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Question 1. Which medication is the first-line reperfusion strategy for a patient with STEMI who presents within 90 minutes of symptom onset and has no contraindications? A) Intravenous streptokinase B) Tenecteplase (TNK) infusion C) Primary percutaneous coronary intervention (PCI) D) Clopidogrel loading dose Answer: C Explanation: Primary PCI is preferred over fibrinolysis when it can be performed promptly (≤90 min) because it yields higher patency rates and lower bleeding risk. Question 2. The TIMI risk score for NSTEMI includes all of the following EXCEPT: A) Age ≥65 years B) Prior coronary artery bypass graft (CABG) C) Presence of ≥3 risk factors for coronary artery disease D) Systolic blood pressure <120 mm Hg Answer: B Explanation: Prior CABG is not a component of the TIMI score; the score uses age, risk factors, known CAD, aspirin use, severe angina, ST changes, and cardiac markers. Question 3. In a hemodynamically stable patient with narrow-complex SVT, the most appropriate initial vagal maneuver is: A) Carotid sinus massage B) Valsalva maneuver C) Ice water immersion of the face D) High-dose adenosine Answer: B
Explanation: The Valsalva maneuver is the first-line vagal technique for SVT; carotid massage is contraindicated in patients with carotid disease. Question 4. A patient with a wide-complex tachycardia and a pulse is hemodynamically stable. Which antiarrhythmic is preferred when the rhythm is presumed to be ventricular tachycardia? A) Amiodarone B) Lidocaine C) Procainamide D) Magnesium sulfate Answer: A Explanation: Amiodarone is the drug of choice for stable VT because it is effective and has a relatively favorable safety profile. Question 5. Which of the following is an absolute indication for temporary transvenous pacing? A) Second-degree AV block Mobitz type I with asymptomatic bradycardia B) Third-degree AV block with hypotension C) Sinus bradycardia of 55 bpm in an athlete D) First-degree AV block with PR interval 210 ms Answer: B Explanation: Symptomatic third-degree AV block causing hypotension requires immediate pacing. Question 6. In acute decompensated heart failure (ADHF) with pulmonary edema, the first-line non-invasive ventilation modality is: A) Continuous positive airway pressure (CPAP) B) Bi-level positive airway pressure (BiPAP) C) High-flow nasal cannula D) Mechanical ventilation with endotracheal intubation
C) Intravenous tissue plasminogen activator (tPA) infusion D) Immediate surgical embolectomy without anticoagulation Answer: B Explanation: Immediate anticoagulation with IV heparin is the first step; definitive revascularization (embolectomy or thrombolysis) follows. Question 10. In a hypertensive emergency with encephalopathy, the preferred initial IV antihypertensive agent is: A) Labetalol B) Nitroprusside C) Hydralazine D) Clonidine Answer: A Explanation: Labetalol provides rapid, controlled BP reduction with combined α- and β-blockade, suitable for neurologic emergencies. Question 11. Which of the following is the most appropriate drug for rapid sequence intubation (RSI) in a patient with severe asthma exacerbation? A) Etomidate B) Ketamine C) Propofol D) Midazolam Answer: B Explanation: Ketamine preserves airway reflexes, provides bronchodilation, and maintains hemodynamics, making it ideal for asthmatic patients. Question 12. The “cannot intubate, cannot ventilate” scenario is best managed by: A) Inserting a laryngeal mask airway (LMA)
B) Performing a surgical cricothyrotomy C) Attempting a blind nasotracheal intubation D) Continuing bag-mask ventilation Answer: B Explanation: When both ventilation and intubation fail, emergent cricothyrotomy provides a definitive airway. Question 13. A 55-year-old with suspected PE has a Wells score of 8. Which next step is most appropriate? A) D-dimer assay B) Immediate CT pulmonary angiography (CTPA) C) V/Q scan D) Lower-extremity duplex ultrasound Answer: B Explanation: A high Wells score (>6) warrants direct imaging with CTPA without a D-dimer. Question 14. Which of the following defines a massive pulmonary embolism? A) PE with right-ventricular dilation on echo B) PE causing hypotension (SBP <90 mm Hg) or shock C) PE with elevated D-dimer >2 μg/mL D) PE with troponin elevation Answer: B Explanation: Massive PE is characterized by sustained hypotension, cardiogenic shock, or cardiac arrest. Question 15. In status asthmaticus, the adjunctive medication with the strongest evidence for reducing hospital admission when added to inhaled β-agonists and steroids is:
A) Age >80 years B) Prior myocardial infarction within 3 months C) Intracranial hemorrhage on CT D) Blood glucose <50 mg/dL Answer: C Explanation: Presence of intracranial hemorrhage on imaging precludes thrombolysis. Question 19. The NIHSS score is primarily used to: A) Determine eligibility for endovascular thrombectomy B) Predict risk of hemorrhagic transformation after tPA C) Quantify neurologic deficit severity in acute ischemic stroke D) Assess long-term functional outcome Answer: C Explanation: NIHSS provides a standardized measure of stroke severity at presentation. Question 20. The first-line medication for status epilepticus after benzodiazepine failure is: A) Phenobarbital B) Phenytoin (or fosphenytoin) C) Valproic acid D) Levetiracetam Answer: B Explanation: Phenytoin/fosphenytoin is the recommended second-line agent after benzodiazepines.
