NREMT Paramedic Exam Prep: Study Guide, Practice Questions & 4-Week Plan

This guide is for the current National Registry Paramedic Certification Examination, the version in use since July 1, 2024. Work the 21 original practice questions below, then use your misses to choose your next study task.

Practice questions: 21 original items

Original practice questions written by Castleport Test Prep. These are not official National Registry questions and this is not a full-length exam.

Case 1: Opioid overdose that improves, then doesn't

Fictional patient for practice. A 38-year-old is unresponsive at home after a reported opioid overdose. The scene is safe. You feel a strong carotid pulse at 64 beats/min. The patient is not breathing. Your partner brings a bag-valve mask (BVM) and naloxone.

NRP-01 · Clinical Judgment (recognize cues) · Select TWO

Which two findings tell you this patient needs assisted breaths, not chest compressions, right now?

• A. A definite carotid pulse
• B. No breathing
• C. The reported opioid history
• D. The patient's age
• E. Naloxone is on scene

New findings: You ventilate effectively with the BVM, and naloxone is given per protocol. The patient now breathes on their own at 14 breaths/min with good depth. SpO₂ is 96% on oxygen. They open their eyes to voice but stay drowsy.

NRP-02 · Clinical Judgment (evaluation) · Multiple-choice

Which interpretation fits best?

• A. Breathing has improved; keep monitoring closely and transport for medical care
• B. An SpO₂ of 96% proves breathing won't get worse again
• C. Drowsiness proves the treatment didn't help
• D. A spontaneous rate of 14/min with good depth still requires assisted ventilation

New findings: During transport the patient becomes harder to rouse. Breathing drops to 4 breaths/min and is shallow. SpO₂ falls to 88%. The carotid pulse is still strong at 66 beats/min.

NRP-03 · Clinical Judgment (take action) · Multiple-choice

What is the best immediate response?

• A. Wait, because naloxone already worked once
• B. Resume effective assisted ventilation and give more naloxone per protocol
• C. Turn up the oxygen and hold off on ventilating until you arrive
• D. Start chest compressions

Self-check: Finish this sentence before moving on: "The finding changed from ___ to ___, so my action changed from ___ to ___."

Case 2: Chest pressure with a slow heart rate

Fictional patient for practice. Dispatch at 0620: a 61-year-old man with "chest pressure, feels faint." He is pale, sweaty and slow to answer questions.

He has had central chest pressure since 0545, radiating to his jaw, with nausea. He has no allergies and can chew and swallow.

NRP-04 · Clinical Judgment (recognize cues) · Select THREE

Which three findings demand your immediate attention?

• A. Heart rate 38 beats/min
• B. Blood pressure 82/50 mmHg
• C. ST elevation in II, III and aVF
• D. SpO₂ 96%
• E. Glucose 112 mg/dL
• F. Temperature 98.8 °F

NRP-05 · Clinical Judgment (define hypothesis) · Multiple-choice

What best explains his presentation?

• A. Inferior STEMI complicated by third-degree AV block and poor perfusion
• B. Vasovagal syncope
• C. Hypoglycemia
• D. Stable supraventricular tachycardia

NRP-06 · Clinical Judgment (generate solutions) · Drag-and-drop

Sort each action into Do now or Hold or avoid now.

• Chewable aspirin
• STEMI notification to the receiving hospital
• Establish IV access
• Sublingual nitroglycerin
• Complete a detailed secondary survey on scene before moving him

New findings: En route, after atropine per protocol, his heart rate is 36 beats/min and blood pressure is 74/42 mmHg. He is now hard to rouse. The monitor still shows third-degree AV block.

NRP-07 · Clinical Judgment (evaluation) · Multiple-choice

What is the next best action?

• A. Begin transcutaneous pacing, with sedation or pain control as he tolerates
• B. Adenosine 6 mg rapid IV push
• C. Sublingual nitroglycerin
• D. Recheck in 10 minutes before changing anything

Medical/Obstetrics/Gynecology

NRP-08 · Medical · Multiple-choice

A 67-year-old woman has right arm drift and slurred speech. Her husband found her this way at 0715. She was normal when they went to bed at 2300. What time do you document as "last known well"?

• A. 0715
• B. 2300
• C. The time of the 911 call
• D. The time EMS arrived

NRP-09 · Medical · Multiple-choice

A 70-year-old man has new left-sided weakness and slurred speech. His blood glucose is 46 mg/dL. What is the most appropriate next step?

