CEN Certified Emergency Nurse Exam — Questions and Answers

Question 1: An upright KUB film of a patient with stomach pain reveals air under the diaphragm. What of the following is most likely to be the cause?

intra-abdominal bleeding
intussusception
bowel obstruction
bowel perforation (Correct answer)

Correct answer: bowel perforation

Bowel perforation is the most frequent source of air under the diaphragm. Air under the diaphragm may be seen on a chest x-ray or KUB as a result of air leaking caused by a bowel perforation.

Question 2: Which spinal injury pattern is most commonly associated with a diving accident causing cervical spine injury?

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

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

Dopamine
Amiodarone
Atropine (Correct answer)
Epinephrine

Correct answer: Atropine

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

Question 4: A patient presents with priapism following recreational drug use. Which drug class is most commonly associated with this condition?

Benzodiazepines
Opioids
Cocaine and other stimulants (Correct answer)
Cannabis

Correct answer: Cocaine and other stimulants

Cocaine and other stimulants cause priapism through alpha-adrenergic mechanisms that disrupt normal penile blood flow regulation.

Question 5: A patient has a zone II penetrating neck injury with active bleeding. Which is the priority intervention?

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

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

Bloody show of labor
Placenta previa (Correct answer)
Cervical polyp
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 7: Which medication is first-line for treatment of an acute hypertensive encephalopathy with a BP of 240/140 mmHg?

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

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

Less than 30 seconds
Less than 5 seconds
Less than 10 seconds (Correct answer)
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 9: A 14-year-old female with a positive pregnancy test presents with lower abdominal pain and vaginal spotting. Pelvic exam reveals cervical motion tenderness and no adnexal mass. Quantitative hCG is 2,500 mIU/mL with no intrauterine pregnancy on transvaginal ultrasound. Which condition is most likely?

Pelvic inflammatory disease
Ectopic pregnancy (Correct answer)
Ovarian cyst rupture
Threatened miscarriage

Correct answer: Ectopic pregnancy

A positive pregnancy test with no IUP on TVUS, hCG >1500–2000 mIU/mL, and pelvic pain indicates ectopic pregnancy until proven otherwise.

Question 10: A patient with a history of heart failure presents with a BP of 70/40 mmHg, cool extremities, and an elevated BNP. Which hemodynamic profile is most consistent with cardiogenic shock?

Low CVP, low PCWP, high CO
Normal CVP, low PCWP, low CO
High CVP, high PCWP, low CO (Correct answer)
Low CVP, high PCWP, normal CO

Correct answer: High CVP, high PCWP, low CO

Cardiogenic shock is characterized by elevated filling pressures (high CVP and PCWP) and reduced cardiac output due to pump failure.

Question 11: What is the NIH Stroke Scale (NIHSS) primarily used for in the emergency setting?

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

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 12: 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 tolerated oral fluids in the ED
The patient has only a mild headache with normal exam
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 13: 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?

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

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 14: An obstruction of the sphincter of Oddi caused by a gallstone affects a customer. What is the most typical side effect of this illness?

appendicitis
pancreatitis (Correct answer)
hepatitis
cholecystitis

Correct answer: pancreatitis

Pancreatitis is the most frequent side effect of a gallstone obstruction of the sphincter of Oddi. Pancreatitis is brought on by inflammation of the pancreas, which is caused by blockage of the sphincter of Oddi.

Question 15: A patient presents with a suspected aortic dissection. Which combination of findings is most classic?

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

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 16: A newborn is delivered and does not cry, has poor muscle tone, and a heart rate of 60 bpm at 1 minute. After warming and stimulation, the HR remains <60. What is the next step?

Perform positive pressure ventilation and begin chest compressions (Correct answer)
Provide blow-by oxygen only
Administer epinephrine via endotracheal tube
Wait 2 more minutes before intervening

Correct answer: Perform positive pressure ventilation and begin chest compressions

Neonatal HR <60 bpm after initial resuscitation steps requires PPV and chest compressions at a 3:1 compression-to-ventilation ratio.

Question 17: A patient presents with sudden-onset dyspnea and unilateral leg swelling. Wells score is 6. What is the next step?

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

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 18: 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
IV fluid resuscitation with normal saline followed by insulin infusion (Correct answer)
Sodium bicarbonate to correct acidosis
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 19: Confirmation of endotracheal tube placement should be verified by which MOST reliable method?

Chest X-ray only
Auscultation of bilateral breath sounds
Chest rise observation
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 20: A patient with active upper GI bleeding presents with hematemesis, BP 82/50 mmHg, and HR 128 bpm. Which assessment finding represents the highest priority concern?