Question 21. A 30-year-old presents with sudden “thunderclap” headache, neck stiffness, and a CT that is normal. The next best step is: A) Lumbar puncture for xanthochromia B) Immediate administration of IV mannitol C) MRI brain with diffusion weighting D) High-dose steroids Answer: A Explanation: In suspected subarachnoid hemorrhage with a negative CT, lumbar puncture is indicated to detect xanthochromia. Question 22. Which of the following is the most appropriate initial empiric therapy for bacterial meningitis in an adult older than 50 years? A) Vancomycin + ceftriaxone + ampicillin B) Ceftriaxone + dexamethasone C) Vancomycin + cefepime + ampicillin D) Ceftriaxone + vancomycin Answer: D Explanation: For adults >50, ceftriaxone plus vancomycin covers the most common pathogens (Strep pneumoniae, N. meningitidis, Listeria is less common after 50). Question 23. In the primary survey of trauma (ABCDE), the “C” (circulation) assessment includes all EXCEPT: A) Rapid control of external hemorrhage B) Evaluation of pulse quality and rate C) Assessment of capillary refill time D) Immediate placement of a Foley catheter Answer: D Explanation: Foley catheter placement is part of secondary survey; it is not a primary “C” assessment.
Explanation: Mannitol reduces ICP rapidly; hyperventilation is a temporizing measure, and steroids are not beneficial for traumatic edema. Question 27. The most appropriate initial fluid for a patient with septic shock and a known allergy to gelatin-based solutions is: A) 0.9% Normal saline B) Lactated Ringer’s solution C) 5% Dextrose in water (D5W) D) 3% Hypertonic saline Answer: B Explanation: Lactated Ringer’s is isotonic, avoids gelatin, and is preferred for volume resuscitation in sepsis. Question 28. In a patient with suspected heat stroke, the fastest method to lower core temperature is: A) Evaporative cooling with fans and mist B) Ice water immersion C) Application of cold packs to the groin and axillae D) Intravenous cold saline infusion Answer: B Explanation: Ice water immersion reduces core temperature most rapidly (≈0.15 °C/min). Question 29. The Parkland formula for burn resuscitation calculates fluid needs based on: A) Total body surface area (TBSA) burned × 2 mL/kg × %TBSA B) TBSA burned × 4 mL/kg × %TBSA C) TBSA burned × 2 mL/kg × %TBSA (first 24 h) D) TBSA burned × 4 mL/kg × %TBSA (first 24 h)
Answer: C Explanation: Parkland formula: 2 mL × body weight (kg) × %TBSA burned; half given in first 8 h, remainder over next 16 h. Question 30. A 25-year-old woman with an ectopic pregnancy is hemodynamically unstable. The immediate next step is: A) Methotrexate administration B) Diagnostic laparoscopy C) Emergent laparotomy with salpingectomy D) Observation and repeat β-hCG in 48 h Answer: C Explanation: Hemodynamic instability mandates emergent surgical intervention; medical therapy is reserved for stable patients. Question 31. In the work-up of acute pancreatitis, which laboratory value is most specific for diagnosis? A) Serum amylase >3× upper limit B) Serum lipase >3× upper limit C) Elevated AST/ALT ratio > D) Elevated alkaline phosphatase Answer: B Explanation: Serum lipase is more specific than amylase for acute pancreatitis. Question 32. The Ranson criteria for assessing severity of acute pancreatitis includes all of the following EXCEPT: A) Age >55 years B) Serum glucose >200 mg/dL on admission C) Serum calcium <8 mg/dL at 48 h D) Hematocrit >45% on admission
Answer: B Explanation: Post-operative adhesions account for >60% of SBO cases. Question 36. In diabetic ketoacidosis (DKA), the initial fluid of choice is: A) 0.45% saline B) 0.9% saline C) Lactated Ringer’s D) 5% dextrose in normal saline Answer: B Explanation: Isotonic saline restores intravascular volume; dextrose is added later once glucose falls <250 mg/dL. Question 37. Which electrolyte abnormality is most likely to cause peaked T-waves on ECG? A) Hypercalcemia B) Hypermagnesemia C) Hyperkalemia D. Hyponatremia Answer: C Explanation: Elevated serum potassium produces classic peaked T waves. Question 38. The initial treatment for severe hyperkalemia with ECG changes includes: A) Sodium bicarbonate infusion only B) Calcium gluconate IV push followed by insulin-glucose C) Kayexalate orally D) Loop diuretic alone