• A. Go straight to a thrombectomy-capable stroke center
• B. Treat the low blood sugar per protocol, then repeat the neuro exam
• C. Give aspirin for a presumed stroke
• D. Lower his blood pressure before transport

NRP-10 · OB/Gyn · Select THREE

A 26-year-old woman has sudden lower abdominal pain and looks pale. Which three findings most raise concern for a ruptured ectopic pregnancy?

• A. Vaginal bleeding
• B. A pregnancy diagnosed two weeks ago
• C. A missed menstrual period
• D. Right lower quadrant pain when you press on the left lower quadrant
• E. Tenderness over the kidney area (costovertebral angle) with painful urination
• F. Right upper quadrant pain and a history of gallstones

NRP-11 · Medical · Multiple-choice

A 62-year-old man with a left ventricular assist device (LVAD) is alert and talking but feels lightheaded. You can't feel a radial pulse, the automatic blood pressure cuff fails, and you hear a continuous hum over his chest. What is the best action?

• A. Start chest compressions because he has no pulse
• B. Disconnect the controller before getting a 12-lead ECG
• C. Don't start CPR; judge perfusion clinically, check the device alarms and contact the VAD coordinator
• D. Use pulse oximetry as your main measure of perfusion

NRP-12 · OB/Gyn · Multiple-choice

Eight days after giving birth, a woman has a headache that won't go away, blurry vision and high blood pressure on repeated readings. She had no preeclampsia during pregnancy. Which interpretation is most appropriate?

• A. Postpartum preeclampsia is an urgent concern that needs emergency evaluation
• B. Delivery rules out a pregnancy-related blood pressure problem
• C. An uncomplicated pregnancy makes these symptoms normal recovery
• D. These symptoms can wait for her routine follow-up visit

Cardiology & Resuscitation

NRP-13 · Cardiology · Multiple-choice

An adult collapses. There is no pulse, CPR is underway, the monitor shows ventricular tachycardia and the defibrillator is charged. What do you do now?

• A. Defibrillate, then resume CPR immediately
• B. Perform synchronized cardioversion
• C. Begin transcutaneous pacing
• D. Hold the shock until an antiarrhythmic has been given

NRP-14 · Cardiology · Options box

These adults have a pulse and primary tachyarrhythmias causing their symptoms. For each patient, choose one answer from these three:

• Immediate synchronized cardioversion for rhythm-related hemodynamic instability
• Vagal maneuvers, then adenosine
• Avoid AV-nodal blocking drugs; IV procainamide is an option under protocol

NRP-15 · Cardiology · Multiple-choice

A 58-year-old man has chest pressure. His blood pressure is 138/84 mmHg and heart rate 88 beats/min, and you've given aspirin. He took tadalafil 20 hours ago. What's correct about nitroglycerin?

• A. Give it; his systolic pressure is above 100
• B. Give half the usual dose
• C. Withhold it; he took tadalafil within the past 48 hours
• D. Give it; tadalafil only matters within 12 hours

Airway, Respiration & Ventilation

NRP-16 · Airway · Multiple-choice

You place a supraglottic airway in an apneic overdose patient. Which monitoring is essential from this point on?

• A. Continuous waveform capnography
• B. Pulse oximetry alone
• C. Listening to breath sounds once after placement
• D. Watching chest rise

NRP-17 · Airway (pediatric) · Multiple-choice

A 4-year-old has a strong pulse of 110 beats/min but weak, inadequate breathing. There's no airway obstruction, and your BVM seal and head position are good. How should you breathe for this child?

• A. Withhold breaths, because the child has a pulse
• B. 10 breaths per minute, the adult rate
• C. Compression-only CPR
• D. 1 breath every 2 to 3 seconds (20–30 per minute), each with visible chest rise

Trauma

NRP-18 · Trauma · Build list

A 34-year-old has a gunshot wound to the thigh with spurting bleeding. Put these priorities in MARCH order:

• Respirations
• Circulation
• Hypothermia / head injury
• Massive hemorrhage
• Airway

NRP-19 · Trauma (pediatric) · Multiple-choice

A 6-year-old restrained passenger is alert but pale after a crash. Heart rate 140 beats/min, capillary refill 4 seconds, blood pressure 76/50 mmHg. Which statement is accurate?

