CEN Certified Emergency Nurse Exam — Questions and Answers

Question 1: Which medication is first-line for treatment of an acute hypertensive encephalopathy with a BP of 240/140 mmHg?

Oral nifedipine
Sublingual nitroglycerin
IV labetalol or nicardipine with goal of 20–25% MAP reduction in 1 hour (Correct answer)
Furosemide 80 mg IV push

Correct answer: IV labetalol or nicardipine with goal of 20–25% MAP reduction in 1 hour

Hypertensive encephalopathy requires controlled BP reduction of 20–25% in the first hour using IV agents like labetalol or nicardipine to prevent cerebral hypoperfusion.

Question 2: A patient is ordered IV potassium chloride 40 mEq to be given peripherally. What is the maximum infusion rate for peripheral IV potassium administration?

5 mEq/hr
10 mEq/hr (Correct answer)
20 mEq/hr
40 mEq/hr

Correct answer: 10 mEq/hr

Peripheral potassium infusion should not exceed 10 mEq/hr to prevent phlebitis, pain, and cardiac dysrhythmias.

Question 3: What is the antidote for magnesium sulfate toxicity causing respiratory depression in a preeclamptic patient?

Calcium gluconate 1 g IV (Correct answer)
Furosemide 40 mg IV
Naloxone 0.4 mg IV
Protamine sulfate IV

Correct answer: Calcium gluconate 1 g IV

Calcium gluconate 1 g IV (10 mL of 10% solution) directly antagonizes the neuromuscular effects of magnesium and is the antidote for respiratory depression.

Question 4: A patient is in pulseless ventricular tachycardia. After the second defibrillation attempt, which medication should be given?

Amiodarone 300 mg IV push (Correct answer)
Adenosine 6 mg IV
Lidocaine 1.5 mg/kg
Magnesium sulfate 2g IV

Correct answer: Amiodarone 300 mg IV push

Per ACLS protocol, amiodarone 300 mg IV push is the preferred antiarrhythmic after the second shock in pulseless VT/VF.

Question 5: A woman at 38 weeks presents in active labor and the fetal head is delivered but shoulders cannot be delivered. The obstetrician calls for help. What maneuver is performed first?

McRoberts maneuver with suprapubic pressure (Correct answer)
Zavanelli maneuver
Fundal pressure
Immediate cesarean section

Correct answer: McRoberts maneuver with suprapubic pressure

McRoberts maneuver (hyperflexion of the maternal thighs onto the abdomen) combined with suprapubic pressure is the first-line intervention for shoulder dystocia.

Question 6: A woman delivers a baby and 20 minutes later has heavy vaginal bleeding (estimated 600 mL). The uterus is boggy on palpation. What is the first intervention?

Insert intrauterine balloon tamponade
Immediate surgical intervention
IV fluid resuscitation with 2L normal saline
Administer 10 units oxytocin IM and perform uterine massage (Correct answer)

Correct answer: Administer 10 units oxytocin IM and perform uterine massage

Uterine atony is the most common cause of postpartum hemorrhage and is initially treated with uterine massage and uterotonic medications (oxytocin).

Question 7: Which of the following is a contraindication to administering IV tPA for acute ischemic stroke?

Blood pressure 175/95 mmHg after treatment
Blood glucose of 110 mg/dL
Recent ischemic stroke within the last 3 months (Correct answer)
Age over 80 years

Correct answer: Recent ischemic stroke within the last 3 months

A prior ischemic stroke within 3 months is an absolute contraindication to IV tPA due to significantly increased risk of hemorrhagic transformation.

Question 8: A patient with COPD and a history of CO2 retention presents in respiratory distress. Which oxygen delivery target is most appropriate?

Immediate intubation without supplemental oxygen
SpO2 98–100% via non-rebreather mask
SpO2 95% via simple face mask
SpO2 88–92% via controlled oxygen delivery (Correct answer)

Correct answer: SpO2 88–92% via controlled oxygen delivery

COPD patients with chronic hypercapnia can lose their hypoxic drive to breathe; targeting SpO2 88–92% prevents both hypoxia and CO2 retention.

Question 9: A patient with epiglottitis is in the ER. She is drooling, sitting upright, and has inspiratory stridor. What is the most important initial action?

Perform lateral neck X-ray immediately
Administer racemic epinephrine via nebulizer
Attempt immediate oral intubation in the ER
Keep the patient calm and upright; prepare for definitive airway in the OR (Correct answer)

Correct answer: Keep the patient calm and upright; prepare for definitive airway in the OR

Epiglottitis can cause complete airway obstruction if agitated; keeping the patient calm and moving to the OR for controlled intubation or tracheotomy is the safest approach.

Question 10: A patient presents with sudden-onset dyspnea and unilateral leg swelling. Wells score is 6. What is the next step?

D-dimer level
Lower extremity Doppler ultrasound
CT pulmonary angiography (Correct answer)
V/Q scan

Correct answer: CT pulmonary angiography

A Wells score ≥5 indicates high probability of PE; guidelines recommend proceeding directly to CTPA rather than D-dimer, which has limited value in high-probability cases.

Question 11: The American Heart Association's ACLS guidelines state that applying cricoid pressure when intubating should:

Is no longer recommended. (Correct answer)
Should only be done on children.
None of the above.
Should be done in all cases.

Correct answer: Is no longer recommended.

Cricoid pressure is no longer advised in accordance with the most recent AHA recommendations because it may hinder or delay the insertion of an advanced airway.

Question 12: A patient with preeclampsia at 34 weeks is being treated with IV magnesium sulfate. The nurse notes absent deep tendon reflexes and a respiratory rate of 10. Which action is immediately required?

Administer calcium gluconate IV and stop magnesium (Correct answer)
Administer labetalol IV
Increase the magnesium infusion rate
Intubate the patient emergently

Correct answer: Administer calcium gluconate IV and stop magnesium

Absent DTRs and respiratory depression are signs of magnesium toxicity; calcium gluconate is the antidote and the infusion must be stopped immediately.

Question 13: Confirmation of endotracheal tube placement should be verified by which MOST reliable method?

Chest X-ray only
Chest rise observation
Auscultation of bilateral breath sounds
Continuous waveform capnography (Correct answer)

Correct answer: Continuous waveform capnography

Continuous waveform capnography (ETCO2) is the most reliable method to confirm and continuously monitor ETT placement in the trachea.

Question 14: A patient with sickle cell disease presents with fever of 38.9°C, chest pain, and a new pulmonary infiltrate on CXR. This presentation is most consistent with:

Pulmonary embolism
Spontaneous pneumothorax
Acute chest syndrome (Correct answer)
Vaso-occlusive crisis

Correct answer: Acute chest syndrome

Acute chest syndrome is defined by a new pulmonary infiltrate with fever, chest pain, or respiratory symptoms in a sickle cell patient.

Question 15: Which scoring system is used prehospital to predict which trauma patients need transfer to a trauma center?

SOFA score
APACHE II
Glasgow Coma Scale alone
Revised Trauma Score (RTS) (Correct answer)

Correct answer: Revised Trauma Score (RTS)

The Revised Trauma Score (RTS) uses GCS, systolic BP, and respiratory rate to predict injury severity and guide trauma center triage decisions.

Question 16: A patient presents with acute right lower quadrant pain, fever of 38.6°C, nausea, and rebound tenderness at McBurney's point. The nurse anticipates which diagnosis?

Inguinal hernia incarceration
Mesenteric lymphadenitis
Acute appendicitis (Correct answer)
Ovarian cyst rupture

Correct answer: Acute appendicitis

Acute appendicitis classically presents with RLQ pain at McBurney's point, fever, nausea, and rebound tenderness due to peritoneal inflammation.

Question 17: A 3-year-old ingests an unknown number of iron tablets. Which finding indicates severe iron toxicity?

Hemodynamic instability and metabolic acidosis (Correct answer)
Vomiting and diarrhea within 30 minutes
Blood glucose of 90 mg/dL
Apparent improvement 6–24 hours after ingestion

Correct answer: Hemodynamic instability and metabolic acidosis

Hemodynamic instability and metabolic acidosis indicate systemic iron toxicity affecting cellular metabolism, representing severe poisoning.

Question 18: A 6-week-old infant presents with projectile, non-bilious vomiting after every feeding and a palpable olive-shaped mass in the epigastrium. This is most consistent with:

Hirschsprung's disease
Intussusception
Pyloric stenosis (Correct answer)
Malrotation with volvulus

Correct answer: Pyloric stenosis

Projectile non-bilious vomiting with an olive-shaped epigastric mass in a 4-8 week old infant is the classic presentation of hypertrophic pyloric stenosis.

Question 19: A patient presents with altered mental status, fever, muscle rigidity, and clonus after starting a new antidepressant. What condition should be suspected?

Serotonin syndrome (Correct answer)
Malignant hyperthermia
Anticholinergic toxicity
Neuroleptic malignant syndrome

Correct answer: Serotonin syndrome

Serotonin syndrome presents with the triad of mental status changes, autonomic instability, and neuromuscular abnormalities (especially clonus) following serotonergic medication use.

Question 20: A patient with suspected hyperkalemia (K+ 7.1 mEq/L) and peaked T waves on ECG is being treated. What is the priority first intervention?

Administer sodium bicarbonate IV
Administer calcium gluconate IV (Correct answer)
Administer IV insulin with dextrose
Prepare the patient for emergent hemodialysis

Correct answer: Administer calcium gluconate IV

Calcium gluconate IV is the immediate priority as it stabilizes cardiac membranes within minutes, protecting against fatal dysrhythmias before potassium-lowering measures take effect.

Question 21: What is the priority assessment in a patient with Guillain-Barré syndrome admitted to the emergency department?

Lumbar puncture results
Nerve conduction studies
Serial pulmonary function testing (NIF and FVC) (Correct answer)
Muscle strength grading

Correct answer: Serial pulmonary function testing (NIF and FVC)

The greatest risk in GBS is respiratory failure from ascending paralysis; serial negative inspiratory force (NIF) and FVC monitoring guides the need for intubation.

Question 22: Damage control surgery (DCS) in trauma is characterized by which primary principle?

Performing definitive repair in the first operation regardless of stability
Controlling hemorrhage and contamination quickly, then closing and resuscitating before definitive repair (Correct answer)
Using only laparoscopic techniques to minimize blood loss
Delaying any surgery until fully resuscitated

Correct answer: Controlling hemorrhage and contamination quickly, then closing and resuscitating before definitive repair

DCS involves a rapid initial surgery to control bleeding and contamination, temporary abdominal closure, ICU resuscitation to correct the lethal triad, and then planned reoperation for definitive repair.

Question 23: A patient presents with bradycardia, miosis, excessive salivation, urination, and muscle fasciculations after working in an agricultural field. Which toxidrome is this?