Answer: B Explanation: Calcium stabilizes myocardial membranes; insulin-glucose drives potassium intracellularly. Question 39. A patient with chronic hyponatremia due to SIADH presents with seizures. The safest acute correction method is: A) Rapid infusion of 3% hypertonic saline to raise Na + by 20 mEq/L in 2 h B) 3% hypertonic saline bolus 100 mL, repeat as needed, targeting ≤10 mEq/L rise in 24 h C) Free water restriction alone D) Oral urea Answer: B Explanation: Controlled boluses of hypertonic saline allow safe, gradual correction, minimizing osmotic demyelination risk. Question 40. Which of the following is an indication for emergent dialysis in acute kidney injury? A) BUN 45 mg/dL with stable electrolytes B) Serum creatinine 2.5 mg/dL, no symptoms C) Refractory hyperkalemia >6.5 mmol/L despite medical therapy D) Mild metabolic acidosis (pH 7.32) Answer: C Explanation: Refractory hyperkalemia is a classic indication for emergent dialysis. Question 41. In thyroid storm, the drug that blocks peripheral conversion of T to T3 is: A) Propylthiouracil (PTU) B) Methimazole C) Lithium D) Iodine (Lugol’s)
D) Heart rate and capillary refill Answer: C Explanation: “Work of breathing” evaluates respiratory distress signs such as retractions and nasal flaring. Question 45. In a febrile infant <30 days old with temperature 38.5 °C and no source, the recommended evaluation includes: A) Observation only if well-appearing B) Full sepsis work-up (blood, urine, CSF cultures) and empiric antibiotics C) Only urine culture and discharge if negative D) Immediate lumbar puncture only Answer: B Explanation: Infants <30 days with fever require a complete sepsis evaluation and empiric antibiotics. Question 46. The recommended intraosseous (IO) insertion site in an adult is: A) Proximal tibia, medial aspect B) Distal femur, lateral condyle C) Sternum, manubrium D) Distal humerus, lateral epicondyle Answer: A Explanation: The proximal tibia is the most accessible and reliable adult IO site. Question 47. During ACLS, a patient in pulseless ventricular fibrillation receives the first shock at: A) 120 J monophasic B) 150 J biphasic C) 200 J biphasic
D) 300 J monophasic Answer: B Explanation: Current guidelines recommend 150 J biphasic as the initial shock energy for VF/pulseless VT. Question 48. After ROSC from cardiac arrest, the most important early intervention to improve neurologic outcome is: A) Immediate coronary angiography for all patients B) Targeted temperature management (TTM) to 33 °C C) High-dose steroids D) Routine hyperventilation Answer: B Explanation: TTM (32- 36 °C) reduces cerebral metabolic demand and improves neurologic recovery. Question 49. The most appropriate local anesthetic for a digital block is: A) 0.5% Bupivacaine B) 2% Lidocaine without epinephrine C) 1% Mepivacaine with epinephrine D) 0.75% Ropivacaine Answer: B Explanation: Lidocaine without epinephrine is safe for digits; vasoconstrictors can cause ischemia. Question 50. The antidote for severe benzodiazepine overdose is: A) Flumazenil B) Naloxone C) Physostigmine
B) Intramuscular epinephrine 0.3 mg (1:1000) C) Inhaled albuterol D) Oral corticosteroids Answer: B Explanation: IM epinephrine is the cornerstone of anaphylaxis treatment, rapidly reversing airway edema and hypotension. Question 54. A patient presents with fever, neck stiffness, and a rash. Lumbar puncture shows 300 WBC/μL with 90% neutrophils, low glucose, and high protein. The most appropriate empiric antibiotics are: A) Vancomycin + ceftriaxone + ampicillin B) Ceftriaxone + azithromycin C) Vancomycin + meropenem D) Cefotaxime + vancomycin only Answer: A Explanation: Broad-spectrum coverage for S. pneumoniae, N. meningitidis, and L. monocytogenes (ampicillin) is required in adults. Question 55. In a patient with suspected serotonin syndrome, the most appropriate immediate pharmacologic intervention is: A) Diazepam IV B) Cyproheptadine PO or NG C) Flumazenil IV D) Naloxone IV Answer: B Explanation: Cyproheptamine, a serotonin antagonist, is the specific treatment for serotonin syndrome.
Question 56. The “START” triage system for mass casualty incidents classifies patients as: A) Immediate, Delayed, Minimal, Expectant B) Red, Yellow, Green, Black C) Priority 1- 4 D) Critical, Stable, Minor, Deceased Answer: A Explanation: START uses Immediate, Delayed, Minimal, Expectant categories based on respiration, perfusion, and mental status. Question 57. Which of the following statements about EMTALA is correct? A) Physicians may refuse to treat undocumented immigrants. B) Hospitals must provide a medical screening exam to anyone who presents to the ED. C) Transfer of a patient is allowed without stabilization if the receiving facility agrees. D) Consent is required before any treatment is given. Answer: B Explanation: EMTALA mandates a medical screening exam for all ED arrivals regardless of ability to pay. Question 58. In a patient with a suspected inhalational chemical exposure, the most important immediate decontamination step is: A) Administration of activated charcoal B) Removal of contaminated clothing and thorough skin irrigation C) Gastric lavage D) Whole-body cooling Answer: B
