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Question 1. A 58-year-old man presents with crushing substernal chest pain radiating to the left arm, diaphoresis, and nausea. Which of the following is the most appropriate immediate pharmacologic therapy? A) Metoprolol B) Nitroglycerin sublingual C) Aspirin 325 mg chewable D) Morphine sulfate Answer: C Explanation: Early administration of chewable aspirin reduces mortality in acute coronary syndrome by inhibiting platelet aggregation. Question 2. A patient arrives with a blood pressure of 80/50 mm Hg, HR 120 bpm, and cool clammy skin after a motor vehicle collision. Which type of shock is most likely? A) Distributive B) Obstructive C) Cardiogenic D) Hypovolemic Answer: D Explanation: The vitals indicate hypovolemic shock from fluid loss (e.g., hemorrhage) common in trauma. Question 3. Which ECG finding is diagnostic for a posterior myocardial infarction? A) ST elevation in V1-V B) ST depression in V1-V2 with tall R waves C) New left bundle-branch block D) Diffuse ST elevation Answer: B Explanation: Reciprocal ST depression in anterior leads with tall R waves suggests posterior MI.
Question 4. A 22-year-old woman presents with sudden severe unilateral lower abdominal pain and a positive pregnancy test. The most likely diagnosis is: A) Ovarian torsion B) Ruptured ectopic pregnancy C) Appendicitis D) Pelvic inflammatory disease Answer: B Explanation: Acute unilateral pain in early pregnancy raises suspicion for a ruptured ectopic pregnancy, a surgical emergency. Question 5. Which of the following is the first-line treatment for an acute asthma exacerbation in the ED? A) Intravenous magnesium sulfate B) Inhaled albuterol via metered-dose inhaler with spacer C) Oral prednisone 40 mg D) Subcutaneous epinephrine Answer: B Explanation: Rapid-acting inhaled β 2 - agonists are the cornerstone of acute asthma management. Question 6. A patient with known COPD presents with increased dyspnea, wheezing, and a PaCO₂ of 58 mm Hg. Which ventilation strategy is preferred? A) High-flow nasal cannula B: Non-invasive positive-pressure ventilation (BiPAP) C) Immediate intubation D) Low-flow oxygen nasal cannula Answer: B Explanation: BiPAP reduces work of breathing and improves CO₂ clearance in COPD exacerbations. Question 7. Which of the following is the most sensitive bedside test for detecting intra-abdominal free fluid in a trauma patient?
A) N-acetylcysteine IV B) Sodium bicarbonate C) Fomepizole D) Activated charcoal only Answer: A Explanation: N-acetylcysteine replenishes glutathione and prevents hepatic injury when given early. Question 11. Which of the following is the most appropriate initial step in the management of a patient with suspected tension pneumothorax? A) Needle thoracostomy in the 2nd intercostal space, mid-clavicular line B) Chest tube placement in the 5th intercostal space, anterior axillary line C) High-flow oxygen administration D) Immediate intubation with positive-pressure ventilation Answer: A Explanation: Immediate needle decompression relieves the life-threatening pressure. Question 12. A 70-year-old woman presents with acute onset of dysarthria, right facial droop, and left arm weakness. The most appropriate next step is: A) Administer tPA after CT head shows no hemorrhage B) Start aspirin and arrange for carotid endarterectomy C) Perform lumbar puncture for CSF analysis D) Observe and repeat neuro exam in 4 hours Answer: A Explanation: Rapid thrombolysis with tPA is indicated in ischemic stroke within the therapeutic window after ruling out hemorrhage. Question 13. Which medication is the first-line treatment for hyperkalemia with ECG changes? A) Sodium polystyrene sulfonate B) Calcium gluconate IV
C) Insulin with dextrose D) Albuterol nebulizer Answer: B Explanation: Calcium gluconate stabilizes myocardial membranes, buying time for definitive therapy. Question 14. A 25-year-old male presents after a fall with a Glasgow Coma Scale (GCS) of 6. Which airway maneuver is most appropriate? A) Orotracheal intubation with rapid sequence induction (RSI) B) Nasotracheal intubation C) Insertion of a laryngeal mask airway (LMA) D) Cricothyrotomy Answer: A Explanation: RSI with orotracheal intubation is the standard for a patient with a GCS ≤8. Question 15. Which of the following is the recommended initial fluid for a patient in septic shock? A) 0.9% Normal saline B) Lactated Ringer’s solution C) 5% Dextrose in water D) Albumin 5% Answer: B Explanation: Balanced crystalloids like Lactated Ringer’s reduce the risk of hyperchloremic acidosis compared with normal saline. Question 16. A 4-year-old child presents with a barking cough, inspiratory stridor, and low-grade fever. The most appropriate medication is: A) Nebulized epinephrine B) Oral amoxicillin C) Oral dexamethasone D) Inhaled albuterol
