ventilating at the same time.  

By the way, fixing the inadequate breathing does not mean apply high flow O2 as in your list...a pt. who is breathing inadequately needs to be assisted with PPV.  For tests like that "inadequate" breathing is a key word that should scream "assist ventilation"

to OP

I would agree with your answers to the first three questions, but I didn't see the test questions so I don't know how they're worded.  Paying attention to wording is very important for questions like this.


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## Ridryder911 (Oct 30, 2008)

jrm818 said:


> Breathing takes precedence over C-spine precautions.  If possible you protect the C-spine, but if the question says they are breathing "inadequately," that needs to be fixed ASAP.  As far as the world of quiz questions go, *ABC's THEN C-spine *THEN other fractures.  In the real world with multiple rescuers you can hold cspine while ventilating at the same time.
> 
> By the way, fixing the inadequate breathing does not mean apply high flow O2 as in your list...a pt. who is breathing inadequately needs to be assisted with PPV.  For tests like that "inadequate" breathing is a key word that should scream "assist ventilation"



Actually, one should assume and initially suspect spinal precautions from MOI and initially hold or protect the C-Spine while even establishing the LOC, to prevent head movement on an appeared unresponsive patient. Then one needs to know what type of "opening the airway" technique should be involved such as MJT vs. head tilt. 

Very good points as well on ventilation versus oxygenation. This is one of the highest missed areas of the NREMT examination. Be sure you understand the differences of each. 

R/r911


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## jrm818 (Oct 30, 2008)

I agree that in the real world you hold c-spine as you assess and then begin ventilations...assuming multiple rescuers.  My experience is that in the world of a test, however, such realities are ignored.  If the question tells you the breathing is inadequate and asks what to do first, and you have to pick one option, either assist breathing or take c-spine precautions, the answer is probably "assist breathing."  

In the real world you should have taken the precautions before you discovered the breathing is inadequate, but the test already told you the breathing is inadequate.  Threrefore, if "take spinal precautions" is still an answer option along with "administer hi flow O2" and "assist with PPV," you must have assessed the patient (in order to find the breathing issue) WITHOUT taking precautions.  I should have made clear that I was talking about the silly way these test are written.  I guess the idea is to pick a priority...breathing or C-spine...


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## Ridryder911 (Oct 30, 2008)

An example of the NREMT assessment: (open download and is publicly accessible). WWW.NREMT.org

(Emphasis mine for discussion)

Advanced Level Practical Examination
PATIENT ASSESSMENT – TRAUMA

Candidate: ___________________________________________________________Examiner: ___________________________________________________
Date: ________________________________________________________________Signature: ___________________________________________________
Scenario # __________
Possible Points
Time Start: __________ NOTE: Areas denoted by “**” may be integrated within sequence of Initial Assessment                                Points                Points
Possible         Awarded          
Takes or verbalizes body substance isolation precautions 1	1	
SCENE SIZE-UP		
Determines the scene/situation is safe 1	1	
Determines the mechanism of injury/nature of illness 1	1	
Determines the number of patients 1	1	
Requests additional help if necessary 1	1	
*Considers stabilization of spine 1	*1