Sympathomimetic toxidrome
Cholinergic toxidrome (organophosphate poisoning) (Correct answer)
Opioid toxidrome
Anticholinergic toxidrome

Correct answer: Cholinergic toxidrome (organophosphate poisoning)

The SLUDGE mnemonic (Salivation, Lacrimation, Urination, Defecation, GI distress, Emesis) describes cholinergic toxidrome from organophosphate exposure.

Question 24: A 14-month-old presents with a spiral femur fracture and bruising in multiple stages of healing. The history is inconsistent. What must be considered?

Rickets causing fragile bones
Osteogenesis imperfecta only
Accidental toddler fracture
Non-accidental trauma (child abuse) (Correct answer)

Correct answer: Non-accidental trauma (child abuse)

Spiral fractures in non-ambulatory infants, multiple bruises in different stages of healing, and inconsistent history are red flags for non-accidental trauma.

Question 25: Which spinal injury pattern is most commonly associated with a diving accident causing cervical spine injury?

Compression (burst) fracture with spinal cord injury (Correct answer)
Rotational fracture-dislocation
Jefferson fracture of C1 only
Distraction injury

Correct answer: Compression (burst) fracture with spinal cord injury

Axial loading from diving into shallow water typically causes burst fractures of the cervical spine with risk of spinal cord injury.

Question 26: A patient has a zone II penetrating neck injury with active bleeding. Which is the priority intervention?

Immediate surgical exploration
Direct pressure and airway management (Correct answer)
Diagnostic angiography and embolization
CT angiography of the neck

Correct answer: Direct pressure and airway management

For any penetrating neck injury with active hemorrhage, direct pressure to control bleeding combined with airway management is the immediate priority before any imaging or surgical planning.

Question 27: A 3-year-old is brought in after ingesting an unknown substance. The child has pinpoint pupils, bradycardia, excessive secretions, and bronchospasm. Which antidote is most appropriate?

N-acetylcysteine
Atropine (Correct answer)
Flumazenil
Naloxone

Correct answer: Atropine

The SLUDGE/DUMBELS toxidrome indicates organophosphate or cholinergic poisoning, treated with atropine to block muscarinic effects.

Question 28: A patient with a suspected overdose has a QRS duration of 140 ms on ECG, hypotension, and altered mental status. Which drug class is most likely responsible?

Tricyclic antidepressants (Correct answer)
Benzodiazepines
Opioids
Selective serotonin reuptake inhibitors

Correct answer: Tricyclic antidepressants

Tricyclic antidepressants cause sodium channel blockade, widening the QRS complex and producing the classic toxidrome of hypotension, dysrhythmia, and CNS depression.

Question 29: A patient arrives after a motor vehicle accident. He is hypotensive with a distended abdomen and a seatbelt sign. What is the most appropriate rapid assessment?

Diagnostic peritoneal lavage (DPL)
CT abdomen/pelvis with contrast
Plain abdominal X-ray
Focused Assessment with Sonography for Trauma (FAST) (Correct answer)

Correct answer: Focused Assessment with Sonography for Trauma (FAST)

FAST exam rapidly detects free intra-abdominal fluid (blood) at the bedside and can immediately guide surgical decision-making in a hemodynamically unstable patient.

Question 30: A patient is brought in seizing continuously for 10 minutes. Lorazepam has been given twice without effect. What is the next drug to administer?

Levetiracetam or fosphenytoin IV (Correct answer)
Midazolam 10 mg IM
Propofol infusion
Phenobarbital 20 mg/kg IV

Correct answer: Levetiracetam or fosphenytoin IV

For benzodiazepine-refractory status epilepticus, second-line agents include fosphenytoin, valproate, or levetiracetam IV per current guidelines.

Question 31: When should cardiopulmonary resuscitation in a pregnant patient include lateral uterine displacement?

Not indicated during CPR
After 20 weeks gestation or when the uterus is palpable at the umbilicus (Correct answer)
Only during the third trimester
Only after 30 weeks gestation

Correct answer: After 20 weeks gestation or when the uterus is palpable at the umbilicus

After 20 weeks gestation, the gravid uterus can compress the aorta and inferior vena cava; manual left lateral uterine displacement during CPR improves venous return.

Question 32: A patient with suspected C5 spinal cord injury is hypotensive with bradycardia and warm, flushed skin. This hemodynamic picture is most consistent with:

Neurogenic shock (Correct answer)
Obstructive shock
Hypovolemic shock
Septic shock

Correct answer: Neurogenic shock

Loss of sympathetic tone in neurogenic shock causes vasodilation (warm skin) and bradycardia, distinguishing it from other shock types.

Question 33: The Glasgow Coma Scale (GCS) assesses which three components?

Eye opening, verbal response, motor response (Correct answer)
Pupil reactivity, verbal response, motor response
Respiratory effort, eye opening, motor response
Eye opening, pupil reactivity, verbal response

Correct answer: Eye opening, verbal response, motor response

The GCS evaluates eye opening (1–4), verbal response (1–5), and motor response (1–6) for a maximum score of 15 and minimum of 3.

Question 34: Which ventilator strategy is recommended to reduce lung injury in ARDS patients?

Tidal volume of 10–12 mL/kg ideal body weight
Tidal volume of 6 mL/kg ideal body weight with permissive hypercapnia (Correct answer)
High PEEP with tidal volume 8 mL/kg
Low PEEP to minimize barotrauma

Correct answer: Tidal volume of 6 mL/kg ideal body weight with permissive hypercapnia

Lung-protective ventilation in ARDS uses low tidal volumes of 6 mL/kg IBW to reduce volutrauma, allowing permissive hypercapnia as tolerated.

Question 35: When pain is palpated in the left bottom quadrant of a client with probable appendicitis, it is felt in the right lower quadrant. What does this diagnostic procedure go by?

Rovsing’s sign (Correct answer)
psoas sign
Kernig’s sign
Brudzinski’s sign

Correct answer: Rovsing’s sign

The Rovsing's sign, a physical exam indicator of appendicitis, is pain in the RLQ with palpation in the LLQ. The Psoas sign, which is evaluated by flexing the right hip, is another symptom of potential appendicitis. If this happens, appendicitis can be suspected. Meningitis can be detected by Kernig's and Brudzinski's symptoms.

Question 36: A 17-year-old male presents with sudden onset severe scrotal pain without trauma, nausea, and vomiting. The affected testicle is high-riding with a horizontal lie. The nurse's priority action is:

Administer IV antibiotics and arrange urology follow-up
Prepare the patient for emergent surgical consultation (Correct answer)
Obtain urine culture and start oral antibiotics
Apply ice and administer analgesics

Correct answer: Prepare the patient for emergent surgical consultation

Testicular torsion is a surgical emergency requiring manual detorsion or operative intervention within 4-6 hours to preserve testicular viability.

Question 37: A patient with multiple rib fractures (ribs 4–8) on the right side splints their breathing and has SpO2 of 91%. What is the most effective initial pain management strategy to restore ventilation?

Oral oxycodone every 4 hours
Fentanyl patch application
Thoracic epidural or regional nerve block (Correct answer)
IV morphine titrated to effect

Correct answer: Thoracic epidural or regional nerve block

Thoracic epidural or intercostal nerve blocks provide superior pain control for rib fractures, allowing deep breathing and preventing atelectasis.

Question 38: Which vasopressor is recommended as a first-line agent for septic shock when fluid resuscitation is inadequate?

Epinephrine
Dopamine
Norepinephrine (Correct answer)
Phenylephrine

Correct answer: Norepinephrine

Norepinephrine is the first-line vasopressor for septic shock per Surviving Sepsis Campaign guidelines due to its potent alpha-adrenergic effects and favorable safety profile.

Question 39: A patient has a suspected tension pneumothorax in the field. What is the prehospital treatment?

Apply a flutter valve occlusive dressing
Wait for chest X-ray before treatment
Needle thoracostomy at the 2nd intercostal space, midclavicular line (Correct answer)
Immediate chest tube placement

Correct answer: Needle thoracostomy at the 2nd intercostal space, midclavicular line

Prehospital needle thoracostomy (14–16g needle at 2nd ICS, MCL) is the emergency intervention for suspected tension pneumothorax to relieve pressure.

Question 40: A patient with a blunt abdominal trauma has a positive FAST exam showing free fluid in Morrison's pouch. The patient is hemodynamically unstable. What is the priority intervention?

Repeat FAST exam in 30 minutes
CT scan of the abdomen for definitive injury identification
Diagnostic peritoneal lavage
Emergent surgical exploration (trauma laparotomy) (Correct answer)

Correct answer: Emergent surgical exploration (trauma laparotomy)

A positive FAST with hemodynamic instability indicates significant intraperitoneal hemorrhage requiring emergent operative intervention.

Question 41: A 28-year-old female presents with right lower quadrant pain, vaginal spotting, and a positive pregnancy test. Her BP is 80/50 and HR is 128. What is the priority intervention?

Administer methotrexate immediately
Establish large-bore IV access and prepare for emergency surgery (Correct answer)
Obtain a pelvic ultrasound before any treatment
Perform a pelvic exam and discharge with OB follow-up

Correct answer: Establish large-bore IV access and prepare for emergency surgery

This presentation is consistent with a ruptured ectopic pregnancy causing hemorrhagic shock; immediate IV access, fluid resuscitation, and surgical preparation are priorities.

Question 42: A patient sustains an impalement injury to the right chest with the object still in place. What is the correct field management of the impaled object?

Cut the object to a manageable length and stabilize
Remove the object carefully and apply pressure
Remove the object only if it is obstructing the airway
Stabilize the object in place and do not remove it (Correct answer)

Correct answer: Stabilize the object in place and do not remove it

Impaled objects should never be removed in the field as they may be tamponading hemorrhage; stabilize and transport for OR removal.

Question 43: A child presents with inspiratory stridor, a barking cough, and low-grade fever. What is the priority intervention?

Administer nebulized racemic epinephrine immediately
Administer dexamethasone and allow the child to remain with caregiver (Correct answer)
Perform nasopharyngeal suctioning
Place the child supine for airway assessment

Correct answer: Administer dexamethasone and allow the child to remain with caregiver

Croup is managed with corticosteroids (dexamethasone) and keeping the child calm; separating the child from the caregiver increases agitation and worsens stridor.

Question 44: Which assessment finding indicates a class III hemorrhagic shock (estimated blood loss 1500–2000 mL)?

Heart rate 120–140, decreased BP, confused, decreased urine output (Correct answer)
Heart rate >140, no palpable BP, unconscious
Heart rate <100, BP normal, slightly anxious
Heart rate 100–120, decreased pulse pressure, mildly anxious

Correct answer: Heart rate 120–140, decreased BP, confused, decreased urine output

Class III shock presents with HR 120–140, decreased BP, confusion, and urine output <5–15 mL/hr from significant volume loss.