Explanation: Quantitative capnography provides reliable confirmation of tracheal placement, especially during low pulmonary blood flow. Question 20. A 32-year-old man presents with a swollen, erythematous knee after a fall. Arthrocentesis yields purulent fluid with a WBC count > 50,000 cells/μL. Which antibiotic regimen is most appropriate? A) Cefazolin IV B) Vancomycin plus ceftriaxone IV C) Clindamycin PO D) Ciprofloxacin IV Answer: B Explanation: Empiric coverage for MRSA (vancomycin) and gram-negative organisms (ceftriaxone) is recommended for septic arthritis. Question 21. Which of the following is the most appropriate next step for a patient with a suspected acute myocardial infarction who is allergic to aspirin? A) Administer clopidogrel 300 mg loading dose B) Give aspirin desensitization in the ED C) Use ticagrelor 180 mg loading dose D) Skip antiplatelet therapy until cardiology consult Answer: C Explanation: Ticagrelor provides potent P2Y12 inhibition and can be used when aspirin is contraindicated. Question 22. A 70-year-old man with known severe aortic stenosis presents with syncope while standing. Which of the following is the most likely cause? A) Orthostatic hypotension B) Arrhythmia due to atrial fibrillation C) Fixed cardiac output leading to decreased cerebral perfusion D) Vasovagal reflex Answer: C
Explanation: Severe aortic stenosis limits increase in cardiac output during positional changes, causing syncope. Question 23. Which of the following laboratory values is most predictive of severe traumatic brain injury? A) Serum glucose > 200 mg/dL B) Serum sodium < 130 mmol/L C) Base deficit > 6 mmol/L D) Serum lactate > 4 mmol/L Answer: C Explanation: A large base deficit indicates metabolic acidosis from shock and correlates with worse TBI outcomes. Question 24. A patient presents with a temperature of 39.5 °C, a diffuse maculopapular rash, and a positive Nikolsky sign. The most likely diagnosis is: A) Toxic shock syndrome B) Stevens-Johnson syndrome C) Staphylococcal scalded skin syndrome D) Drug-induced erythema multiforme Answer: B Explanation: Stevens-Johnson syndrome presents with mucocutaneous involvement and positive Nikolsky sign. Question 25. Which of the following is the recommended initial dose of intranasal naloxone for opioid overdose in an adult? A) 0.4 mg B) 2 mg C) 4 mg D) 8 mg Answer: B Explanation: 2 mg intranasal naloxone is the standard adult dose, repeatable if needed.
Explanation: In adults with focal neurologic signs or altered mental status, a CT scan is required before lumbar puncture to rule out mass effect. Question 29. Which of the following best describes the “rule of 9s” in burn assessment? A) Each major body region represents 9% of total body surface area (TBSA) B) The total TBSA burned is calculated by summing multiples of 9% C) The mortality risk increases by 9% for each percent TBSA burned D) The fluid resuscitation formula uses 9 mL/kg per %TBSA burned Answer: A Explanation: The rule of 9s assigns 9% TBSA to each major region (head, each arm, each leg, anterior/posterior trunk). Question 30. A 68-year-old man with chronic kidney disease presents with a new onset of confusion, a serum sodium of 118 mmol/L, and urine osmolality of 550 mOsm/kg. Which therapy is indicated? A) Rapid bolus of 3 % hypertonic saline B) Fluid restriction to 800 mL/day C) Demeclocycline D) Loop diuretics alone Answer: A Explanation: Severe hyponatremia with neurologic symptoms requires cautious hypertonic saline to raise serum sodium safely. Question 31. In a patient with suspected pulmonary embolism, which D-dimer cutoff is considered negative in patients under 50 years old? A) 500 ng/mL B) 1000 ng/mL C) 1500 ng/mL D) Age-adjusted (age × 10) ng/mL Answer: A
