CPR MCQ Bank - NCLEX & Advanced NORCET Level

SECTION A - NCLEX LEVEL (Questions 1-10)

Question 1 - Image-Based (Algorithm)

• A. Check pulse and assess rhythm immediately
• B. Administer epinephrine 1 mg IV/IO
• C. Resume CPR for 2 minutes and establish IV/IO access
• D. Administer amiodarone 300 mg IV

Rationale: Per the AHA algorithm (Step 4), after the first shock for VF/pVT, CPR is immediately resumed for 2 minutes while IV/IO access is obtained. Pulse check before the 2-minute CPR cycle is incorrect - rhythm/pulse checks are only done after the CPR cycle. Epinephrine is introduced in Step 6 (after the second shock) and amiodarone in Step 8 (after the third shock).

• Roberts and Hedges' Clinical Procedures in Emergency Medicine

Question 2 - Clinical Scenario

• A. Rate of 80-100/min, depth of 1.5 inches
• B. Rate of 100-120/min, depth of 2.0-2.4 inches
• C. Rate of 120-140/min, depth of at least 3 inches
• D. Rate of 60-80/min, depth of 2.5 inches

Rationale: AHA guidelines specify compressing the sternum to a depth of 2.0-2.4 inches at a rate of 100-120 compressions/min. Compressing too fast (>120/min) reduces depth and prevents full chest recoil. Compressing too slowly reduces cardiac output. The 50:50 compression-to-relaxation ratio must be maintained.

• Roberts and Hedges' Clinical Procedures in Emergency Medicine, p. 392

Question 3 - Priority Question

• A. Defibrillate immediately
• B. Administer amiodarone 300 mg IV
• C. Administer epinephrine 1 mg IV/IO every 3-5 minutes
• D. Prepare for synchronized cardioversion

Rationale: PEA is a non-shockable rhythm - defibrillation is NOT indicated. Amiodarone is used for refractory shockable rhythms (VF/pVT). Per the algorithm (right side, Step 10), PEA/Asystole management includes CPR, IV/IO access, and epinephrine every 3-5 minutes. Synchronized cardioversion is contraindicated in pulseless patients.

• Roberts and Hedges' Clinical Procedures in Emergency Medicine

Question 4 - Image Interpretation

• A. Lidocaine 1.5 mg/kg
• B. Vasopressin 40 units IV
• C. Magnesium sulfate 2g IV
• D. Amiodarone 300 mg IV

Rationale: Step 8 of the AHA algorithm introduces amiodarone for refractory VF/pVT after the third shock. Amiodarone (300 mg IV, second dose 150 mg) is the antiarrhythmic of choice. While lidocaine is an alternative, amiodarone is the first-line per AHA. Only two drugs are currently recommended for cardiac arrest - epinephrine and amiodarone - and no ACLS drug has been proven to improve long-term survival.

• Roberts and Hedges' Clinical Procedures in Emergency Medicine, p. 313

Question 5 - Select All That Apply (NCLEX-style)

• A. Allow full chest recoil between compressions
• B. Stop compressions to deliver medications IV
• C. Rotate rescuers every 2-3 minutes
• D. Keep pauses in compressions to a minimum
• E. Compress to a depth of 1.5 inches
• F. Avoid leaning on the chest between compressions

Rationale:

• (A) Full chest recoil allows blood to re-enter the heart from the vena cava - essential for adequate ventricular filling.
• (C) Rotating rescuers every 2-3 minutes prevents fatigue-related decline in compression quality.
• (D) Minimizing pauses is critical - even short pauses profoundly reduce coronary perfusion pressure.
• (F) Not leaning prevents compression of the chest between compressions, restoring venous return.
• (B) is WRONG - medications can and should be given during compressions to avoid interruptions.
• (E) is WRONG - depth must be 2.0-2.4 inches, not 1.5.
• Roberts and Hedges' Clinical Procedures in Emergency Medicine

Question 6 - Clinical Scenario

• A. Mouth-to-mouth ventilation only
• B. 30 compressions : 2 breaths ratio
• C. Chest compression-only CPR (hands-only CPR)
• D. 15 compressions : 2 breaths ratio

Rationale: Chest compression-only CPR (CC-CPR/Hands-Only CPR) is endorsed by AHA for untrained lay bystanders. Studies show CC-CPR is as effective as standard CPR for witnessed adult cardiac arrest. In Arizona, switching to this approach increased bystander CPR rates from 28% to 40% and survival improved from 7.8% to 13.3%. The AHA shifted from "ABC" to "CAB" (Compressions, Airway, Breathing) since 2010, with emphasis on high-quality chest compressions.