Question 45: A 9-month-old presents with sudden onset of colicky abdominal pain, drawing up the legs, and currant-jelly stools. Which diagnosis should be suspected?

Hirschsprung disease
Intussusception (Correct answer)
Pyloric stenosis
Necrotizing enterocolitis

Correct answer: Intussusception

Intussusception classically presents in infants 6–36 months with episodic colicky pain, drawing up of the legs, and currant-jelly stools.

Question 46: A patient develops profuse watery diarrhea, abdominal cramping, and low-grade fever 10 days after completing a course of clindamycin. Which pathogen is most likely responsible?

Campylobacter jejuni
Salmonella typhi
Escherichia coli O157:H7
Clostridioides difficile (Correct answer)

Correct answer: Clostridioides difficile

C. difficile infection classically follows antibiotic use, which disrupts normal intestinal flora and allows C. difficile to proliferate and produce cytotoxins causing colitis.

Question 47: A patient in hemorrhagic shock receives a 1:1:1 ratio of packed red blood cells, fresh frozen plasma, and platelets. What does this ratio represent?

Prevention of transfusion-related lung injury
Treatment for dilutional anemia only
Damage control resuscitation to prevent trauma-induced coagulopathy (Correct answer)
Standard maintenance fluid replacement

Correct answer: Damage control resuscitation to prevent trauma-induced coagulopathy

1:1:1 (PRBCs:FFP:platelets) is the damage control resuscitation strategy to replace all coagulation factors and prevent lethal trauma triad.

Question 48: Which assessment is CONTRAINDICATED in a patient with suspected placenta previa?

Abdominal ultrasound
IV access and blood type/crossmatch
External fetal monitoring
Digital cervical examination (Correct answer)

Correct answer: Digital cervical examination

Digital cervical examination is absolutely contraindicated in placenta previa as it can disrupt the placenta, causing life-threatening hemorrhage.

Question 49: What is the drug of choice to prevent and treat seizures in eclampsia?

Lorazepam 2 mg IV
Magnesium sulfate 4–6 g loading dose IV (Correct answer)
Phenytoin 20 mg/kg IV
Diazepam 10 mg IV

Correct answer: Magnesium sulfate 4–6 g loading dose IV

Magnesium sulfate is the drug of choice for eclampsia prophylaxis and treatment, given as a 4–6 g IV loading dose over 20–30 minutes followed by a maintenance infusion.

Question 50: Which ABG result is most consistent with acute respiratory acidosis?

pH 7.52, PaCO2 28, HCO3 22
pH 7.38, PaCO2 40, HCO3 24
pH 7.28, PaCO2 58, HCO3 24 (Correct answer)
pH 7.30, PaCO2 35, HCO3 16

Correct answer: pH 7.28, PaCO2 58, HCO3 24

A low pH with an elevated PaCO2 and normal bicarbonate (no metabolic compensation yet) indicates acute respiratory acidosis.

Question 51: A 4-month-old presents with poor feeding, bulging fontanelle, and inconsolable high-pitched crying. Temperature is 38.8°C rectally. What is the most critical concern?

Pyloric stenosis
Febrile seizure
Intussusception
Intracranial hemorrhage or bacterial meningitis (Correct answer)

Correct answer: Intracranial hemorrhage or bacterial meningitis

A bulging fontanelle with fever and high-pitched cry in an infant suggests increased intracranial pressure from bacterial meningitis or hemorrhage.

Question 52: Which assessment finding in a burn patient indicates the need for immediate endotracheal intubation?

Full-thickness burn to the right hand
Burns covering 30% TBSA on the extremities
Singed nasal hairs with hoarse voice and stridor (Correct answer)
Carbon monoxide level of 15%

Correct answer: Singed nasal hairs with hoarse voice and stridor

Singed nasal hairs, hoarseness, and stridor signal impending upper airway obstruction from inhalation injury requiring immediate intubation before edema worsens.

Question 53: A patient with a history of warfarin use presents with a traumatic intracerebral hemorrhage. Which reversal agent is most appropriate?

4-factor prothrombin complex concentrate (PCC) (Correct answer)
Fresh frozen plasma alone
Vitamin K alone
Protamine sulfate

Correct answer: 4-factor prothrombin complex concentrate (PCC)

4-factor PCC provides the fastest and most complete reversal of warfarin anticoagulation in life-threatening hemorrhage compared to FFP or vitamin K alone.

Question 54: What is the appropriate size (French) for a chest tube inserted for a hemothorax?

28–32 Fr or larger tube (Correct answer)
Needle thoracostomy only
20–22 Fr small-bore tube
12–14 Fr pigtail catheter

Correct answer: 28–32 Fr or larger tube

A large-bore chest tube (28–32 Fr or larger) is required for hemothorax to allow adequate drainage of blood and prevent clotting of the tube.

Question 55: A patient presents with painless bright red rectal bleeding noticed only on toilet paper after defecation, without abdominal pain or change in bowel habits. Which condition is most likely?

Internal hemorrhoids (Correct answer)
Anal fissure
Colorectal carcinoma
Diverticulosis

Correct answer: Internal hemorrhoids

Internal hemorrhoids commonly cause painless bright red bleeding on toilet paper because they are above the dentate line, where somatic pain fibers are absent.

Question 56: A 3-year-old with febrile seizure is actively seizing for 8 minutes. What is the first-line treatment?

Rectal acetaminophen only
Phenobarbital 20 mg/kg IV
Lorazepam or diazepam IV/rectal (Correct answer)
Phenytoin 20 mg/kg IV

Correct answer: Lorazepam or diazepam IV/rectal

Benzodiazepines (lorazepam IV or rectal diazepam) are the first-line agents to abort febrile status epilepticus in children.

Question 57: A patient presents with chest pain radiating to the left arm, diaphoresis, and nausea. The 12-lead ECG shows ST elevation in leads II, III, and aVF. Which coronary artery is most likely occluded?

Left main coronary artery
Left circumflex artery
Left anterior descending artery
Right coronary artery (Correct answer)

Correct answer: Right coronary artery

ST elevation in leads II, III, and aVF indicates an inferior STEMI, most commonly caused by right coronary artery occlusion.

Question 58: A patient is intubated and the ventilator alarms for high peak airway pressure. Breath sounds are absent on the left. What is the most likely cause?

Pulmonary edema
Right mainstem intubation (Correct answer)
Mucus plug in the right bronchus
Ventilator malfunction

Correct answer: Right mainstem intubation

Right mainstem intubation is common because the right bronchus is less angled; it causes absent breath sounds on the left and increased peak airway pressures.

Question 59: Cushing's triad, indicating severely elevated ICP, consists of which three findings?

Tachycardia, hypotension, tachypnea
Hypertension, tachycardia, hyperthermia
Bradycardia, hypotension, bradypnea
Bradycardia, hypertension, irregular respirations (Correct answer)

Correct answer: Bradycardia, hypertension, irregular respirations

Cushing's triad is bradycardia, hypertension (widened pulse pressure), and irregular respirations, representing a brainstem response to severely elevated ICP.

Question 60: What is the initial energy setting for defibrillation of ventricular fibrillation using a biphasic defibrillator?

50 J
100 J
200 J (Correct answer)
360 J

Correct answer: 200 J

For biphasic defibrillators, the initial energy for defibrillation of VF is 120–200 J (commonly 200 J), while monophasic uses 360 J.

Question 61: A 6-week-old infant presents with nonbilious projectile vomiting after every feeding. The infant is hungry after vomiting and has an olive-shaped mass palpable in the epigastrium. Which diagnosis is most likely?

GERD
Pyloric stenosis (Correct answer)
Volvulus
Intussusception

Correct answer: Pyloric stenosis

Nonbilious projectile vomiting with a palpable olive-shaped mass in a 4–8 week old infant is classic for hypertrophic pyloric stenosis.

Question 62: A patient presents with muscle weakness, peaked T-waves on ECG, and a serum potassium of 6.8 mEq/L. Which intervention is the FIRST priority to protect the heart?

Administer IV calcium gluconate (Correct answer)
Administer sodium polystyrene sulfonate (Kayexalate)
Initiate hemodialysis
Administer IV regular insulin with dextrose

Correct answer: Administer IV calcium gluconate

Calcium gluconate is given first to stabilize the cardiac membrane and protect against fatal dysrhythmias before potassium-lowering measures.

Question 63: A patient converts from VF to a normal sinus rhythm after resuscitation. Which post-cardiac arrest intervention has the strongest evidence for improving neurological outcomes?

Targeted temperature management (32–36°C) (Correct answer)
High-dose epinephrine infusion
Prophylactic anticonvulsants
Immediate coronary angiography

Correct answer: Targeted temperature management (32–36°C)

Targeted temperature management (TTM) at 32–36°C for 24 hours post-cardiac arrest has strong evidence for improving neurological outcomes in comatose survivors.

Question 64: Which drug and dose is correct for pediatric epinephrine administration during cardiac arrest via IV/IO route?

0.01 mg/kg of 1:10,000 concentration (Correct answer)
0.01 mg/kg of 1:1000 concentration
0.1 mg/kg of 1:1000 concentration
0.1 mg/kg of 1:10,000 concentration

Correct answer: 0.01 mg/kg of 1:10,000 concentration

Pediatric IV/IO epinephrine dose is 0.01 mg/kg of the 1:10,000 (0.1 mg/mL) concentration during cardiac arrest.

Question 65: Which sign is associated with cardiac tamponade in addition to hypotension and muffled heart sounds?

Jugular venous distension (Correct answer)
Tracheal deviation
Kussmaul's sign
Pulsus alternans

Correct answer: Jugular venous distension

Beck's triad for cardiac tamponade includes hypotension, muffled heart sounds, and jugular venous distension (JVD) due to impaired venous return.

Question 66: What is the emergency treatment for ovarian torsion?

Emergent surgical detorsion (Correct answer)
IV antibiotics and observation
Anticoagulation therapy
Hormonal suppression therapy

Correct answer: Emergent surgical detorsion

Ovarian torsion requires emergent surgical detorsion to restore blood flow and preserve ovarian viability; delay leads to ischemia and ovarian loss.

Question 67: A patient is receiving CPR from the team. In response to an electrical shock, the beat will be:

SVT
Asystole
PEA
Ventricular fibrillation (Correct answer)

Correct answer: Ventricular fibrillation

The two rhythms regarded as ""shockable"" cardiac arrest rhythms are ventricular fibrillation and pulseless ventricular tachycardia. As cardiac arrest rhythms, asystole and PEA do not react to electrical shock.