Hematemesis with hemodynamic instability (Correct answer)
Melena without hemodynamic changes
Coffee-ground emesis
Bright red blood per rectum only

Correct answer: Hematemesis with hemodynamic instability

Hematemesis with hemodynamic instability indicates massive active hemorrhage requiring immediate resuscitation and emergency endoscopy.

Question 21: 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
Administer 10 units oxytocin IM and perform uterine massage (Correct answer)
IV fluid resuscitation with 2L normal saline
Immediate surgical intervention

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 22: 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?

Diverticulosis
Internal hemorrhoids (Correct answer)
Anal fissure
Colorectal carcinoma

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

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

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

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

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 25: 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
Terminate resuscitation after 20 minutes without ROSC
Continue resuscitation until the patient is warm — 'not dead until warm and dead' (Correct answer)
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 26: Which trauma patient is most likely to benefit from permissive hypotension strategy (target MAP 50 mmHg) during resuscitation?

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

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

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

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 28: 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?

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

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 29: 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?

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

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 30: A 28-year-old presents with amenorrhea for 8 weeks, sudden lower abdominal pain, and a positive urine pregnancy test. A beta-hCG is 2500 mIU/mL with no intrauterine pregnancy on transvaginal ultrasound. What is the management?

Progesterone supplementation for threatened abortion
Observation and weekly hCG levels outpatient
Methotrexate or surgical treatment for ectopic pregnancy (Correct answer)
Discharge and repeat ultrasound in 48 hours only

Correct answer: Methotrexate or surgical treatment for ectopic pregnancy

An hCG of 2500 mIU/mL above the discriminatory zone with no IUP on TVUS is presumptive ectopic pregnancy requiring definitive treatment with methotrexate (if stable) or surgery.

Question 31: 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?

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

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

Epinephrine
Norepinephrine (Correct answer)
Dopamine
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 33: A patient post-trauma has a GCS of 8. According to current guidelines, what intervention is most appropriate?

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

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 34: What is the emergency treatment for ovarian torsion?

IV antibiotics and observation
Emergent surgical detorsion (Correct answer)
Hormonal suppression therapy
Anticoagulation 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 35: A patient with increased intracranial pressure (ICP) is being managed. Which intervention is most appropriate as a temporizing measure?

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

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

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

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

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
Attempt to push the cord back above the presenting part

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

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

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

Calcium gluconate 1 g IV (Correct answer)
Naloxone 0.4 mg IV
Protamine sulfate IV
Furosemide 40 mg 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 40: 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
Aspiration pneumonia
Spontaneous pneumothorax
Acute respiratory distress syndrome (ARDS) (Correct answer)

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 41: Preload describes:

The pressure in the arterial system that the heart must overcome to pump the blood
The volume of blood entering the right side of the heart (Correct answer)
The pressure in the venous system that the heart must overcome to pump the blood
The volume of blood entering the left side of the heart

Correct answer: The volume of blood entering the right side of the heart

The amount of blood that enters the right side of the heart is called preload. The heart's fibers are stretched by this volume before contraction. Atrial pressure is a frequent way to quantify preload.

Question 42: Which sign is most specific for cardiac tamponade on physical examination?

Jugular venous distension alone
Beck's triad: hypotension, muffled heart sounds, and JVD (Correct answer)
Pulsus alternans greater than 20 mmHg
Bilateral crackles with S3 gallop

Correct answer: Beck's triad: hypotension, muffled heart sounds, and JVD

Beck's triad (hypotension, muffled heart sounds, JVD) is the classic physical examination finding of cardiac tamponade, though it is not always present.

Question 43: A patient is in pulseless ventricular tachycardia. After the second defibrillation attempt, which medication should be given?

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

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 44: A patient with a suspected C-spine injury arrives immobilized. NEXUS criteria would allow cervical spine clearance WITHOUT imaging if which criterion is met?

Patient is alert with GCS 15 only
Patient is alert, not intoxicated, has no distracting injury, no focal neuro deficit, no midline tenderness (Correct answer)
Patient has midline cervical tenderness
Patient has no visible neck injury

Correct answer: Patient is alert, not intoxicated, has no distracting injury, no focal neuro deficit, no midline tenderness

NEXUS criteria allow clinical C-spine clearance without imaging if all five criteria are met: alert, no intoxication, no focal neurological deficit, no midline tenderness, and no distracting injuries.

Question 45: For fluid resuscitation of a burn patient, the Parkland formula calculates volume based on which variables?