Explanation: A D-dimer < 500 ng/mL effectively rules out PE in low-risk patients under 50. Question 32. Which of the following is the most appropriate initial treatment for a patient with a confirmed diagnosis of meningococcal meningitis? A) Ceftriaxone plus vancomycin B) Penicillin G alone C) Ceftriaxone plus dexamethasone D) Vancomycin plus meropenem Answer: C Explanation: Ceftriaxone covers N. meningitidis; dexamethasone reduces inflammatory complications when given before or with the first dose of antibiotics. Question 33. A 30-year-old pregnant woman at 32 weeks gestation presents with severe hypertension (BP 170/110 mm Hg), proteinuria, and headaches. Which medication is first-line for acute management? A) Labetalol IV B) Hydralazine IV C) Nifedipine oral D) Magnesium sulfate IV Answer: A Explanation: Labetalol IV rapidly lowers blood pressure and is safe in pregnancy; magnesium sulfate is used for seizure prophylaxis, not BP control. Question 34. Which of the following best describes the “FAST” exam components? A) Cardiac, pulmonary, abdominal, and lower extremity venous B) Pericardial, pleural, peritoneal, and renal C) Pericardial, pleural, hepatorenal, and splenic D) Pericardial, pleural, peritoneal, and thoracic aorta Answer: B
Explanation: Salter-Harris II fractures are generally managed non-operatively with closed reduction and casting. Question 38. Which of the following best characterizes the “golden hour” concept in trauma care? A) The first 60 minutes after injury, during which definitive surgical care should be performed B) The period when fluid resuscitation should be avoided to prevent coagulopathy C) The time frame in which rapid assessment and life-saving interventions dramatically improve survival D) The interval after which antibiotics become ineffective for open fractures Answer: C Explanation: The golden hour emphasizes early recognition and intervention to reduce mortality. Question 39. A 68-year-old man with known COPD presents with acute dyspnea, wheezing, and an SpO₂ of 84 % on room air. Which of the following is the most appropriate initial oxygen delivery method? A) 100 % non-rebreather mask B) High-flow nasal cannula at 60 L/min C) Simple face mask at 10 L/min D) Nasal cannula at 2 L/min Answer: B Explanation: High-flow nasal cannula provides high FiO₂ and some positive pressure, improving oxygenation while allowing CO₂ clearance. Question 40. Which of the following is the most appropriate next step for a patient with suspected opioid withdrawal exhibiting yawning, lacrimation, and piloerection? A) Intravenous methadone 10 mg B) Oral clonidine 0.1 mg every 6 hours C) Intramuscular naloxone 0.4 mg D) Intravenous lorazepam 2 mg
Answer: B Explanation: Clonidine alleviates autonomic symptoms of opioid withdrawal without precipitating respiratory depression. Question 41. In a patient with suspected acute bacterial meningitis, which adjunctive therapy improves outcomes? A) High-dose vitamin C B) Dexamethasone before or with the first antibiotic dose C) Intravenous immunoglobulin D) Antifibrinolytic agents Answer: B Explanation: Dexamethasone reduces neurologic complications when administered early. Question 42. A 30-year-old woman presents with a 2-day history of dysuria, flank pain, and fever. Urinalysis shows nitrites and leukocyte esterase. Which antibiotic is the most appropriate empiric choice for an uncomplicated pyelonephritis in a non-pregnant adult? A) Nitrofurantoin PO B) Ciprofloxacin PO C) Trimethoprim-sulfamethoxazole PO D) Amoxicillin-clavulanate PO Answer: B Explanation: Fluoroquinolones achieve high renal tissue concentrations and are first-line for pyelonephritis. Question 43. Which of the following scoring systems is used to assess the severity of pancreatitis? A) APACHE II B) Ranson’s criteria C) Glasgow Coma Scale D) CURB- 65
Explanation: PCC provides rapid reversal of warfarin-associated coagulopathy, more effective than FFP. Question 47. Which of the following is the most reliable bedside test to assess for increased intracranial pressure in a comatose patient? A) Pupillary size and reactivity B) Fundoscopic examination for papilledema C) Measurement of optic nerve sheath diameter via ultrasound D) Opening pressure during lumbar puncture Answer: C Explanation: Optic nerve sheath diameter correlates with ICP and can be measured quickly at the bedside. Question 48. A 72-year-old man presents with sudden onset of left-sided weakness and facial droop. CT head shows a hyperdense middle cerebral artery sign. Which therapy is indicated within 3 hours of symptom onset? A) Intravenous alteplase (tPA) B) Endovascular mechanical thrombectomy only C) Aspirin 325 mg PO D) Heparin infusion Answer: A Explanation: IV tPA is indicated for acute ischemic stroke within the therapeutic window if no contraindications exist. Question 49. Which of the following is the most appropriate initial analgesic for a patient with acute renal colic? A) NSAID (ketorolac IV) B) Morphine sulfate IV C) Acetaminophen PO D) Gabapentin PO Answer: A