INITIAL ASSESSMENT/RESUSCITATION	1	
Verbalizes general impression of the patient 1	1	
Determines responsiveness/level of consciousness 1	1	
Determines chief complaint/apparent life-threats	1	
*Airway
-Opens and assesses airway (1 point) -Inserts adjunct as indicated (1 point)	2	*
*Breathing*
-Assess breathing (1 point)
-Assures adequate ventilation (1 point) 4
-Initiates appropriate oxygen therapy (1 point)
-Manages any injury which may compromise breathing/ventilation (1 point)	4	
*Circulation*
-Checks pulse (1point)
-Assess skin [either skin color, temperature, or condition] (1 point) 4
-Assesses for and controls major bleeding if present (1 point)
-Initiates shock management (1 point)	4	
Identifies priority patients/makes transport decision 1	1	
FOCUSED HISTORY AND PHYSICAL EXAMINATION/RAPID TRAUMA ASSESSMENT		
Selects appropriate assessment 1	1	
Obtains, or directs assistant to obtain, baseline vital signs 1	1	
Obtains SAMPLE history 1	1	
DETAILED PHYSICAL EXAMINATION		
Head
-Inspects mouth**, nose**, and assesses facial area (1 point)
-Inspects and palpates scalp and ears (1 point)
3
-Assesses eyes for PERRL** (1 point)	3	
Neck**
-Checks position of trachea (1 point)
-Checks jugular veins (1 point)
3
-Palpates cervical spine (1 point)	3	
Chest**
-Inspects chest (1 point)
-Palpates chest (1 point)
3
-Auscultates chest (1 point)	3	
Abdomen/pelvis**
-Inspects and palpates abdomen (1 point)
-Assesses pelvis (1 point)
3
-Verbalizes assessment of genitalia/perineum as needed (1 point)	3	
Lower extremities**
-Inspects, palpates, and assesses motor, sensory, and distal circulatory functions (1 point/leg)	2	
Upper extremities
-Inspects, palpates, and assesses motor, sensory, and distal circulatory functions (1 point/arm)	2	
Posterior thorax, lumbar, and buttocks**
-Inspects and palpates posterior thorax (1 point) 2
-Inspects and palpates lumbar and buttocks area (1 point)	2	
Manages secondary injuries and wounds appropriately 1	1	
Performs ongoing assessment	1	
Time End: ______________________                                                                                                                                     Total Points	43	


CRITICAL CRITERIA
____ Failure to initiate or call for transport of the patient within 10 minute time limit
____ Failure to take or verbalize body substance isolation precautions
____ Failure to determine scene safety
____ Failure to assess for and *provide spinal protection *when indicated
____ Failure to voice and ultimately provide high concentration of oxygen
____ Failure to assess/provide adequate ventilation
____ Failure to find or appropriately manage problems associated with airway, breathing, hemorrhage or shock [hypoperfusion]
____ Failure to differentiate patient’s need for immediate transportation versus continued assessment/treatment at the scene
____ Does other detailed/focused history or physical exam before assessing/treating threats to airway, breathing, and circulation
____ Orders a dangerous or inappropriate intervention
You must factually document your rationale for checking any of the above critical items on the reverse side of this form.


Not splitting hairs but one should assume c-spine on poly trauma and of course any real potential of MOI with involvement requiring airway interventions. 

R/r 911


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## jrm818 (Oct 31, 2008)

Agreed for a practical.  What i was talking about was a written test...more along the lines of this (taken from my class...breathing rate modified to illustrate the point...one can envision a number of variations written like this)

You are called to a local store for a fight in the lot.  PD have secured the scene when you arrive.  Find a 40 y/o male lying supine on asphalt.  Assessment reveals BP 90/60, p 110 strong, regular, RR 6 gurgling.  Pt. aons in response to shoulder pinch.  You note blood spurting form an open wound on right thigh.  Your first action would be:

a. control the bleeding from the thigh
b. begin positive-pressure ventilation with a BVM connected to O2 at 15 LPM
c. Place the pt. on a long backboard, cover with a blanket, and elevate the foot of the board 12 inches.

here no mention of spinal precautions are made in the question.  In real life or a practical exam the 2nd EMT should have taken spinal precautions while the first did the assessment.  that did not happen in this fake test world.  The only option for using spinal precautions is C - but clearly the PT. needs ventilation, so B is the "BEST" answer for the first action.


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## Code 3 (Oct 31, 2008)

jrm818 said:


> By the way, fixing the inadequate breathing does not mean apply high flow O2 as in your list...a pt. who is breathing inadequately needs to be assisted with PPV.  For tests like that "inadequate" breathing is a key word that should scream "assist ventilation"



My list isn't for inadequate breathing but the for the practical exam on Bleeding Control: Shock Management. Those are the four items the proctor looks for when he tells you your patient is displaying signs of hypoperfusion.

