Certified Flight Registered Nurse (CFRN) — Questions and Answers

Question 1: When calculating mean arterial pressure (MAP), which formula is correct?

MAP = (SBP + DBP) ÷ 2
MAP = SBP - DBP × 2
MAP = SBP × 0.6 + DBP
MAP = DBP + 1/3(SBP - DBP) (Correct answer)

Correct answer: MAP = DBP + 1/3(SBP - DBP)

MAP = DBP + 1/3(pulse pressure) = DBP + 1/3(SBP - DBP), reflecting that diastole occupies approximately two-thirds of the cardiac cycle.

Question 2: After a car accident, a 50-year-old guy with chest trouble is being transported by the flying crew. On the right side of the midlung field, an air space consolidation may be seen on a chest radiograph. This discovery suggests that

Hemothorax
Pulmonary contusion (Correct answer)
Cardiac tamponade
Pneumothorax

Correct answer: Pulmonary contusion

The chest radiograph revealing airspace consolidation in the midlung field on the right side in a 50-year-old man with chest pain following a motor vehicle collision is indicative of a pulmonary contusion.

Question 3: A 6-week-old infant presents with bilious vomiting and abdominal distension. Which diagnosis should the flight nurse prioritize as most life-threatening?

Intussusception
Pyloric stenosis
Hirschsprung disease
Midgut volvulus (Correct answer)

Correct answer: Midgut volvulus

Midgut volvulus causes rapid intestinal ischemia and can be fatal within hours if untreated, making it the most immediately life-threatening cause of bilious vomiting in an infant.

Question 4: Which hemodynamic profile is expected in distributive (septic) shock?

High CO, high SVR, high PCWP
High CO, low SVR, normal or low PCWP (Correct answer)
Low CO, low SVR, low PCWP
Low CO, high SVR, high PCWP

Correct answer: High CO, low SVR, normal or low PCWP

Septic/distributive shock causes massive vasodilation (low SVR) and a hyperdynamic state (high CO) due to inflammatory mediators overriding normal vascular tone.

Question 5: When assessing spinal cord injury level, a patient has intact biceps (C5), absent wrist extensors, and no hand function. At what level is the neurological injury?

T1
C7
C6 (Correct answer)
C5

Correct answer: C6

Wrist extensors are innervated by C6; their absence with intact C5 function localizes the injury to C6 as the most caudal intact motor level.

Question 6: When performing a needle decompression for tension pneumothorax in an obese patient, which landmark and technique is MOST appropriate?

4th–5th intercostal space, anterior axillary line, 14-gauge angiocath using the superior rib border (Correct answer)
2nd intercostal space, midclavicular line, 14-gauge angiocath
3rd intercostal space, midaxillary line, 16-gauge angiocath
2nd intercostal space, midclavicular line, 10-gauge angiocath at least 8 cm long

Correct answer: 4th–5th intercostal space, anterior axillary line, 14-gauge angiocath using the superior rib border

In obese patients, the 4th–5th ICS anterior axillary line has less chest wall thickness and improves first-attempt success for needle decompression.

Question 7: During a critical care transport, a patient's EtCO2 suddenly drops from 38 to 10 mmHg while SPO2 remains unchanged at 99%. What is the MOST likely explanation?

Circuit disconnect or esophageal detector failure (Correct answer)
Pulmonary embolism causing increased dead space
Inadvertent esophageal intubation during transport
Right mainstem intubation from tube migration

Correct answer: Circuit disconnect or esophageal detector failure

An abrupt EtCO2 drop to near-zero with maintained SpO2 most likely indicates a ventilator circuit disconnect rather than esophageal intubation.

Question 8: During a scene flight, the pilot announces an emergency landing is required. The flight nurse should:

Continue patient care procedures uninterrupted
Administer sedation to prevent patient injury on landing
Immediately brace, secure equipment, and prepare for impact (Correct answer)
Radio dispatch for a new aircraft to meet them

Correct answer: Immediately brace, secure equipment, and prepare for impact

On emergency landing notification, all crew must immediately brace, secure unsecured equipment, and prepare for impact per emergency protocols — patient care is secondary to survival.

Question 9: A flight nurse is transporting a 2-day-old neonate who becomes jittery and lethargic. A point-of-care blood glucose is 28 mg/dL (1.6 mmol/L). What is the most appropriate immediate intervention?