Question 68: Which type of traumatic brain injury is associated with a 'lucid interval' followed by rapid deterioration?

Intracerebral contusion
Subdural hematoma
Epidural hematoma (Correct answer)
Diffuse axonal injury

Correct answer: Epidural hematoma

Epidural hematoma, usually from a torn middle meningeal artery after temporal bone fracture, classically presents with a brief lucid interval followed by rapid neurological deterioration.

Question 69: ALL OF THE FOLLOWING ARE POSSIBLE CAUSES OF CARDIAC ARREST, EXCEPT:

Hypoxia
Tension Pneumothorax
Hypervolemia (Correct answer)
Hypokalemia

Correct answer: Hypervolemia

Correction of these causes can frequently reverse a cardiac arrest. These causes are known as the H's and T's and include hypovolemia (NOT hypervolemia), hypoxia, hydrogen ion excess (acidosis), hypo or hyperkalemia, hypothermia, tension pneumothorax, tamponade, toxins, and thrombosis (pulmonary or coronary).

Question 70: Which medication is the first-line treatment for symptomatic bradycardia with hypotension in a stable patient?

Epinephrine
Atropine (Correct answer)
Dopamine
Amiodarone

Correct answer: Atropine

Atropine 0.5 mg IV is the first-line treatment for symptomatic bradycardia according to ACLS guidelines.

Question 71: A patient presents with ascending muscle weakness that began in the lower extremities one week after a GI illness. Deep tendon reflexes are absent. What is the most likely diagnosis?

Multiple sclerosis
Guillain-Barré syndrome (Correct answer)
Transverse myelitis
Myasthenia gravis

Correct answer: Guillain-Barré syndrome

Guillain-Barré syndrome is an acute demyelinating polyneuropathy that presents with ascending weakness and areflexia, often triggered by a preceding infection.

Question 72: An 18-month-old presents with multiple bruises in various stages of healing, bilateral retinal hemorrhages, and a tense fontanelle. The parents report the baby 'fell off the couch.' Which diagnosis should the nurse suspect?

Idiopathic thrombocytopenic purpura
Hemophilia
Accidental head injury consistent with history
Non-accidental trauma (abusive head trauma) (Correct answer)

Correct answer: Non-accidental trauma (abusive head trauma)

Bilateral retinal hemorrhages with unexplained intracranial injury and inconsistent history in a young child are highly specific for abusive head trauma.

Question 73: A patient with bacterial meningitis should receive which treatment combination as soon as possible?

Ceftriaxone alone
Ceftriaxone + dexamethasone + acyclovir
Acyclovir alone until cultures return
Vancomycin + ceftriaxone + dexamethasone (Correct answer)

Correct answer: Vancomycin + ceftriaxone + dexamethasone

Empiric treatment for bacterial meningitis includes vancomycin (for resistant organisms) plus ceftriaxone (broad coverage) plus dexamethasone (to reduce inflammation and neurological sequelae).

Question 74: When performing rapid sequence intubation (RSI), what is the purpose of applying cricoid pressure (Sellick maneuver)?

Prevent regurgitation and aspiration of gastric contents (Correct answer)
Facilitate passage of the endotracheal tube
Improve visualization of the vocal cords
Reduce the dose of sedative required

Correct answer: Prevent regurgitation and aspiration of gastric contents

Cricoid pressure compresses the esophagus against the cervical vertebra to prevent passive regurgitation and aspiration during RSI.

Question 75: It is believed that a client who was a confined passenger in a high-speed car collision has intra-abdominal hemorrhage. Which of the following tests, if the patient is largely stable, is the most effective way to check for hepatic or splenic rupture?

ultrasound
MRI
CT (Correct answer)
CBC

Correct answer: CT

If the patient is stable enough, CT is the finest diagnostic tool to check for bleeding. In this situation, imaging techniques like MRI and ultrasound are less effective. A CBC may show that there has been blood loss, but it cannot identify the cause of the bleeding.

Question 76: A patient presents with right-sided facial droop, left arm weakness, and slurred speech that started 45 minutes ago. CT shows no hemorrhage. The patient has no contraindications. What is the priority treatment?

Emergent carotid endarterectomy
Aspirin 325 mg and admit for observation
IV alteplase (tPA) within the 3–4.5 hour window (Correct answer)
Anticoagulation with heparin drip

Correct answer: IV alteplase (tPA) within the 3–4.5 hour window

IV alteplase is the standard of care for ischemic stroke presenting within 3–4.5 hours of symptom onset when there are no contraindications.

Question 77: A patient presents after acetaminophen overdose 4 hours ago. The Rumack-Matthew nomogram is used to determine treatment. Which antidote is indicated?

Sodium bicarbonate infusion
Flumazenil IV
Activated charcoal only
N-acetylcysteine (NAC) (Correct answer)

Correct answer: N-acetylcysteine (NAC)

N-acetylcysteine replenishes glutathione, preventing toxic accumulation of NAPQI and hepatotoxicity in acetaminophen overdose.

Question 78: A 5-year-old presents with fever, drooling, a toxic appearance, and refuses to swallow. The child prefers to sit upright leaning forward. Which diagnosis requires immediate airway management preparation?

Viral croup
Peritonsillar abscess
Retropharyngeal abscess
Epiglottitis (Correct answer)

Correct answer: Epiglottitis

The tripod position with drooling, toxic appearance, and dysphagia in a child are classic signs of epiglottitis, an airway emergency.

Question 79: A patient presents with sudden onset severe headache described as 'the worst headache of my life.' What is the priority diagnosis to rule out?

Migraine with aura
Hypertensive urgency
Cluster headache
Subarachnoid hemorrhage (Correct answer)

Correct answer: Subarachnoid hemorrhage

A thunderclap headache (worst of life) is subarachnoid hemorrhage until proven otherwise, requiring immediate CT head without contrast.

Question 80: A patient with carbon monoxide poisoning has a carboxyhemoglobin level of 30% and is confused. Which oxygen delivery is the treatment priority?

Hyperbaric oxygen therapy
Intubation with 40% FiO2
100% oxygen via non-rebreather mask (Correct answer)
Nasal cannula at 4 L/min

Correct answer: 100% oxygen via non-rebreather mask

100% oxygen via non-rebreather mask is the immediate treatment for CO poisoning; it reduces CO half-life from ~5 hours on room air to ~60–90 minutes.

Question 81: Which finding on a 12-lead ECG most urgently requires immediate defibrillation?

Atrial fibrillation with rapid ventricular response
Torsades de pointes with stable pulse
Ventricular fibrillation (Correct answer)
Third-degree heart block

Correct answer: Ventricular fibrillation

Ventricular fibrillation produces no effective cardiac output and requires immediate unsynchronized defibrillation.

Question 82: A patient presents with crushing chest pain, diaphoresis, and ST elevation in leads II, III, and aVF. Which coronary artery is most likely occluded?

Left circumflex artery
Left anterior descending
Left main coronary artery
Right coronary artery (Correct answer)

Correct answer: Right coronary artery

ST elevation in leads II, III, and aVF indicates an inferior MI, which is most commonly caused by occlusion of the right coronary artery.

Question 83: A patient with increased intracranial pressure (ICP) is being managed. Which intervention is most appropriate as a temporizing measure?

Administer normal saline bolus 1L
Lower blood pressure to below 120/80 mmHg
Elevate head of bed to 30 degrees and hyperventilate to PaCO2 35 mmHg (Correct answer)
Administer morphine for pain

Correct answer: Elevate head of bed to 30 degrees and hyperventilate to PaCO2 35 mmHg

Head-of-bed elevation to 30 degrees improves venous drainage, and mild hyperventilation (PaCO2 35 mmHg) causes cerebral vasoconstriction to temporize elevated ICP.

Question 84: Which assessment is most important before administering thrombolytics (tPA) to a patient with ischemic stroke?

12-lead ECG to rule out MI
CT scan of the head without contrast to exclude hemorrhage (Correct answer)
MRI brain to confirm ischemic territory size
Serum troponin to rule out cardiac embolism

Correct answer: CT scan of the head without contrast to exclude hemorrhage

Non-contrast CT of the head must be performed before tPA to rule out hemorrhagic stroke, which is an absolute contraindication to thrombolytic therapy.

Question 85: A patient with type 1 diabetes presents with Kussmaul respirations, fruity breath, blood glucose of 520 mg/dL, and a serum potassium of 3.8 mEq/L. When should insulin be initiated in DKA management?

Immediately upon diagnosis
Only after potassium is greater than 3.5 mEq/L and IV fluids are running (Correct answer)
Only after blood glucose drops below 300 mg/dL
After sodium bicarbonate administration

Correct answer: Only after potassium is greater than 3.5 mEq/L and IV fluids are running

Insulin drives potassium into cells; it must not be given until potassium is ≥3.5 mEq/L and IV fluid resuscitation is underway to prevent life-threatening hypokalemia.

Question 86: A patient presents with sudden severe headache described as 'the worst headache of my life,' neck stiffness, and photophobia. The CT scan is negative. What is the next priority intervention?

Obtain an MRI of the brain
Administer IV analgesics and discharge
Administer empiric antibiotics only
Perform lumbar puncture to assess for xanthochromia (Correct answer)

Correct answer: Perform lumbar puncture to assess for xanthochromia

A thunderclap headache with a negative CT warrants lumbar puncture to detect xanthochromia, indicating subarachnoid hemorrhage.

Question 87: Using a Bag-mask device, you are delivering ventilations. Suddenly, the patient's chest does not lift in response to the ventilation. To maintain an open airway, you must reposition the patient. You don't see his chest rise as you try to ventilate him. This is most likely brought on by:

The patient has suffered an MI
The bag-mask device is faulty
Cardiac tamponade
Airway obstruction (Correct answer)

Correct answer: Airway obstruction

An airway blockage is the most likely reason why the chest doesn't raise during ventilations. It is improbable that a defective bag-mask device would malfunction in the middle of providing ventilations, notwithstanding the possibilities.

Question 88: When calculating the Parkland formula for burn resuscitation, what fluid is used in the first 24 hours?

Lactated Ringer's solution (Correct answer)
5% dextrose in water (D5W)
Normal saline with albumin
Hypertonic saline 3%

Correct answer: Lactated Ringer's solution

The Parkland formula calls for 4 mL/kg/% TBSA burned of Lactated Ringer's solution over 24 hours.

Question 89: A patient presents with confusion, the smell of bitter almonds on their breath, and lactic acidosis after a house fire. Which antidote should be given?

Sodium bicarbonate
Hydroxocobalamin (Cyanokit) (Correct answer)
Sodium thiosulfate alone
Methylene blue

Correct answer: Hydroxocobalamin (Cyanokit)

Hydroxocobalamin binds cyanide to form cyanocobalamin, which is safely excreted; it is the preferred antidote for cyanide poisoning.