Explanation: NSAIDs reduce ureteral spasm and provide effective pain relief; they are first-line for renal colic. Question 50. A 19-year-old female presents with a “butterfly” rash, joint pain, and positive ANA. Which laboratory test is most specific for systemic lupus erythematosus? A) Anti-dsDNA antibodies B) Anti-centromere antibodies C) Anti-smooth muscle antibodies D) Anti-Ro/SSA antibodies Answer: A Explanation: Anti-double-stranded DNA antibodies have high specificity for SLE. Question 51. A 45-year-old man with a history of chronic alcoholism presents with confusion, asterixis, and a serum ammonia level of 120 μg/dL. The most appropriate initial therapy is: A) Lactulose PO or NG tube B) Rifaximin PO C) Sodium benzoate IV D) Hemodialysis Answer: A Explanation: Lactulose reduces ammonia absorption by acidifying the colon and is first-line for hepatic encephalopathy. Question 52. Which of the following is the most appropriate initial imaging modality for a suspected cervical spine fracture in an alert, cooperative patient? A) Plain radiographs (AP, lateral, odontoid) B) CT cervical spine without contrast C) MRI cervical spine with gadolinium D) Ultrasound of the neck Answer: B
Explanation: IV nitroglycerin reduces preload and afterload, improving symptoms of acute decompensated heart failure. Question 56. Which of the following is the most appropriate dose of intranasal midazolam for procedural sedation in a 4-year-old child? A) 0.1 mg/kg B) 0.2 mg/kg C) 0.3 mg/kg D) 0.5 mg/kg Answer: B Explanation: Intranasal midazolam 0.2 mg/kg provides effective sedation with rapid onset in pediatric patients. Question 57. A 30-year-old man presents with a painless, enlarging scrotal mass. Doppler ultrasound shows absent blood flow to the testis. The most appropriate management is: A) Immediate orchiectomy B) Observation and repeat ultrasound in 24 hours C) High-dose antibiotics D) Manual detorsion only Answer: A Explanation: Testicular torsion with absent flow requires prompt surgical exploration and orchiectomy if non-viable. Question 58. Which of the following is the most appropriate initial therapy for a patient with an acute exacerbation of chronic heart failure and a serum potassium of 5.8 mmol/L? A) Intravenous furosemide 40 mg B) Intravenous potassium-free diuretic (e.g., torsemide) C) Discontinue all diuretics and give IV potassium chloride D) Administer IV calcium gluconate Answer: B
Explanation: Loop diuretics without potassium supplementation help remove excess fluid while avoiding further hyperkalemia. Question 59. A 72-year-old man on chronic steroids for COPD presents with fever, cough, and a new infiltrate on chest X-ray. Which of the following is the most appropriate empiric antibiotic regimen? A) Azithromycin PO alone B) Ceftriaxone plus azithromycin IV C) Vancomycin plus piperacillin-tazobactam IV D) Levofloxacin PO only Answer: B Explanation: Combination therapy covers typical and atypical organisms for community-acquired pneumonia. Question 60. Which of the following is the most accurate method for confirming proper placement of a central venous catheter tip? A) Chest X-ray showing tip at the carina level B) Transduction of central venous pressure waveform C) Ultrasound visualization of catheter tip in the SVC D) Blood gas analysis from catheter (PaO₂ > 40 mm Hg) Answer: C Explanation: Real-time ultrasound can directly visualize catheter tip location in the superior vena cava, providing immediate confirmation. Question 61. A 19-year-old college student presents after binge drinking with tremor, agitation, and visual hallucinations. Which medication is most appropriate for management? A) Intravenous lorazepam 2 mg q15 min as needed B) Oral haloperidol 5 mg C) Intravenous thiamine 100 mg only D) Oral diphenhydramine 50 mg Answer: A