Provide a 5 mL/kg bolus of formula via orogastric tube.
Administer glucagon 1 mg intramuscularly.
Administer an intravenous bolus of 2 mL/kg of D10W. (Correct answer)
Administer an intravenous bolus of 2 mL/kg of D25W.

Correct answer: Administer an intravenous bolus of 2 mL/kg of D10W.

Symptomatic hypoglycemia in a neonate is a medical emergency requiring immediate correction with intravenous dextrose. The appropriate concentration for a neonate is D10W to avoid the hyperosmolarity and potential for venous damage associated with higher concentrations like D25W or D50W. The standard bolus dose is 2 mL/kg of D10W. While feeding is important, it is not rapid enough for a symptomatic infant. Glucagon is a second-line option if IV access cannot be obtained.

Question 10: Battle's sign, a clinical indicator of basilar skull fracture, refers to ecchymosis over which anatomical area?

The temporal fossa
Periorbital region (raccoon eyes)
Mastoid process posterior to the ear (Correct answer)
The bridge of the nose

Correct answer: Mastoid process posterior to the ear

Battle's sign is ecchymosis over the mastoid process, resulting from blood tracking along the skull base fracture, typically appearing 12-24 hours post-injury.

Question 11: A CFRN is caring for a patient with an IABP (intra-aortic balloon pump) during transport. The balloon should inflate and deflate in relation to the cardiac cycle in which way?

Inflate during diastole, deflate just before systole (Correct answer)
Inflate during systole, deflate during diastole
Inflate during diastole, deflate during mid-systole
Inflate continuously at a fixed rate

Correct answer: Inflate during diastole, deflate just before systole

The IABP inflates during diastole to augment coronary perfusion and deflates just before systole to reduce afterload.

Question 12: A flight patient with severe TBI has a GCS of 6 and a BP of 90/60 mmHg. What is the primary hemodynamic goal during transport?

Maintain SBP ≥ 90 mmHg to prevent secondary brain injury (Correct answer)
Prioritize MAP > 110 mmHg at all times
Target SBP 70-80 mmHg to reduce cerebral edema
Allow permissive hypotension to limit hemorrhage

Correct answer: Maintain SBP ≥ 90 mmHg to prevent secondary brain injury

Hypotension (SBP < 90 mmHg) in TBI significantly worsens outcomes by reducing cerebral perfusion pressure and causing secondary brain injury.

Question 13: In rotor-wing aircraft operations, 'wire strike' refers to collision with power lines. Which approach phase carries the highest wire strike risk?

High-altitude cruise at 1,500 feet AGL
Low-level approach to an unprepared landing zone at night or in low visibility (Correct answer)
Vertical ascent from a hospital helipad
En route flight at 500 feet AGL in clear daytime conditions

Correct answer: Low-level approach to an unprepared landing zone at night or in low visibility

Low-level approaches to unprepared LZs at night or in low visibility dramatically increase wire strike risk because lines are nearly impossible to see.

Question 14: A patient at 20 weeks gestation requires intubation during air transport. Compared to a non-pregnant patient, rapid sequence intubation in pregnancy requires consideration of:

Higher succinylcholine dose due to increased plasma volume
Avoidance of cricoid pressure to prevent airway trauma
Faster oxygen desaturation and increased aspiration risk (Correct answer)
Decreased aspiration risk due to lower gastric volumes

Correct answer: Faster oxygen desaturation and increased aspiration risk

Pregnancy decreases FRC and increases oxygen consumption, causing rapid desaturation; delayed gastric emptying and increased gastric acid raise aspiration risk during intubation.

Question 15: A patient's end-tidal CO2 (ETCO2) drops suddenly to near zero after intubation. What is the most likely cause?

Kinked ETT
Esophageal intubation (Correct answer)
Mucus plug
Right mainstem intubation

Correct answer: Esophageal intubation

A sudden drop of ETCO2 to near zero after intubation is the hallmark of esophageal intubation, as the esophagus does not produce CO2 in exhaled gas.

Question 16: A flight nurse is managing a 58-year-old male patient intubated for respiratory failure. Suddenly, the ventilator's high-pressure alarm sounds, and the patient's oxygen saturation begins to drop. Using the DOPE mnemonic, which of the following potential causes corresponds to 'O'?