Question 90: A patient with a stab wound to the right chest has decreased breath sounds on the right, hypotension, and tracheal deviation to the left. What is the immediate priority?

Pericardiocentesis
IV fluid resuscitation
Chest X-ray
Needle decompression at 2nd ICS right MCL (Correct answer)

Correct answer: Needle decompression at 2nd ICS right MCL

This presentation is classic for right-sided tension pneumothorax; immediate needle decompression is required before imaging to prevent cardiovascular collapse.

Question 91: Which rewarming method is most appropriate for a patient in severe hypothermia (28°C) with cardiac arrest?

Passive external rewarming (warm blankets)
Active external rewarming (warming blankets, forced air)
Extracorporeal membrane oxygenation (ECMO) (Correct answer)
IV warm fluids only

Correct answer: Extracorporeal membrane oxygenation (ECMO)

ECMO is the most effective method for severe hypothermia with cardiac arrest as it simultaneously rewarmed the blood and provides circulatory support.

Question 92: A 58-year-old patient presents with sudden-onset 'worst headache of my life.' CT head is negative. What is the next most important diagnostic step?

Cerebral angiography immediately
Repeat CT in 6 hours
MRI brain with gadolinium
Lumbar puncture for xanthochromia (Correct answer)

Correct answer: Lumbar puncture for xanthochromia

A negative CT does not rule out subarachnoid hemorrhage; lumbar puncture looking for xanthochromia (yellow discoloration) is essential to confirm or exclude the diagnosis.

Question 93: During a mass casualty incident, a patient is found apneic. After repositioning the airway, the patient remains apneic. Under START triage, this patient is classified as:

Expectant (Black) (Correct answer)
Immediate (Red)
Delayed (Yellow)
Minor (Green)

Correct answer: Expectant (Black)

Under START triage, a patient who is apneic after airway repositioning is classified as Expectant (Black), indicating survival is unlikely with available resources.

Question 94: Which fracture pattern is associated with massive pelvic hemorrhage and hemodynamic instability?

Isolated pubic ramus fracture
Avulsion fracture of the ischial tuberosity
Open-book pelvic fracture (AP compression injury) (Correct answer)
Stable lateral compression fracture

Correct answer: Open-book pelvic fracture (AP compression injury)

An open-book pelvis (AP compression) disrupts the pelvic ring and stretches or tears the pelvic venous plexus and iliac vessels, causing massive hemorrhage.

Question 95: Which intervention is contraindicated in a patient with suspected increased intracranial pressure (ICP)?

Administering hypertonic saline 3%
Maintaining PaCO2 between 35–45 mmHg
Vigorous suctioning for more than 15 seconds (Correct answer)
Elevating the head of bed to 30 degrees

Correct answer: Vigorous suctioning for more than 15 seconds

Prolonged suctioning causes hypoxia and Valsalva responses that spike ICP; suction attempts should be brief and limited.

Question 96: During delivery, the umbilical cord prolapses through the cervix. What is the priority nursing action?

Attempt to push the cord back above the presenting part
Apply warm saline packs to the cord
Place the patient in knee-chest or Trendelenburg position and call for C-section (Correct answer)
Clamp and cut the cord immediately

Correct answer: Place the patient in knee-chest or Trendelenburg position and call for C-section

Cord prolapse requires immediate knee-chest or Trendelenburg positioning to relieve pressure on the cord and emergent cesarean delivery.

Question 97: A patient with a suspected ectopic pregnancy has a positive beta-hCG of 2,800 mIU/mL with no intrauterine pregnancy seen on transvaginal ultrasound. She is hemodynamically stable. What is the expected management?

Methotrexate administration after OB/GYN evaluation if criteria are met (Correct answer)
Repeat beta-hCG in 48 hours and discharge to home
Administer RhoGAM only and discharge
Immediate surgical intervention

Correct answer: Methotrexate administration after OB/GYN evaluation if criteria are met

Hemodynamically stable ectopic pregnancy may be managed with methotrexate if the patient meets criteria (no cardiac activity, tube < 3.5 cm, compliant); OB/GYN must evaluate.

Question 98: A 68-year-old is found unresponsive with a glucose of 22 mg/dL. After administering 50 mL of D50W IV, there is no improvement. What should the nurse consider next?

Obtain a repeat glucose and wait 15 minutes
Assess for concurrent causes such as alcohol use or adrenal insufficiency (Correct answer)
Repeat the D50W bolus immediately
Administer glucagon 1 mg IM

Correct answer: Assess for concurrent causes such as alcohol use or adrenal insufficiency

Failure to respond to dextrose suggests the hypoglycemia is refractory, possibly due to alcohol-induced hypoglycemia or adrenal insufficiency requiring additional treatment.

Question 99: Which clinical sign differentiates a herniation syndrome from a metabolic cause of coma?

Small reactive pupils bilaterally
Unilateral fixed and dilated pupil (Correct answer)
Symmetric sluggish pupils
Bilateral pinpoint pupils

Correct answer: Unilateral fixed and dilated pupil

A unilateral fixed and dilated pupil (blown pupil) indicates compression of cranial nerve III from uncal herniation, a structural cause, unlike the symmetric findings seen in metabolic coma.

Question 100: A patient on warfarin presents with an INR of 9.5 and active GI bleeding. What is the most appropriate reversal agent?

Protamine sulfate IV
Fresh frozen plasma (FFP) only
4-factor prothrombin complex concentrate (4F-PCC) plus Vitamin K IV (Correct answer)
Vitamin K 10 mg IV only

Correct answer: 4-factor prothrombin complex concentrate (4F-PCC) plus Vitamin K IV

4F-PCC provides rapid reversal of warfarin-induced coagulopathy in life-threatening bleeding, and Vitamin K ensures sustained reversal; this combination is preferred over FFP alone.

Question 101: A patient with 72 hours of persistent vomiting has ABG results showing pH 7.52, HCO3 32 mEq/L, and labs showing K+ 2.8 mEq/L, Cl- 88 mEq/L. Which IV fluid replacement is most appropriate?

D5W with sodium bicarbonate
0.9% Normal saline with potassium chloride (KCl) (Correct answer)
Lactated Ringer's solution
3% Hypertonic saline

Correct answer: 0.9% Normal saline with potassium chloride (KCl)

Normal saline with KCl replaces the chloride lost through gastric contents (correcting hypochloremic metabolic alkalosis) and replenishes the hypokalemia caused by prolonged vomiting.

Question 102: A hiker presents with core temperature of 28°C, absent shivering, and loss of consciousness. What is the correct classification of this hypothermia?

Moderate hypothermia
Severe hypothermia (Correct answer)
Mild hypothermia
Profound hypothermia

Correct answer: Severe hypothermia

Severe hypothermia is defined as a core temperature below 30°C and is characterized by absent shivering and impaired consciousness.

Question 103: A patient presents with fever, hypotension, altered mental status, and a petechial rash spreading rapidly over the trunk. The nurse suspects:

Allergic vasculitis
Meningococcal septicemia (Correct answer)
Rocky Mountain spotted fever
Immune thrombocytopenic purpura

Correct answer: Meningococcal septicemia

Rapidly spreading petechiae with fever, hypotension, and altered mental status is the hallmark presentation of meningococcal septicemia, a life-threatening emergency.

Question 104: A patient sustains a gunshot wound to the abdomen with evisceration of bowel through the wound. What is the correct initial management of the eviscerated bowel?

Apply a dry sterile gauze and pressure dressing
Push the bowel back into the abdomen
Clamp and ligate protruding bowel
Cover with a moist, sterile dressing (Correct answer)

Correct answer: Cover with a moist, sterile dressing

Eviscerated bowel should be covered with a moist, sterile dressing to prevent desiccation and contamination while the patient is prepared for surgical repair.

Question 105: Which antidote is used for methanol or ethylene glycol poisoning to competitively inhibit alcohol dehydrogenase?

Fomepizole (4-MP) (Correct answer)
N-acetylcysteine
Ethanol
Hydroxocobalamin

Correct answer: Fomepizole (4-MP)

Fomepizole is the preferred antidote for methanol and ethylene glycol poisoning as it inhibits alcohol dehydrogenase without the side effects of ethanol.

Question 106: A patient with a tricyclic antidepressant (TCA) overdose presents with a wide QRS complex and hypotension. Which treatment is most appropriate?

Activated charcoal via NG tube
Sodium bicarbonate 1–2 mEq/kg IV bolus (Correct answer)
Magnesium sulfate IV
Physostigmine IV

Correct answer: Sodium bicarbonate 1–2 mEq/kg IV bolus

Sodium bicarbonate alkalinizes the blood and increases sodium channel availability, reversing TCA-induced cardiac toxicity and wide QRS.

Question 107: Intussusception most commonly occurs at which anatomical location?

Duodenojejunal junction
Sigmoid colon
Ileocecal valve (ileocolic) (Correct answer)
Jejunum-ileum junction

Correct answer: Ileocecal valve (ileocolic)

Ileocolic intussusception at the ileocecal valve is the most common type in children, often presenting with intermittent colicky pain and currant jelly stools.

Question 108: A patient presents with heat stroke (core temp 41.5°C) and altered mental status. Which cooling method achieves the fastest core temperature reduction?

Tepid sponge bath with fanning
Cold water immersion (Correct answer)
Ice packs to axilla and groin
Cool IV fluids alone

Correct answer: Cold water immersion

Cold water immersion (15–17°C) is the most effective and fastest method of cooling in exertional heat stroke.

Question 109: What is the antidote for organophosphate/cholinergic poisoning?

Flumazenil
N-acetylcysteine
Physostigmine
Atropine and pralidoxime (2-PAM) (Correct answer)

Correct answer: Atropine and pralidoxime (2-PAM)

Atropine blocks muscarinic receptors (treats secretions and bradycardia) and pralidoxime reactivates acetylcholinesterase in organophosphate poisoning.

Question 110: Which lab value is most indicative of rhabdomyolysis requiring aggressive IV fluid resuscitation?

Elevated D-dimer
Elevated BNP
Elevated creatine kinase (CK) (Correct answer)
Elevated troponin

Correct answer: Elevated creatine kinase (CK)

Markedly elevated CK indicates extensive muscle breakdown characteristic of rhabdomyolysis, and IV fluids protect the kidneys from myoglobin-induced injury.

Question 111: A patient with a known history of COPD is in respiratory distress. SpO2 is 84%. Which oxygen delivery target is most appropriate for this patient?

SpO2 88-92% via controlled oxygen delivery (Correct answer)
SpO2 >99% via mechanical ventilation
SpO2 100% via non-rebreather mask
SpO2 95-98% via simple face mask

Correct answer: SpO2 88-92% via controlled oxygen delivery

COPD patients may rely on hypoxic drive; targeting SpO2 88-92% prevents CO2 retention while maintaining adequate oxygenation.