• Barash, Cullen, and Stoelting's Clinical Anesthesia, 9e

Question 7 - Pharmacology

• A. Increases myocardial contractility by beta-1 stimulation
• B. Causes coronary and cerebral vasodilation
• C. Alpha-1-mediated systemic vasoconstriction increases coronary perfusion pressure
• D. Directly converts VF to sinus rhythm

Rationale: Epinephrine's primary beneficial effect in cardiac arrest is through alpha-1 adrenergic receptor stimulation, causing peripheral vasoconstriction. This increases aortic diastolic pressure, which drives coronary perfusion pressure (the gradient that perfuses the heart during CPR diastole). Notably, concerns have been raised that epinephrine may worsen neurologic outcomes due to cerebral vasoconstriction, which is why it remains controversial. Epinephrine does NOT directly defibrillate.

• Roberts and Hedges' Clinical Procedures in Emergency Medicine, p. 313

Question 8 - AED Scenario

• A. Check for a pulse and if absent, defibrillate manually
• B. Immediately resume CPR for 2 minutes
• C. Administer epinephrine and wait for the next rhythm analysis
• D. Intubate the patient immediately

Rationale: "No shock advised" on an AED indicates a non-shockable rhythm (PEA or asystole). The correct response is to immediately resume CPR. Defibrillation is only indicated for shockable rhythms (VF/pulseless VT). The survival rate drops 7-10% per minute without defibrillation when VF is present, but defibrillating asystole or PEA provides no benefit and may harm.

• Roberts and Hedges' Clinical Procedures in Emergency Medicine

Question 9 - Pediatric CPR

• A. 30:2
• B. 15:2
• C. 5:1
• D. 30:1

Rationale: For pediatric CPR with two rescuers, the ratio is 15:2 (15 compressions : 2 breaths). For a single rescuer performing CPR on a child, the ratio is 30:2 (same as adults). For infants, two-finger compression or the thumb-encircling technique is used. This differs from adult CPR where 30:2 applies regardless of rescuer number.

• Barash, Cullen, and Stoelting's Clinical Anesthesia, 9e

Question 10 - Post-Arrest Care

• A. Immediate coronary angiography regardless of ECG findings
• B. Maintain MAP >65 mmHg and SBP >90 mmHg
• C. Administer high-dose corticosteroids to reduce cerebral edema
• D. Hyperventilate to reduce cerebral CO2

Rationale: Post-ROSC hemodynamic stabilization is the immediate priority. Hypotension (MAP <65, SBP <90) dramatically reduces cerebral blood flow and causes secondary brain injury - especially dangerous because cerebral autoregulation is often lost after cardiac arrest. Current recommendations target MAP >65 mmHg and SBP >90 mmHg using IV fluids and vasopressors as needed. Hyperventilation is harmful as it causes cerebral vasoconstriction and reduces CBF.

• ROSEN's Emergency Medicine, p. 71

SECTION B - ADVANCED NORCET LEVEL (Questions 11-20)

Question 11 - Advanced Algorithm (Image-Based)

• A. Ventricular fibrillation
• B. Return of spontaneous circulation (ROSC)
• C. Pulseless electrical activity
• D. Worsening cerebral ischemia

Rationale: A sharp increase in ETCO2 (usually >25-30 mmHg) during CPR is a reliable indicator of ROSC. When cardiac output is restored, CO2 that accumulated in tissues during the low-flow state is rapidly transported to the lungs and exhaled, causing a sudden spike in PETCO2. ETCO2 is used as a real-time CPR quality monitor - values <10 mmHg during CPR predict poor outcomes and may indicate futility.