• A. His blood pressure is normal because it's above 70
• B. Children aren't hypotensive until systolic pressure drops below 90
• C. He's hypotensive for his age; with the fast heart rate and slow refill, treat him for shock and transport quickly
• D. The fast heart rate is probably anxiety; recheck in 15 minutes

EMS Operations

NRP-20 · EMS Operations · Multiple-choice

An alert, oriented 40-year-old refuses transport after telling you he wants to end his life. Under NASEMSO's model refusal guidance, what is the best response?

• A. He's oriented, so have him sign a refusal
• B. Maintain safety, contact medical direction, and follow the applicable emergency mental-health procedures rather than accepting a routine refusal
• C. Leave once a family member arrives to stay with him
• D. Physically restrain him yourself before help arrives

NRP-21 · EMS Operations (pediatric) · Select THREE

A 14-year-old hit by a car has an open femur fracture, and his parents can't be reached. Under NASEMSO's model guidance, which three stated conditions support treating and transporting him under the emergency exception (implied consent)?

• A. The injury threatens his life or health
• B. His legal guardian isn't available to give consent
• C. Treatment can't safely wait until consent is obtained
• D. He says he's willing to go
• E. A teacher on scene signs for him
• F. A police officer is present

Check your results

The set samples all six domains through text exercises representing five response formats used on the exam: multiple-choice (one answer), multiple-response (select a stated number), build list (put in order), drag-and-drop (sort into groups) and options box (choose per row). Record your choices, then reveal each answer.

The National Registry scores each scored item all-or-nothing. Use the same convention here: a multiple-response, sorting, options-box or ordering item counts only if every part is right. (Specifications, p. 6)

Count your correct items by domain:

Your score is feedback on these 21 items. It isn't a scaled score or a prediction of passing. Two or three items per domain is far too few to measure a domain. Use your misses to choose what to study next, using the error log below.

How to turn a miss into your next study task

Log every miss. Also log every correct guess, and every right answer you couldn't explain.

Match the next task to the kind of mistake:

• Missing knowledge. Reread the source section, then explain the rule and its limits in your own words.
• Missed cue. Name the exact finding that should have changed your decision.
• Wrong priority. Write one sentence on why the right action fits these findings better than yours did.
• Format slip (picked two when it said three, misread the row instruction). Reread the instructions on an official sample item.
• Math error. Carry the units through every step and reverse-check the answer.

Exam format and domain weights

At a glance: 110–150 questions · 3 hours 30 minutes · computer adaptive · $175 per attempt · Pearson test center only · no separate psychomotor exam. (NREMT Paramedic handbook; Paramedic pathway)

Pediatric questions are integrated throughout the examination. Clinical Judgment is the biggest slice, but it isn't a separate topic to memorize. It's how you reason through airway, cardiac, trauma and medical patients as their findings change. Source: NREMT Paramedic Examination Specifications, pp. 3–4.

The percentages are shares of exam questions. They are not a prescription for study hours.

How clinical judgment questions work

The National Registry measures clinical judgment as a six-step cycle. You repeat it as the scene changes.

The two cases come first because they show how clinical judgment items work: the patient changes, and your next decision has to change with them. Each stage gives you only what you'd know at that moment.

The domain also samples communication and leadership during an EMS response.

Scenario items can use any format, including ECG strips and other graphics. Because scoring is all-or-nothing, a select-three item with one wrong pick earns nothing. Read the selection count before you click. (Specifications, pp. 2–3, 6)

The best format practice is the National Registry's own. Open the official sample items and the Clinical Judgment sample packet at least once before test day, so the screens look familiar. Our cases describe ECG findings in words, which practices the decision, not reading a strip.

Your 4-week NREMT Paramedic study plan

Assumptions: you've finished (or nearly finished) a qualifying Paramedic program. You can reserve five 60-minute study slots a week, which comes to 20 sessions and up to 20 hours. This is our editorial plan. It isn't an official requirement, and no number of hours guarantees a pass.