Question 112: A patient post-trauma has a GCS of 8. According to current guidelines, what intervention is most appropriate?

Administer mannitol empirically
Observe with serial neuro checks only
Intubate to protect the airway (Correct answer)
Perform immediate lumbar puncture

Correct answer: Intubate to protect the airway

A GCS ≤8 is the clinical threshold for airway compromise; endotracheal intubation is indicated to protect the airway and provide controlled ventilation.

Question 113: A 5-year-old ingests an unknown pill from a grandparent's medication bottle. The child is bradycardic with a BP of 70/40, and ECG shows widened QRS. What drug class is most likely?

Benzodiazepines
Antihistamines
Calcium channel blockers or beta-blockers (Correct answer)
SSRIs

Correct answer: Calcium channel blockers or beta-blockers

Cardiovascular drug ingestions, particularly calcium channel blockers and beta-blockers, commonly cause bradycardia, hypotension, and conduction abnormalities in pediatric patients.

Question 114: A 2-year-old presents with sudden onset barky cough, inspiratory stridor, and low-grade fever. What is the most likely diagnosis?

Croup (laryngotracheobronchitis) (Correct answer)
Bacterial tracheitis
Foreign body aspiration
Epiglottitis

Correct answer: Croup (laryngotracheobronchitis)

Croup is caused by parainfluenza virus and presents with the classic barky cough, stridor, and low-grade fever in children aged 6 months to 3 years.

Question 115: A patient presents after a lightning strike with confusion, entry and exit burns, and a heart rate of 35 bpm with a third-degree AV block. What is the priority intervention?

IV magnesium sulfate for dysrhythmia
Topical burn treatment of entry/exit wounds
Defibrillation immediately
CPR and ACLS protocol; transcutaneous pacing (Correct answer)

Correct answer: CPR and ACLS protocol; transcutaneous pacing

Lightning strike causing complete heart block and bradycardia requires ACLS-guided resuscitation including transcutaneous pacing if unresponsive to atropine.

Question 116: Which formula is used to estimate the endotracheal tube size for a child between ages 1 and 10?

(Age / 4) + 4 (Correct answer)
(Age + 16) / 4
Weight in kg / 10
(Age / 4) + 3.5

Correct answer: (Age / 4) + 4

The formula (Age/4) + 4 estimates the uncuffed ETT size in mm for children aged 1–10 years.

Question 117: A patient presents with sudden onset severe vertigo, nausea, and inability to walk. Head impulse test is negative and there is direction-changing nystagmus. What diagnosis should be suspected?

Benign paroxysmal positional vertigo (BPPV)
Labyrinthitis
Vestibular neuritis
Cerebellar stroke (Correct answer)

Correct answer: Cerebellar stroke

A negative head impulse test with direction-changing nystagmus and inability to walk are central (not peripheral) signs suggesting cerebellar stroke requiring urgent MRI.

Question 118: A burn patient has burns covering the entire anterior trunk, both arms completely, and the head. Using the Rule of Nines, what is the TBSA burned?

63%
45% (Correct answer)
36%
54%

Correct answer: 45%

Anterior trunk = 18%, both arms = 18% total (9% each), head = 9% = total 45% TBSA using the Rule of Nines.

Question 119: Magnesium toxicity in a preeclamptic patient on magnesium sulfate infusion is first evidenced by loss of which reflex?

Corneal reflex
Pupillary reflex
Gag reflex
Patellar (knee-jerk) reflex (Correct answer)

Correct answer: Patellar (knee-jerk) reflex

Loss of the patellar reflex (deep tendon reflex) is the earliest clinical sign of magnesium toxicity, occurring at serum levels of 7–10 mEq/L before respiratory depression.

Question 120: A pregnant patient at 36 weeks presents with sudden painless bright red vaginal bleeding. Which condition is most likely?

Uterine rupture
Vasa previa
Placenta previa (Correct answer)
Placental abruption

Correct answer: Placenta previa

Painless bright red vaginal bleeding in the third trimester is the hallmark presentation of placenta previa.

Question 121: Which urine finding best differentiates prerenal azotemia from intrinsic renal failure?

Urine sodium >40 mEq/L indicates prerenal failure
Gross hematuria indicates prerenal failure
Urine specific gravity <1.010 indicates prerenal failure
Urine sodium <20 mEq/L with concentrated urine indicates prerenal (Correct answer)

Correct answer: Urine sodium <20 mEq/L with concentrated urine indicates prerenal

Urine sodium <20 mEq/L indicates prerenal azotemia because functional kidneys are avidly conserving sodium in response to reduced renal perfusion.

Question 122: Which finding in a febrile infant under 30 days old warrants a full sepsis workup including lumbar puncture?

Temperature ≥38.5°C with URI symptoms
Temperature of 37.9°C rectally with otherwise normal exam
Any temperature ≥38.0°C rectally (Correct answer)
Fever only with a positive RSV test

Correct answer: Any temperature ≥38.0°C rectally

Any rectal temperature ≥38.0°C in an infant under 30 days old warrants a full sepsis evaluation including CBC, blood culture, UA, urine culture, and lumbar puncture.

Question 123: A 65-year-old patient post-knee replacement develops sudden dyspnea, tachycardia, and hypoxia. ECG shows sinus tachycardia with an S1Q3T3 pattern. What is the most appropriate initial diagnostic test?

D-dimer assay
Chest X-ray
V/Q scan
CT pulmonary angiography (CTPA) (Correct answer)

Correct answer: CT pulmonary angiography (CTPA)

CTPA is the gold-standard imaging test for diagnosing pulmonary embolism in a high-probability patient with the clinical and ECG findings described.

Question 124: A patient is brought in after a near-drowning in cold water. Despite 25 minutes of CPR with no ROSC, what principle should guide management?

Administer high-dose epinephrine immediately
Continue resuscitation until the patient is warm — 'not dead until warm and dead' (Correct answer)
Terminate resuscitation after 20 minutes without ROSC
Consult neurology before continuing resuscitation

Correct answer: Continue resuscitation until the patient is warm — 'not dead until warm and dead'

Hypothermia is protective to the brain; drowning victims in cold water may survive neurologically intact with prolonged resuscitation after rewarming.

Question 125: Which of the following best describes distributive shock?

Decreased preload due to hemorrhage
Massive vasodilation causing maldistribution of blood flow (Correct answer)
Decreased cardiac output due to myocardial failure
Obstruction of cardiac output by pulmonary embolism

Correct answer: Massive vasodilation causing maldistribution of blood flow

Distributive shock (e.g., septic, anaphylactic, neurogenic) is characterized by widespread vasodilation leading to inadequate tissue perfusion despite normal or elevated cardiac output.

Question 126: A patient presents with pain, pallor, and numbness of the fingers after exposure to extreme cold. The fingers are waxy with hard white skin. Which stage of frostbite is this?

Superficial frostbite (second degree)
First-degree frostbite
Frostnip
Deep frostbite (third/fourth degree) (Correct answer)

Correct answer: Deep frostbite (third/fourth degree)

Hard, white, waxy skin extending below the dermis with numbness indicates deep frostbite involving deep tissues.

Question 127: A patient with a traumatic amputation of the right forearm has uncontrolled arterial bleeding. A tourniquet is applied. Which documentation is mandatory?

Patient's blood type
Reason for tourniquet application
Name of the person who applied it
Time of tourniquet application (Correct answer)

Correct answer: Time of tourniquet application

The time of tourniquet application must be documented because prolonged application beyond 2 hours increases the risk of limb loss.

Question 128: Which finding best differentiates cardiogenic pulmonary edema from ARDS on chest X-ray?

Cardiomegaly and Kerley B lines in cardiogenic edema (Correct answer)
Pleural effusions only in ARDS
Air bronchograms in cardiogenic edema but not ARDS
Bilateral infiltrates in cardiogenic edema vs. unilateral in ARDS

Correct answer: Cardiomegaly and Kerley B lines in cardiogenic edema

Cardiomegaly and Kerley B lines (representing dilated lymphatics) on CXR support cardiogenic pulmonary edema rather than ARDS.

Question 129: A client's penetrating abdominal injuries has resulted in hypovolemia. What is the best procedure for resuscitating fluids quickly?

jugular central line
femoral central line
subclavian central line
large bore peripheral IV (Correct answer)

Correct answer: large bore peripheral IV

A large bore peripheral IV is the ideal route of rapid fluid resuscitation for a client with hypovolemia brought on by blood loss from a penetrating abdominal trauma since it will enable faster fluid delivery than a central line.

Question 130: Which finding is characteristic of a positive Murphy's sign?

Referred shoulder pain during splenic palpation
Rebound tenderness at the right lower quadrant
Pain and inspiratory arrest during deep RUQ palpation (Correct answer)
Flank pain with percussion over the CVA

Correct answer: Pain and inspiratory arrest during deep RUQ palpation

Murphy's sign is positive when the patient experiences sharp pain and stops inspiring during deep right upper quadrant palpation, indicating acute cholecystitis.

Question 131: A patient at 32 weeks gestation presents with sudden severe abdominal pain, rigid abdomen, and dark vaginal bleeding. Fetal heart tones are absent. Which complication is most likely?

Placental abruption with fetal demise (Correct answer)
Vasa previa
Uterine rupture
Placenta previa

Correct answer: Placental abruption with fetal demise

Painful dark vaginal bleeding with board-like rigidity and fetal demise indicates severe placental abruption with complete placental separation.

Question 132: A patient with sickle cell disease presents in vaso-occlusive crisis with severe pain rated 10/10. What is the priority nursing intervention?

Administer IV opioids promptly per protocol and ensure adequate hydration (Correct answer)
Obtain hemoglobin electrophoresis before pain management
Encourage ambulation to improve circulation
Apply ice packs to affected areas for vasoconstriction

Correct answer: Administer IV opioids promptly per protocol and ensure adequate hydration

Prompt IV opioid administration and IV hydration are the priority in vaso-occlusive crisis to relieve pain and improve microvascular flow; delays in pain management worsen outcomes.

Question 133: A pregnant trauma patient at 28 weeks gestation is in hemorrhagic shock. Which positioning modification is essential during resuscitation?

Left lateral uterine displacement to relieve aortocaval compression (Correct answer)
Prone positioning
Supine position only
Trendelenburg position with both legs elevated

Correct answer: Left lateral uterine displacement to relieve aortocaval compression

Left lateral uterine displacement relieves aortocaval compression by the gravid uterus, improving venous return and cardiac output.