• Roberts and Hedges' Clinical Procedures in Emergency Medicine

Question 12 - Pathophysiology (Image-Based)

• A. Complete heart block
• B. Ventricular fibrillation (VF)
• C. Sinus bradycardia
• D. Junctional escape rhythm

Rationale: The diagram shows reentry: Panel A shows normal dual-pathway conduction; Panel B shows one pathway with slow conduction and another with unidirectional block; Panel C shows antegrade conduction looping around; Panel D shows the completed reentry circuit. Reentry is the primary electrophysiologic mechanism behind VF and pulseless VT - the most common shockable rhythms in sudden cardiac arrest (SCA). During VF, myocytes consume oxygen and ATP at the same or higher rate than during normal contraction.

• Roberts and Hedges' Clinical Procedures in Emergency Medicine, p. 310

Question 13 - Advanced Pharmacology

• A. Epinephrine consistently improves both ROSC and long-term neurologic outcomes
• B. Epinephrine improves ROSC rates but may worsen neurologic outcomes via cerebral vasoconstriction
• C. Epinephrine has been removed from ACLS guidelines due to harm
• D. Epinephrine 0.2 mg IV is the current recommended dose every 5-10 minutes

Rationale: Only epinephrine and amiodarone are currently recommended ACLS drugs, but neither has proven long-term survival benefit. More critically, epinephrine is associated with worsened final outcomes, possibly through prolonged cerebral vasoconstriction - a clinically significant finding that has prompted debate. The recommended dose remains 1 mg IV/IO every 3-5 minutes. This represents a major controversy in resuscitation medicine.

• Roberts and Hedges' Clinical Procedures in Emergency Medicine, p. 313

Question 14 - Team Leadership & Resuscitation

• A. The team leader should always perform defibrillation, not compressions
• B. The team leader performing compressions compromises their ability to monitor rhythm, direct drug administration, and maintain overall control of the resuscitation
• C. Only physicians are permitted to perform chest compressions
• D. The team leader should exclusively manage the airway

Rationale: The team leader's role is to oversee and direct - not to perform tasks. They must monitor rhythm, order initiation/termination of compressions, direct drug delivery, observe CPR quality, and order rescuer rotations. If the team leader is physically performing compressions, they lose situational awareness and overall control of the resuscitation rapidly deteriorates. Per guidelines, the team leader should stand where they can direct the entire resuscitation.

• Roberts and Hedges' Clinical Procedures in Emergency Medicine, p. 394

Question 15 - ACLS Drug Sequencing

• A. Repeat 300 mg IV bolus
• B. 150 mg IV (second dose)
• C. 360 mg IV (loading dose)
• D. Switch to lidocaine 1 mg/kg IV

Rationale: The AHA ACLS protocol for amiodarone in refractory VF/pulseless VT is:

• First dose: 300 mg IV/IO
• Second dose: 150 mg IV/IO If amiodarone is unavailable, lidocaine is an acceptable alternative. The sequential dosing prevents toxicity from excessive cumulative doses (amiodarone can cause hypotension, bradycardia).
• Roberts and Hedges' Clinical Procedures in Emergency Medicine

Question 16 - Advanced Pathophysiology

• A. Are in a resting state with minimal oxygen demand
• B. Consume oxygen and ATP at the same or higher rate than during normal contraction
• C. Receive adequate perfusion through retrograde coronary flow
• D. Stop all electrical activity completely

Rationale: This is a critical concept. During VF, despite disorganized contraction, myocytes are electrically active and metabolically consuming O2 and ATP at rates equal to or exceeding normal contraction. This explains why CPR quality (washing out ischemic metabolic byproducts, maintaining coronary perfusion) directly affects defibrillation success - a metabolically "exhausted" myocardium is refractory to defibrillation. Shallow compressions fail to clear these byproducts.

• Roberts and Hedges' Clinical Procedures in Emergency Medicine, p. 310

Question 17 - LVAD/Device Scenario

• A. CPR is absolutely contraindicated in LVAD patients
• B. Standard ACLS algorithms should be followed; peripheral pulses may be absent even with LVAD functioning
• C. External defibrillation cannot be used in LVAD patients
• D. The LVAD provides adequate perfusion so CPR is unnecessary

Rationale: LVAD patients present unique challenges - the absence of peripheral pulses is normal even with the device functioning (continuous flow). In arrest, standard ACLS algorithms are followed. Verify the machine is connected, battery is charged, and it has an audible hum. External defibrillation can be used (pads placed >10 cm from device in anteroposterior configuration, lowest effective energy). Standard CPR may potentially dislodge the device (a concern), but ACLS should not be withheld.