Mucus plug obstructing the endotracheal tube (Correct answer)
Endotracheal tube displaced into the esophagus
Ventilator circuit disconnection
Tension pneumothorax

Correct answer: Mucus plug obstructing the endotracheal tube

The DOPE mnemonic is a tool for troubleshooting acute desaturation in an intubated patient. It stands for Displacement, Obstruction, Pneumothorax, and Equipment failure. The 'O' specifically refers to Obstruction, which can be caused by factors like a mucus plug, kinking of the tube, or the patient biting the tube. [16, 20]

Question 17: The flight nurse calculates oxygen cylinder duration using the formula: Duration = (Cylinder pressure × Cylinder factor) / Flow rate. For a D cylinder (factor 0.16) at 1,800 psi with a flow rate of 4 L/min, the duration is:

72 minutes (Correct answer)
120 minutes
30 minutes
45 minutes

Correct answer: 72 minutes

Duration = (1,800 × 0.16) / 4 = 288 / 4 = 72 minutes; always plan for at least 30 minutes extra beyond transport time.

Question 18: Which finding during waveform capnography indicates esophageal intubation?

Gradually rising ETCO2 over 5 breaths
Shark fin waveform pattern
Absence of CO2 waveform after intubation (Correct answer)
Continuous plateau waveform at 35-45 mmHg

Correct answer: Absence of CO2 waveform after intubation

Absence of a CO2 waveform after intubation is the most reliable indicator of esophageal placement, as the esophagus does not produce CO2.

Question 19: A patient at 34 weeks is receiving magnesium sulfate for seizure prophylaxis. The flight nurse notes absent deep tendon reflexes and a respiratory rate of 10/min. The CORRECT immediate action is:

Stop magnesium and administer calcium gluconate IV (Correct answer)
Reduce the magnesium infusion rate by half
Increase supplemental oxygen and continue monitoring
Administer naloxone to reverse respiratory depression

Correct answer: Stop magnesium and administer calcium gluconate IV

Absent DTRs with respiratory depression indicates magnesium toxicity; the antidote is calcium gluconate 1 gram IV given slowly to reverse neuromuscular blockade.

Question 20: A flight nurse suspects tension pneumothorax in an intubated patient. What is the immediate intervention?

Increase PEEP to re-expand the lung
Needle decompression at the second intercostal space, midclavicular line (Correct answer)
Reposition the ETT
Chest X-ray confirmation before treatment

Correct answer: Needle decompression at the second intercostal space, midclavicular line

Tension pneumothorax is a clinical diagnosis requiring immediate needle decompression without waiting for imaging due to rapidly fatal hemodynamic collapse.

Question 21: A flight nurse is assessing a patient with a suspected tension pneumothorax. Which finding is MOST specific for this diagnosis in the flight environment?

Tracheal deviation away from the affected side
Absent breath sounds on the affected side with hypotension and JVD (Correct answer)
SpO2 of 88% on 15 L/min non-rebreather mask
Respiratory rate of 30 breaths per minute

Correct answer: Absent breath sounds on the affected side with hypotension and JVD

The triad of absent breath sounds, hypotension, and JVD strongly indicates tension pneumothorax requiring immediate needle decompression.

Question 22: According to Dalton's Law, if the total atmospheric pressure at sea level is 760 mmHg and oxygen comprises 21% of air, what is the partial pressure of oxygen (PaO2) at sea level?

159.6 mmHg (Correct answer)
21 mmHg
713 mmHg
100 mmHg

Correct answer: 159.6 mmHg

Dalton's Law states that the partial pressure of a gas equals its fractional concentration multiplied by total pressure (0.21 × 760 = 159.6 mmHg).

Question 23: A flight patient is receiving a vasopressor infusion via IV pump. What altitude-related equipment concern applies?

Pump alarms may be inaudible due to rotor noise
Electronic IV pumps are inaccurate above 10,000 feet MSL
Vasopressors crystallize at low cabin temperatures
Air entrained in tubing from altitude change can cause air embolism (Correct answer)

Correct answer: Air entrained in tubing from altitude change can cause air embolism

As altitude increases, any air in IV lines can expand and be introduced into the patient; priming lines thoroughly and monitoring for air bubbles is essential during ascent.