Question 134: A patient with acute liver failure develops worsening confusion, decorticate posturing, and papilledema. The most immediately life-threatening complication is:

Cerebral edema with increased intracranial pressure (Correct answer)
Hepatorenal syndrome
Acute variceal hemorrhage
Spontaneous bacterial peritonitis

Correct answer: Cerebral edema with increased intracranial pressure

Cerebral edema with increased ICP is the leading cause of death in acute liver failure, requiring immediate neurological monitoring and ICP-lowering interventions.

Question 135: A patient presents with altered mental status, fever, autonomic instability, and clonus after starting a new SSRI. What condition should be suspected?

Neuroleptic malignant syndrome
Malignant hyperthermia
Serotonin syndrome (Correct answer)
Anticholinergic toxidrome

Correct answer: Serotonin syndrome

Serotonin syndrome is caused by excess serotonergic activity and presents with the triad of altered mental status, autonomic instability, and neuromuscular abnormalities including clonus.

Question 136: A patient in the third trimester develops epigastric pain, nausea, thrombocytopenia, elevated LFTs, and hemolysis. What syndrome is present?

Acute fatty liver of pregnancy
Cholestasis of pregnancy
Hyperemesis gravidarum
HELLP syndrome (Correct answer)

Correct answer: HELLP syndrome

HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) is a severe variant of preeclampsia presenting with epigastric pain, thrombocytopenia, elevated LFTs, and microangiopathic hemolysis.

Question 137: A patient taking phenytoin presents with a seizure. Phenytoin level is therapeutic. Which electrolyte abnormality is the most common correctable cause of breakthrough seizures?

Hypermagnesemia
Hypernatremia
Hypercalcemia
Hyponatremia (Correct answer)

Correct answer: Hyponatremia

Hyponatremia is the most common electrolyte disturbance causing or exacerbating seizures, and must be corrected carefully to avoid osmotic demyelination.

Question 138: A patient with a lap-belt injury mechanism presents with abdominal wall bruising in a horizontal pattern and lower back pain. Which injury should the nurse specifically suspect?

Pancreatic transection
Splenic laceration
Chance fracture of the lumbar spine (Correct answer)
Aortic injury

Correct answer: Chance fracture of the lumbar spine

Lap-belt injuries classically cause a Chance fracture (horizontal fracture through a lumbar vertebra) along with intra-abdominal injuries.

Question 139: A cirrhotic patient presents with confusion, asterixis, and jaundice. The nurse anticipates which primary diagnosis?

Acute portal vein thrombosis
Hepatic encephalopathy (Correct answer)
Esophageal variceal bleeding
Spontaneous bacterial peritonitis

Correct answer: Hepatic encephalopathy

Hepatic encephalopathy presents with altered mental status and asterixis (flapping tremor) in cirrhotic patients due to ammonia accumulation from impaired liver detoxification.

Question 140: A trauma patient develops a massive hemothorax. Initial management includes placement of a large-bore (36–40 Fr) chest tube. If initial drainage exceeds what volume, is operative intervention indicated?

500 mL
1000–1500 mL (Correct answer)
250 mL
2000 mL

Correct answer: 1000–1500 mL

Initial drainage >1000–1500 mL from a hemothorax or ongoing drainage >200 mL/hr is the threshold for operative intervention.

Question 141: What is the NIH Stroke Scale (NIHSS) primarily used for in the emergency setting?

Quantifying neurological deficits and guiding thrombolysis decisions (Correct answer)
Classifying hemorrhagic vs. ischemic stroke
Predicting long-term functional outcome only
Determining eligibility for surgery

Correct answer: Quantifying neurological deficits and guiding thrombolysis decisions

The NIHSS quantifies neurological deficits on a standardized scale and helps guide tPA eligibility and treatment decisions in acute ischemic stroke.

Question 142: A trauma patient has absent breath sounds on the left, tracheal deviation to the right, and hypotension. What is the immediate intervention?

Perform needle decompression at the second intercostal space, midclavicular line on the left (Correct answer)
Obtain portable chest X-ray before any intervention
Administer 2 L normal saline rapidly
Insert a chest tube at the fifth intercostal space, midaxillary line on the right

Correct answer: Perform needle decompression at the second intercostal space, midclavicular line on the left

Absent breath sounds with tracheal deviation and hemodynamic instability indicate tension pneumothorax requiring immediate needle decompression on the affected side.

Question 143: A 6-week-old infant presents with bilious vomiting, abdominal distension, and bloody stools. What is the most urgent concern?

Malrotation with midgut volvulus (Correct answer)
Pyloric stenosis
Gastroenteritis
Intussusception

Correct answer: Malrotation with midgut volvulus

Bilious vomiting in a neonate is malrotation with midgut volvulus until proven otherwise; it is a surgical emergency requiring immediate imaging and operative intervention.

Question 144: A patient at 34 weeks gestation presents with painless, bright red vaginal bleeding. What is the most likely cause?

Bloody show of labor
Cervical polyp
Placenta previa (Correct answer)
Placental abruption

Correct answer: Placenta previa

Painless bright red vaginal bleeding in the third trimester is the classic presentation of placenta previa, where the placenta covers the cervical os.

Question 145: During the primary survey of a trauma patient, which step follows airway management?

Circulation with hemorrhage control
Breathing and ventilation (Correct answer)
Exposure and environment control
Disability (neurological status)

Correct answer: Breathing and ventilation

The ATLS primary survey follows A-B-C-D-E: Airway → Breathing → Circulation → Disability → Exposure.

Question 146: Which trauma patient is most likely to benefit from permissive hypotension strategy (target MAP 50 mmHg) during resuscitation?

Patient with suspected spinal cord injury
68-year-old with TBI and abdominal bleeding
Patient in septic shock
25-year-old with penetrating abdominal trauma, no TBI (Correct answer)

Correct answer: 25-year-old with penetrating abdominal trauma, no TBI

Permissive hypotension is used in penetrating trauma without TBI to prevent coagulopathy worsening while limiting crystalloid dilution.

Question 147: A 10-year-old with sickle cell disease presents with fever (38.6°C), chest pain, and hypoxia. CXR shows a new infiltrate. What is this complication called?

Vaso-occlusive crisis
Aplastic crisis
Splenic sequestration
Acute chest syndrome (Correct answer)

Correct answer: Acute chest syndrome

Acute chest syndrome in sickle cell disease presents with fever, respiratory symptoms, hypoxia, and a new pulmonary infiltrate and is a life-threatening complication.

Question 148: Which sign, elicited on abdominal examination, is most specific for peritonitis?

Grey Turner's sign (flank ecchymosis)
Rebound tenderness (Blumberg's sign) (Correct answer)
Cullen's sign (periumbilical ecchymosis)
Chvostek's sign (facial muscle twitch)

Correct answer: Rebound tenderness (Blumberg's sign)

Rebound tenderness (Blumberg's sign) — pain that is worse with sudden release of deep pressure than with pressure itself — indicates peritoneal irritation consistent with peritonitis.

Question 149: A patient has a suspected foreign body airway obstruction and becomes unconscious. What is the immediate next step?

Administer high-flow oxygen via mask
Begin CPR and look for the object during ventilation attempts (Correct answer)
Continue abdominal thrusts
Perform emergency tracheotomy

Correct answer: Begin CPR and look for the object during ventilation attempts

If a choking victim becomes unresponsive, lower them to the floor, begin CPR, and look in the mouth for the object before each breath attempt.

Question 150: A 22-year-old sexually active woman presents with a right adnexal mass, acute pelvic pain, and a negative pregnancy test. Doppler shows absent blood flow to the right ovary. What is the next step?

Laparoscopic cystectomy as scheduled surgery
IV antibiotics for tubo-ovarian abscess
Emergency surgical consultation for ovarian torsion (Correct answer)
Observation and repeat ultrasound in 24 hours

Correct answer: Emergency surgical consultation for ovarian torsion

Absent ovarian blood flow on Doppler in the setting of acute pain indicates ovarian torsion requiring emergency surgical consultation and operative detorsion.

Question 151: Which nursing intervention is the highest priority for a patient with confirmed small bowel obstruction presenting with abdominal distension and bilious vomiting?

Encourage small sips of clear fluids
Position the patient in Trendelenburg
Insert a nasogastric tube and connect to low intermittent suction (Correct answer)
Administer a Fleet enema to stimulate passage

Correct answer: Insert a nasogastric tube and connect to low intermittent suction

Nasogastric tube insertion with low intermittent suction decompresses the obstructed GI tract, relieves distension, reduces vomiting, and prevents aspiration.

Question 152: A 10-year-old with Type 1 diabetes presents with Kussmaul respirations, fruity breath, blood glucose of 480 mg/dL, and pH 7.18. What is the priority treatment?

IV insulin bolus immediately
Sodium bicarbonate to correct acidosis
IV fluid resuscitation with normal saline followed by insulin infusion (Correct answer)
Subcutaneous insulin and oral fluids

Correct answer: IV fluid resuscitation with normal saline followed by insulin infusion

Fluid resuscitation with NS is the first priority in pediatric DKA to correct dehydration and restore perfusion; insulin infusion is started after fluids.

Question 153: A patient presents with confusion, lactic acidosis, and bradycardia after intentional ingestion of his wife's heart medication. Bedside glucose is 220 mg/dL. Which medication overdose is most likely?

Digoxin
Metformin
Calcium channel blocker (Correct answer)
Beta-blocker

Correct answer: Calcium channel blocker

Calcium channel blocker toxicity causes bradycardia, hypotension, and hyperglycemia (by blocking insulin release from pancreatic beta cells).

Question 154: Which ECG change is most characteristic of hyperkalemia when the serum potassium level is above 6.5 mEq/L?

Prominent U waves
ST depression in lateral leads
Peaked tall T waves (Correct answer)
Prolonged PR interval only

Correct answer: Peaked tall T waves

Peaked, tall, narrow T waves are the earliest ECG manifestation of hyperkalemia and typically appear when potassium exceeds 5.5–6.5 mEq/L.

Question 155: A neonate born to a GBS-positive mother who did not receive intrapartum prophylaxis develops respiratory distress, poor feeding, and temperature instability at 36 hours of life. What is the immediate management priority?

Expectant management with vital signs monitoring
Lumbar puncture before any antibiotics
Oral amoxicillin and discharge to home
Blood cultures and empiric IV antibiotics (ampicillin + gentamicin) (Correct answer)

Correct answer: Blood cultures and empiric IV antibiotics (ampicillin + gentamicin)

Early-onset neonatal sepsis from GBS requires blood cultures followed immediately by empiric IV ampicillin and gentamicin.

Question 156: A 4-year-old presents with sudden choking while eating peanuts, and now has unilateral decreased breath sounds and hyperresonance on the right. What is the most likely diagnosis?