Use this pattern for ordinary review sessions. The baseline and timed mix have their own allocations below:

The timed mix in Week 4 uses 1.4 minutes per item, which is 210 minutes divided by 150 items. That's a pace reference, not a rule. (Handbook)

Adjusting the plan:

• Two weeks left. Do two sessions per study day. Keep all six domains and the repair day.
• More time. Spread the sessions out, and add more unfamiliar cases from your program.
• Need testing accommodations. Start that first, before paying or booking. The National Registry wants requests at least 45 days before the date you want to test, so a four-week study plan is shorter than the request lead time. Wait for the decision before paying and for the letter before scheduling. (Accommodations Policy 62.02; official checklist)
• After an unsuccessful attempt. Use the score report together with your error log, and check the retest rules below before you rebuild the plan.

Worked example: drip-rate math

Calculation practice only. This is not a dosing recommendation.

The order: 0.08 mcg/kg/min for a 75 kg patient. The bag: 4 mg in 250 mL total. Find: the pump rate in mL/hour.

Reverse check: 22.5 mL/hour × 16 mcg/mL = 360 mcg/hour. That's 6 mcg/min, and 6 mcg/min ÷ 75 kg = 0.08 mcg/kg/min.

Two errors to check for are mistakes in the mg-to-mcg step and the minutes-to-hours step. Skipping either one changes the answer a lot.

How the adaptive test decides pass or fail

The exam is computer adaptive. When you get a question right, the next one is usually harder; when you miss one, the next is usually easier. The computer uses your response pattern to estimate your ability and compares that estimate with a fixed passing standard.

• When it ends. The test can stop at 110 items if the computer is 95% confident you're above or below the standard. Otherwise it keeps going until it can decide, you reach 150 items, or time runs out.
• Pilot items. 20 unscored pilot items are mixed in, and you can't tell which ones they are.
• Question count. Stopping at 110 or running to 150 tells you nothing about whether you passed.
• Results. Results are posted to your National Registry account, usually within three business days. They are never available at the test center.
• If you pass, you don't get score details.
• If you don't pass, you see a scaled score from 100 to 1500. The passing point is 950, so you can see how far you were from it.

Sources: Specifications, pp. 5–6; Handbook, Examination Format and Examination Results; Examinations Structure, Computer Adaptive Tests

What changed, and which CPR guidelines to study

July 1, 2024 redesign. The National Registry added the Clinical Judgment domain. It also discontinued its separate Paramedic psychomotor (skills) exam and built communication, leadership and clinical judgment into the computer exam instead. Your program still verifies your skills: Program Directors must have a CoAEMSP Student Minimum Competency record on file for each student. Guides that tell Paramedic candidates to book a National Registry skills exam are out of date. (Specifications, p. 2; Paramedic pathway)

2025 AHA guidelines. On October 27, 2025, the National Registry announced a process for:

• reviewing every live question against the 2025 AHA CPR and ECC guidelines;
• removing questions that conflict with them;
• developing new 2025-aligned questions that would undergo review and pilot testing, with an expected 12 to 15 months before they become operational.

Calculated from the notice's date, that projection corresponds to about late October 2026 through late January 2027. The notice does not give a single switch date. (NREMT news, Oct. 27, 2025)

What to do: study the 2025 guidelines. The notice says questions found to conflict with the new guidelines will be removed as the review proceeds. Topics that changed in 2025 include:

• for responsive adults and children with severe choking, the standard sequence now starts with back blows before abdominal thrusts;
• infant BLS, where the two-finger compression technique is no longer recommended.

The practice set does not test these two changed procedures. (AHA 2025 Executive Summary, Parts 6 and 7)

Before you schedule

Eligibility. You need all of the following:

• a current EMT-level (or higher) National Registry certification or state license;
• completion within the past two years of a CAAHEP-accredited Paramedic program, or one with a CoAEMSP Letter of Review;
• your Program Director's verification of course completion.

(Paramedic pathway)

ATT. Your Authorization to Test (ATT) is valid for up to 90 days. Check that the name on it matches your unexpired government-issued ID exactly.

Rescheduling and no-shows.

• Rescheduling or canceling through Pearson costs $30, plus a call-center fee if you do it by phone.
• Missing your appointment without notifying Pearson at least one business day (24 hours) before forfeits your fee.

At the test center.

• You have 5 minutes to accept the non-disclosure agreement. If you miss that window, it counts as an attempt and you lose the fee.
• A 10-minute tutorial on the item types comes before the 3½-hour exam.

(Handbook)

Need accommodations? Submit your request at least 45 days before the date you want to test. Create your application, but wait for the accommodations decision before paying. Allow at least 30 days for processing, and do not schedule until you receive the decision letter. Follow its instructions. See our NREMT exam accommodations guide and the official accommodations checklist. For the application steps, see the official Paramedic certification process.