I think there is a lot of confusion between real world application and what the OP was trying to ask. Everything that I stated came straight from practicals and is what Rid listed.


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## tatersalad (Oct 31, 2008)

<puts on nomex tighty whiteys>

Rid, after reading one of the other posts re: testing. Where is the BSI component graded on the assessment? I'm in way over my head even asking the question, but I'm trying to get a sense of the flow.

thanks, ts


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## flhtci01 (Oct 31, 2008)

tatersalad said:


> <puts on nomex tighty whiteys>
> 
> Rid, after reading one of the other posts re: testing. Where is the BSI component graded on the assessment? I'm in way over my head even asking the question, but I'm trying to get a sense of the flow.
> 
> thanks, ts





Ridryder911 said:


> An example of the NREMT assessment: (open download and is publicly accessible). WWW.NREMT.org
> 
> CRITICAL CRITERIA
> ____ Failure to initiate or call for transport of the patient within 10 minute time limit
> ...



BSI is a critical criteria (Pass/Fail). If BSI is done immediately while checking scene safety, you don't have to worry about it.  I am not sure but I think if you touch the patient before donning or vebalizing BSI you fail.   I am not sure if you could pass if you do it later.


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## tatersalad (Oct 31, 2008)

Okay, so do BSI as part of scene safety assessment, and verbalize when testing.

thanks flhtci01


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## lalaneedstopass (Oct 31, 2008)

BSI and scene safety are ALWAYS FIRST!!! BSI should basically be done while en route to the call, unless of course you get there and need addl PPE.

Thanks for all of your responses. However, I still haven't gotten my other question answered. For it to be considered a significant MOI in adults how great does a fall need to be? 20' or 15'? 2 times the height or 3 times the height? And I'll see if I can find the questions I was having issues with to give you all a better clue of what I was dealing with.


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## lalaneedstopass (Oct 31, 2008)

Questions exact wording from learning express.

30.  When using an AED, after delivering the third shock, you should 


      A. perform CPR for 1 minute

_B. check the patient's pulse_ *correct answer*

      C. analyze the rhythm

     D. assess ABCs and transport


34.  Your patient is bleeding heavily from a single laceration on her leg. You attempt to stop the bleeding with a gloved fingertip placed over the wound but are unsuccessful. Your next step should be to



_A. remove the gauze to be sure you have the right spot_*correct answer*

      B. elevate the limb and apply more diffuse pressure

     C. use pressure points

      D. apply PASGs


45.  Your patient is a 19-year-old male who has been in a motorcycle crash. Vital signs are: pulse, 102 and weak; respirations, 28, shallow; BP 116/78. He has suspected spinal injury, as well as a deformed, swollen, painful right foot. Blood loss is not significant. Your care should focus on



      A. immobilizing the injured foot in position of function

_B. immobilizing the patient and transporting him rapidly_*correct answer*

     C. opening the airway and ventilating the patient

      D. applying the PASG and inflating all compartments


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## jrm818 (Oct 31, 2008)

This breathing/spinal question is exactly the sort of question I was talking about.  This is a written question, not a practical examination.

Notice the question says nothing about spinal precautions.  The test forces you to choose between treating breathing and taking spinal precautions.  (unfortunately) there is no option for "i already took precautions when I was assessing the patient, you stupid test."

In the real world of course you would do BOTH.  That is not an option in this test question.  As far as I am concerned, learning express is wrong, and the correct answer is C.  The pt. is breathing inadequately, the _most_ important thing is to fix that.  Choice C does not exclude the possibility of taking spinal precautions, but even if it did, in such a ridiculous hypothetical world, breathing is more important.  paralyzed > dead (as far as these questions are concerned).

By contrast, choice B suggests that the breathing problems are ignored, and the pt. is strapped to a LSB and tossed in the ambulance. Rapid transport is also important, but not to the exclusion of treating the pt's breathing problem.