Question 24: A patient with a C5 spinal cord injury is being transported on a backboard. What pressure injury concern requires immediate attention?

Occiput and sacrum are highest-risk bony prominences requiring padding (Correct answer)
Skin breakdown only occurs after 6+ hours on a hard surface
Pressure injuries are not a concern during short transport windows
The thoracic spine is the highest-risk area for pressure necrosis

Correct answer: Occiput and sacrum are highest-risk bony prominences requiring padding

SCI patients have impaired sensation and vasomotor control, dramatically accelerating pressure injury formation; pad all bony prominences, especially occiput, sacrum, and heels, even during brief transports.

Question 25: A patient was stung by multiple Africanized honeybees and is now showing signs of anaphylaxis. After administering epinephrine, which additional medication is most critical in flight?

Magnesium sulfate
IV corticosteroids and IV antihistamines (Correct answer)
Oral diphenhydramine only
Calcium gluconate

Correct answer: IV corticosteroids and IV antihistamines

IV corticosteroids and antihistamines are used after epinephrine to prevent biphasic anaphylaxis and reduce ongoing inflammatory response.

Question 26: A CFRN is preparing to intubate an obese patient. What positioning modification is most beneficial for preoxygenation and intubation success?

Prone position with towel under chest
Flat supine position with head ring
Reverse Trendelenburg or ramped position with ear-to-sternal notch alignment (Correct answer)
Left lateral decubitus position

Correct answer: Reverse Trendelenburg or ramped position with ear-to-sternal notch alignment

The ramped position (ear-to-sternal notch alignment) improves glottic view, increases FRC, and offsets the weight of abdominal contents from the diaphragm in obese patients.

Question 27: At altitude, nitrogen-filled ETT cuffs may over-inflate due to gas expansion. What is the preferred filling agent during flight?

Nitrogen
Normal saline or sterile water (Correct answer)
Carbon dioxide
Room air

Correct answer: Normal saline or sterile water

Normal saline or sterile water is preferred to fill ETT cuffs during flight because liquids are incompressible and do not expand with altitude changes.

Question 28: The flight team is preparing to land at an unsecured scene of a motor vehicle accident at night. Which of the following communications from the ground crew would be most critical for the CFRN to confirm with the pilot prior to final approach?

The estimated time of arrival of the ground ambulance.
The number of patients and their general condition.
The presence of any overhead wires or obstructions near the landing zone. (Correct answer)
The name and certification level of the ground provider in charge.

Correct answer: The presence of any overhead wires or obstructions near the landing zone.

While all information is useful, confirming the absence of hazards in the landing zone (LZ) is the most critical safety priority. Overhead wires, poles, trees, and uneven terrain pose a significant and immediate threat to the aircraft and crew, especially during a night landing. The pilot must be aware of all potential obstructions to land safely.

Question 29: A 45-year-old male involved in a blast injury from an improvised explosive device presents with tympanic membrane rupture, respiratory distress with hemoptysis, and abdominal pain. These findings are consistent with which phase of blast injury?

Primary blast injury from overpressure wave damage to air-filled structures (Correct answer)
Tertiary blast injury from patient displacement
Secondary blast injury from fragmentation projectiles
Quaternary blast injury from structural collapse

Correct answer: Primary blast injury from overpressure wave damage to air-filled structures

Primary blast injury is caused by the overpressure wave directly affecting air-filled organs such as the tympanic membranes, lungs (blast lung), and gastrointestinal tract.

Question 30: A CFRN is transporting a head-injured patient requiring neuroprotective ventilation. What ETCO2 target is most appropriate?

45-50 mmHg
35-40 mmHg (Correct answer)
25-30 mmHg
50-55 mmHg

Correct answer: 35-40 mmHg

Normocapnia (ETCO2 35-40 mmHg) is the target for neuroprotective ventilation; hypocapnia causes cerebral vasoconstriction and worsens ischemia.

Certified Flight Registered Nurse (CFRN)

The CFRN certification, administered by BCEN, validates advanced nursing competency for registered nurses who provide patient care in air medical transport environments, covering flight physiology, trauma, medical emergencies, resuscitation principles, and special populations.

Questions

35 min

Time Limit

72%

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