• Roberts and Hedges' Clinical Procedures in Emergency Medicine, p. 335-336

Question 18 - Survival Statistics & Decision Making

• A. 10-20% reduction
• B. 40-50% reduction
• C. 56-80% reduction
• D. 5-10% reduction

Rationale: Survival from VF/SCA drops 7-10% for every minute without treatment (no CPR, no defibrillation). At 8 minutes: 8 × 7% = 56% to 8 × 10% = 80% reduction. If CPR is initiated, the decline slows to 3-4%/minute. This underscores why immediate bystander CPR and early defibrillation are critical. Immediate CPR + defibrillation has been shown to increase survival up to fourfold in witnessed VF arrest.

• Roberts and Hedges' Clinical Procedures in Emergency Medicine, p. 4197

Question 19 - Defibrillator Management (Advanced)

• A. Stop CPR immediately - the AICD will terminate the arrhythmia
• B. Continue CPR; the shocks are harmless to rescuers; if the shocks impede CPR performance, apply a magnet over the device corner to disable it
• C. Defibrillate immediately with pads placed directly over the AICD
• D. Administer lidocaine to suppress AICD discharge

Rationale: AICD shocks during CPR are harmless to rescuers (low current density at the rescuer's hands). CPR should continue. If AICD shocks are impeding CPR performance OR if SVT occurs during resuscitation, the AICD can be disabled by placing a magnet over the corner of the device from which leads emerge (pause until AICD activity ceases). External defibrillation pads must be placed >10 cm from the pulse generator - never directly over it. Anteroposterior pad placement is preferred.

• Roberts and Hedges' Clinical Procedures in Emergency Medicine, p. 335

Question 20 - Critical Thinking (Highest Level NORCET)

• A. Cooling to 33°C is definitively superior to 36°C for neurologic outcomes
• B. TTM at 36°C versus 33°C showed no significant difference in outcomes in landmark RCTs; fever prevention remains the core goal
• C. TTM is contraindicated in patients with prolonged downtime >15 minutes
• D. TTM must be started within 1 hour of ROSC for any benefit

Rationale: The TTM Trial (2013, NEJM) randomized 950 patients to 33°C vs 36°C and found no significant difference in mortality or neurologic outcomes. A subsequent trial (Dankiewicz et al., TTM2, NEJM 2021) found normothermia (avoiding fever >37.8°C) was non-inferior to hypothermia at 33°C. Current practice therefore focuses on fever prevention post-ROSC rather than mandatory deep cooling. However, active fever treatment and neurological monitoring remain standard of care. TTM is not absolutely contraindicated by downtime alone.

• ROSEN's Emergency Medicine; Miller's Anesthesia, 10e

Summary Table

• Roberts and Hedges' Clinical Procedures in Emergency Medicine (Roberts & Hedges)
• ROSEN's Emergency Medicine: Concepts and Clinical Practice
• Barash, Cullen, and Stoelting's Clinical Anesthesia, 9th ed.
• Miller's Anesthesia, 10th ed.
• AHA 2015 ACLS Guidelines; TTM Trial (Nielsen et al., NEJM 2013); TTM2 Trial (Dankiewicz et al., NEJM 2021)

1. 2-rescuer pediatric CPR uses 15:2, not 30:2
2. Infant compression technique - 2-finger or thumb-encircling method
3. Pediatric defibrillation is weight-based (2 J/kg first, 4 J/kg after)

Card 1 - Adult Arrest: Shockable Rhythm (VF)

58-year-old male | Ventricular Fibrillation | Shockable pathway

Card 2 - Adult Arrest: Non-Shockable (PEA)

72-year-old female | PEA post-PE | Non-shockable pathway

Card 3 - Pediatric Arrest: Child (Drowning/VF)

5-year-old, 20 kg | Near-drowning | VF | Ventilation-first approach

Card 4 - Pediatric Arrest: Infant (Asystole/Choking)

8-month-old, 8 kg | Choking/Asystole | Thumb-encircling technique | Brachial pulse | Neutral head

Bonus - Master Decision Reference Card

All-ages comparison | Shockable vs non-shockable | Exam trap highlights