The bleeding question is also clearly wrong.  I don't konw what learningexpress is, but they need to work on listing the correct answers.  In fact the answer doesn't make sense, as you pressed with a gloved finger, not gauze.  There is no gauze to remove.  That said, if blood soaks through, you are correct that you do not remove it.  That will just undo any clotting that has occured.

as to signifigant MOI - that is local protocol based.  Mine will personally be changing come November.  It varies.

by the way - notice that for an average 6ish foot guy 2-3x height = 12-18ft.  Thats pretty close to 15-20ft.  Anywhere in that range is significant, dependent on age, PMH (osetoporosis? etc.), and other circumstances.


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## lalaneedstopass (Oct 31, 2008)

Here are some more questions I'm having trouble with understanding from my EMT-B Review Manual by Stephen J. Rahm

33. As you are performing CPR on an elderly man, his wife presents you with a DNR order. Your most appropriate course of action is to:
a. ignore the document and continue CPR
b. comply with the document and stop CPR
c. continue CPR until medical control is notified *correct answer*
d. withhold CPR until medical control validates the order

_Now nowhere in this question does it say how valid the DNR is. So if it does meet all the criteria then wouldn't you stop? Or do you contact med control??_

69. A paramedic unit arrives at the scene to provide assistance. After one of the paramedics intubates the child, you should deliver ventilations at a rate of:
a. 6 to 8 breaths/min
b. 8 to 10 breaths/min  *correct*
c. 10 to 12 breaths/min
d. 12 to 20 breaths/min

_I thought it was 12 to 20 breaths/min for children/infants, is it different since the child has been intubated?_

134. A 42 y/o man was ejected from his car after it struck a bridge pillar at a high rate of speed. You find him lying approximately 50' from the car. After manually stabilizing his head, your next action should be to:
a. assess the quality of his breathing
b. grasp the angles of the jaw and lift *correct*
c. administer high-concentration oxygen
d. determing the pts. LOC

_Now it's obvious you want to do a jaw thrust maneuver but since it's an option wouldn't you need to check LOC first? Since nowhere in the question does it state what it is and checking LOC does come before ABC's and after stabilization in trauma pts._

AND... once again this question that seems very stupid to me...

137. You have applied a pressure bandage and addl dressings to a large laceration with severe arterial bleeding. The bandages are quickly blood-soaked. You should next:
a. elevate the extremity and apply a proximal arterial tourniquet
b. apply pressure to the pulse point that is most distal to the injury
c. place addl dressings on the wound until bleeding stops
d. remove the bandages and apply pressure at the site of the bleeding *correct*

_Now, in the case of canceling out... obviously not A since that is "if all else fails" type of thing. B is wrong because you want pressure above not below.. and C is wrong because you cannot just keep adding to soak through since the pt will continue to lose blood. and then D is wrong because you should never remove bandages. So is this basically a question of instead of being most right what is less wrong?_


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## Code 3 (Oct 31, 2008)

lalaneedstopass said:


> However, I still haven't gotten my other question answered. For it to be considered a significant MOI in adults how great does a fall need to be? 20' or 15'? 2 times the height or 3 times the height?



I answered this already in my original post:

_"The general rule is 15 feet for adults and 10 feet for children. In falls greater than 20 feet, the internal organs have a higher chance of injury due to decceleration forces."_

If you're using the Brady textbook, check the chapter titled Mechanisms of Injury: Kinetics of Trauma.



			
				jrm818 said:
			
		

> as to signifigant MOI - that is local protocol based. Mine will personally be changing come November. It varies.



Careful with this statement. For individuals that are preparing for the NREMT exam, the information they need to know is *not* based on local protocols and the numbers can sometimes vary. For instance, the NREMT exam requires a systolic B/P of at least 90 in order to assist with nitroglycerin; however, my local protocols state the systolic B/P needs to be at 100 or greater.


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## lalaneedstopass (Nov 3, 2008)

Code 3 said:


> For instance, the NREMT exam requires a systolic B/P of at least 90 in order to assist with nitroglycerin; however, my local protocols state the systolic B/P needs to be at 100 or greater.



eh... NREMT, textbooks, testbooks, everywhere I've seen the systolic BP needs to be a min of 100 to assist with nitroglycerin


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