Asthma exacerbation
Pneumonia
Foreign body airway obstruction in the right mainstem bronchus (Correct answer)
Spontaneous pneumothorax

Correct answer: Foreign body airway obstruction in the right mainstem bronchus

Unilateral decreased breath sounds and hyperresonance after choking in a child is classic for a right-sided bronchial foreign body, as the right mainstem bronchus is more vertical.

Question 157: A patient presents with a suspected aortic dissection. Which combination of findings is most classic?

Gradual onset chest pressure with diaphoresis
Sharp pleuritic chest pain with a pleural friction rub
Sudden tearing back pain with unequal blood pressures in both arms (Correct answer)
Tearing chest pain radiating to the jaw and left arm

Correct answer: Sudden tearing back pain with unequal blood pressures in both arms

A sudden tearing or ripping pain radiating to the back with a blood pressure differential greater than 20 mmHg between arms is the classic presentation of aortic dissection.

Question 158: A patient presents with ST-elevation in leads II, III, and aVF. Which coronary artery is most likely occluded?

Left anterior descending
Left main coronary artery
Right coronary artery (Correct answer)
Left circumflex

Correct answer: Right coronary artery

ST elevation in leads II, III, and aVF indicates an inferior STEMI, most commonly caused by right coronary artery (RCA) occlusion.

Question 159: A scuba diver surfaces too rapidly and presents with joint pain, mottled skin, and shortness of breath 30 minutes after ascent. Which treatment is indicated?

100% oxygen and transfer to hyperbaric chamber (Correct answer)
IV morphine for pain management
Nitroglycerin for vascular dilation
Warm bath and aspirin

Correct answer: 100% oxygen and transfer to hyperbaric chamber

Decompression sickness (the bends) is treated with 100% oxygen to accelerate nitrogen elimination and hyperbaric oxygen recompression therapy.

Question 160: A patient with severe asthma exacerbation has a PEFR of 25% predicted. Which disposition is most appropriate?

Discharge with inhaler prescription
Observe for 1 hour and reassess
Discharge after 4 hours of treatment
Admit to ICU and consider intubation (Correct answer)

Correct answer: Admit to ICU and consider intubation

A PEFR below 40% predicted after initial treatment indicates a severe or life-threatening exacerbation requiring ICU admission and possible intubation.

Question 161: A drowning victim is brought in apneic and pulseless. After resuscitation, they regain a pulse but remain comatose with SpO2 88% on room air. What condition should be anticipated?

Pulmonary embolism
Acute respiratory distress syndrome (ARDS) (Correct answer)
Spontaneous pneumothorax
Aspiration pneumonia

Correct answer: Acute respiratory distress syndrome (ARDS)

Near-drowning victims are at high risk for developing ARDS due to aspiration of fluid causing diffuse alveolar damage and refractory hypoxemia.

Question 162: Which clinical finding is most indicative of a ruptured spleen following blunt abdominal trauma?

Left upper quadrant pain with Kehr's sign (referred left shoulder pain) (Correct answer)
Femoral pulse deficit
Hematuria and flank pain
Guarding in the right lower quadrant

Correct answer: Left upper quadrant pain with Kehr's sign (referred left shoulder pain)

Kehr's sign is left shoulder pain caused by irritation of the left hemidiaphragm from splenic hemorrhage, a classic finding of splenic injury.

Question 163: A patient with a closed head injury and GCS of 14 presents to the ED. CT scan shows no intracranial hemorrhage. Which observation criteria allows discharge?

The patient has only a mild headache with normal exam
The patient tolerated oral fluids in the ED
The patient's GCS returned to 15 within 30 minutes
The patient has no history of anticoagulant use, has a reliable adult companion, and clear discharge instructions (Correct answer)

Correct answer: The patient has no history of anticoagulant use, has a reliable adult companion, and clear discharge instructions

Mild TBI discharge requires no anticoagulant use, a reliable companion for home observation, and written instructions for return precautions.

Question 164: A patient with asthma is in severe bronchospasm and is not responding to nebulized albuterol. What is the next most appropriate pharmacological intervention?

Inhaled ipratropium bromide only
Oral prednisone 40 mg
Subcutaneous terbutaline
IV magnesium sulfate 2 g over 20 minutes (Correct answer)

Correct answer: IV magnesium sulfate 2 g over 20 minutes

IV magnesium sulfate causes bronchial smooth muscle relaxation and is indicated for severe asthma exacerbations not responding to standard beta-agonist therapy.

Question 165: Which imaging finding on non-contrast CT is most consistent with a hypertensive intracerebral hemorrhage?

Diffuse sulcal effacement
Hyperdense lesion in the basal ganglia (Correct answer)
Hypodense lesion in the MCA territory
Ring-enhancing lesion with surrounding edema

Correct answer: Hyperdense lesion in the basal ganglia

Hypertensive intracerebral hemorrhage most commonly occurs in the basal ganglia (putamen) and appears as a hyperdense (bright white) lesion on non-contrast CT.

Question 166: What is the initial fluid of choice for hemorrhagic shock in a trauma patient according to current guidelines?

Packed red blood cells with balanced resuscitation (Correct answer)
Dextrose 5% in water 1L
Colloid solution (albumin) 500 mL
Normal saline 2L IV bolus

Correct answer: Packed red blood cells with balanced resuscitation

Current damage control resuscitation guidelines favor early use of packed RBCs in a 1:1:1 ratio with FFP and platelets rather than crystalloid, to restore both volume and coagulation factors.

Question 167: Which of the following should suctioning during a cardiac arrest be restricted to?

Less than 10 seconds (Correct answer)
Less than 30 seconds
Less than 5 seconds
Less than 20 seconds

Correct answer: Less than 10 seconds

The 2010 BLS and ACLS recommendations state that sucking for more than 10 seconds may draw too much oxygen out of the airways, leading to hypoxemia.

Question 168: Which clinical criterion is NOT part of the Berlin Definition of ARDS?

Bilateral opacities on imaging
PaO2/FiO2 ratio below 300 mmHg
A high BNP level confirming cardiac cause (Correct answer)
Respiratory failure not fully explained by cardiac failure

Correct answer: A high BNP level confirming cardiac cause

The Berlin Definition requires bilateral opacities, P/F ratio < 300, respiratory failure within 1 week of insult, and exclusion of cardiac cause—it does not require a high BNP.

Question 169: A patient presents with sudden onset severe epigastric pain, a rigid 'board-like' abdomen, and absent bowel sounds. Which condition is most likely?

Acute appendicitis
Perforated peptic ulcer (Correct answer)
Small bowel obstruction
Acute pancreatitis

Correct answer: Perforated peptic ulcer

Perforated peptic ulcer causes sudden, severe pain with board-like abdominal rigidity due to chemical peritonitis from gastric contents spilling into the peritoneum.

Question 170: A patient with an open abdominal wound has loops of bowel eviscerated. Which nursing action is most appropriate?

Cover with a dry sterile dressing
Cover with a moist saline dressing and do not reinsert (Correct answer)
Push the bowel back into the abdominal cavity
Apply an occlusive plastic dressing tightly

Correct answer: Cover with a moist saline dressing and do not reinsert

Eviscerated abdominal contents should be covered with a moist, sterile saline dressing and never pushed back into the abdomen.

Question 171: A 36-week pregnant patient presents with severe headache, visual disturbances, BP of 160/110 mmHg, and 3+ proteinuria. What is the diagnosis?

HELLP syndrome
Severe preeclampsia (Correct answer)
Gestational hypertension
Eclampsia

Correct answer: Severe preeclampsia

BP ≥160/110 mmHg with headache, visual changes, and proteinuria after 20 weeks meets criteria for severe preeclampsia with severe features.

Question 172: During the primary survey (ABCDE), when is massive hemorrhage control addressed in the updated ATLS framework?

After airway management (A)
During circulation assessment (C)
Before airway — as the first priority (<C>ABC) (Correct answer)
After the secondary survey

Correct answer: Before airway — as the first priority (<C>ABC)

Updated ATLS guidelines add <C> (catastrophic hemorrhage control) before airway management in the primary survey.

Question 173: A patient presents with sudden pleuritic chest pain and absent breath sounds on the left side. Tracheal deviation is noted to the right. What is the priority intervention?

Administer high-flow oxygen and prepare for needle thoracostomy (Correct answer)
Obtain a chest X-ray immediately
Start broad-spectrum antibiotics
Insert a chest tube at the fourth intercostal space

Correct answer: Administer high-flow oxygen and prepare for needle thoracostomy

The presentation describes a tension pneumothorax, a life-threatening emergency requiring immediate needle thoracostomy at the second intercostal space, midclavicular line, before imaging.

Question 174: A 2-year-old presents with sudden onset of choking, coughing, and unilateral decreased breath sounds. Parents report the child was playing with small toys. What is the most likely diagnosis?

Asthma exacerbation
Bronchiolitis
Croup
Foreign body aspiration (Correct answer)

Correct answer: Foreign body aspiration

Sudden onset choking with unilateral decreased breath sounds in a toddler after playing with small objects strongly suggests foreign body aspiration.

Question 175: Which intraosseous (IO) site is preferred in a child under 6 years of age requiring emergent vascular access?

Distal tibia
Femoral vein
External jugular vein
Proximal tibia, 2 cm below the tibial tuberosity (Correct answer)

Correct answer: Proximal tibia, 2 cm below the tibial tuberosity

The proximal tibia (2 cm below the tibial tuberosity on the flat anteromedial surface) is the preferred IO access site in children under 6 due to the flat, accessible bone surface.

Question 176: Which finding on a chest X-ray is most consistent with a massive pleural effusion?

Tracheal deviation away from the affected side with opacification
Bilateral fluffy infiltrates
Air-fluid levels in both lung fields
Tracheal deviation toward the affected side with opacification (Correct answer)

Correct answer: Tracheal deviation toward the affected side with opacification

A massive pleural effusion causes opacification of the hemithorax with tracheal deviation toward the affected side due to atelectasis, unlike tension pneumothorax where the trachea deviates away.

Question 177: In a patient with severe preeclampsia, which antihypertensive agent is most commonly used IV to acutely lower blood pressure?

Nifedipine ER 30 mg oral
Lisinopril 10 mg oral
Labetalol IV or hydralazine IV (Correct answer)
Metoprolol 25 mg oral

Correct answer: Labetalol IV or hydralazine IV

IV labetalol or IV hydralazine are the most commonly used agents for acute severe hypertension in pregnancy; ACE inhibitors are contraindicated.

CEN Certified Emergency Nurse Exam

The Certified Emergency Nurse (CEN) exam validates specialized knowledge in emergency nursing across cardiovascular, respiratory, trauma, and other clinical emergencies.

175

Questions

180 min

Time Limit

75%

To Pass

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