National Registry certification doesn't let you practice by itself. You need a state license, and in many states the certification is one of the requirements for it. (Handbook overview; state EMS offices)

If you don't pass

You can make up to six attempts while your course eligibility remains valid.

• Waiting period. The formal retesting policy says you can schedule a retest 15 days from the date your results post, with the posting date counting as day one. The handbook words it as 15 days from your exam date. Use the date shown in your account, or confirm it with the National Registry before you book.
• After three failed attempts. You must complete remedial education before attempt four. For Paramedic that's 30 credits, through the National Component of the NCCP model or another option the registry accepts. That remediation then covers attempts four through six while other eligibility requirements remain met. Remediation does not extend the two-year course eligibility period. After six unsuccessful attempts, the policy requires a new qualifying education program.
• Rescoring. Request promptly. The fee is $150; the handbook counts 30 days from the exam date, while the examination-policy page counts 30 days from release of the score report. Confirm the deadline with the National Registry.

Sources: Retesting Policy 62.10, v4 (March 31, 2026); Handbook, Retesting and Examination Review. Course eligibility: official certification process. Full details: NREMT exam retake policy and NREMT exam results.

Quick answers

Can I take the Paramedic exam online? No. The Paramedic exam is given at Pearson test centers. (Handbook)

How many questions do I need to get right? There's no fixed number or percentage. The adaptive test compares your ability to the passing standard.

Will they test my local protocol's drug doses? The National Registry builds its exams from national sources: the National EMS Scope of Practice Model, the National EMS Education Standards and its practice analysis. Study national guidelines and your textbook rather than one agency's protocol. (NREMT Examination Content; Examination Overview, Examination Content)

Does the National Registry recommend a prep course or book? No. Its handbook says it doesn't recommend any particular preparation materials. It suggests your textbook and course materials, the current AHA guidelines, the National EMS Education Standards and its sample items. (Handbook, Preparation)

How long does my certification last? That depends on when you finish the national certification process:

• January 1 to June 30: your first expiration is March 31 two years later.
• July 1 to December 31: your first expiration is March 31 three years later.

After that, you recertify. See NREMT recertification. (Paramedic pathway)

Sources

• NREMT Paramedic Examination Specifications (exam administered from July 1, 2024)
• NREMT Paramedic Candidate Handbook, Part 4: About the Examination
• NREMT Paramedic Candidate Handbook: Overview
• NREMT Paramedic Full Education Program Pathway
• NREMT Examination Content
• NREMT AEMT and Paramedic Certification Examinations (sample items)
• NREMT Clinical Judgment Domain Sample Packet
• NREMT: How the 2025 AHA Guidelines Impact National Registry Certification Examinations (Oct. 27, 2025)
• NREMT Examination Retesting Policy 62.10, v4
• NREMT Accommodations Policy 62.02
• NREMT Accommodations Checklist (January 2026)
• NREMT Paramedic Certification Process
• NREMT Examinations Structure
• NREMT Certification Examinations Overview
• NREMT Examination Administration Policies, Examination Review Process
• NASEMSO National Model EMS Clinical Guidelines, v3.0 (March 2022)
• AHA 2025 Guidelines: Adult BLS, Pediatric BLS, Adult ALS, Special Circumstances, Executive Summary
• 2023 ACC/AHA/ACCP/HRS Atrial Fibrillation Guideline, §10.6
• Tadalafil prescribing information, §§5.1 and 7.1 (revised March 2026)
• CDC: High Blood Pressure During Pregnancy (Dec. 13, 2024)

By the Castleport Test Prep Editorial Team.

Last verified: October 20, 2026. We checked the exam format, fees, domains, policies and the 2025 AHA transition notice against the National Registry sources above. We checked each practice item's teaching point against the cited guideline sections. Source checking is not professional clinical review. The study plan is our editorial recommendation, and the practice set doesn't predict an exam result.

Castleport Test Prep is an independent exam prep publisher. We are not affiliated with, endorsed by or approved by the National Registry of Emergency Medical Technicians. Exam and credential names are used to identify their subjects, and trademarks belong to their respective owners. The practice questions are original and unofficial. Clinical content is for exam study and does not replace your medical director's protocols.