Height, weight, and depth of burn
TBSA burned and serum sodium level
TBSA burned (%) and weight (kg): 4 mL × kg × %TBSA of LR in 24 hours (Correct answer)
Weight and age only

Correct answer: TBSA burned (%) and weight (kg): 4 mL × kg × %TBSA of LR in 24 hours

The Parkland formula is 4 mL × weight (kg) × %TBSA burned of lactated Ringer's, with half given in the first 8 hours and the second half over the next 16 hours.

Question 46: 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?

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

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

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

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

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 49: The 'lethal triad' in trauma refers to which three conditions?

Hypothermia, acidosis, and coagulopathy (Correct answer)
Metabolic alkalosis, hyperkalemia, and hypothermia
Tachycardia, hypotension, and anemia
Hypovolemia, hypoxia, and hyponatremia

Correct answer: Hypothermia, acidosis, and coagulopathy

The lethal triad of trauma—hypothermia, acidosis, and coagulopathy—creates a self-perpetuating cycle that leads to exsanguination if not interrupted.

Question 50: 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?

After sodium bicarbonate administration
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
Immediately upon diagnosis

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 51: An ED nurse inserts a nasogastric tube for a patient who has an intestinal obstruction. Which of the following acid-base conditions puts the client at danger as a result?

respiratory alkalosis
metabolic acidosis
respiratory acidosis
metabolic alkalosis (Correct answer)

Correct answer: metabolic alkalosis

An NG tube is inserted to low continuous suction in the event of an intestinal obstruction to remove the stomach's acidic contents, which could otherwise cause vomiting and increase the patient's risk of aspiration. If not corrected, this process could result in a metabolic alkalosis.

Question 52: A hiker presents with core temperature of 28°C, absent shivering, and loss of consciousness. What is the correct classification of this hypothermia?

Mild hypothermia
Moderate hypothermia
Severe hypothermia (Correct answer)
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 53: A patient presents with fever of 40.5°C, muscle rigidity, clonus, diaphoresis, and agitation after starting a new antidepressant. Which condition is most likely?

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

Correct answer: Serotonin syndrome

The triad of altered mental status, autonomic instability, and neuromuscular abnormalities (clonus, hyperreflexia) is characteristic of serotonin syndrome.

Question 54: A patient presents with ST-elevation in leads II, III, and aVF. Which coronary artery is most likely occluded?

Right coronary artery (Correct answer)
Left main coronary artery
Left anterior descending
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 55: The Glasgow Coma Scale (GCS) assesses which three components?

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

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 56: A patient with inflammatory bowel disease presents with severe abdominal pain, absent bowel sounds, abdominal distension, and fever of 39.4°C. Which life-threatening complication is most concerning?

Rectal prolapse
Anal fistula formation
Perianal abscess
Toxic megacolon (Correct answer)

Correct answer: Toxic megacolon

Toxic megacolon is a life-threatening complication characterized by colonic dilation greater than 6 cm with systemic toxicity, requiring emergency surgical evaluation.

Question 57: 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?

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

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

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

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 59: A patient with a suspected pelvic fracture has ongoing hemodynamic instability. Which intervention is priority to reduce pelvic volume and control hemorrhage?

Emergent surgical exploration
Application of a commercial pelvic binder or sheet wrap (Correct answer)
Aggressive IV fluid resuscitation with 4L NS
Bilateral femur traction splints

Correct answer: Application of a commercial pelvic binder or sheet wrap

A pelvic binder reduces pelvic volume and tamponades venous bleeding, serving as a temporizing measure until definitive care.

Question 60: Which scoring system is used prehospital to predict which trauma patients need transfer to a trauma center?

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

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 61: 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?

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

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 62: 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?

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

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 63: 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?

Naloxone
N-acetylcysteine
Atropine (Correct answer)
Flumazenil

Correct answer: Atropine

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

Question 64: What is the initial energy setting for defibrillation of ventricular fibrillation using a biphasic defibrillator?

200 J (Correct answer)
100 J
360 J
50 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 65: A postpartum patient (1 hour after delivery) develops heavy vaginal bleeding with a boggy, enlarged uterus. What is the priority intervention?

Uterine massage and oxytocin administration (Correct answer)
Packing the uterine cavity
Oral ergotamine
Immediate hysterectomy

Correct answer: Uterine massage and oxytocin administration

Uterine atony is the most common cause of postpartum hemorrhage; bimanual uterine massage combined with IV oxytocin is the first-line treatment to stimulate uterine contraction.

Question 66: 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?

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

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

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

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

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

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

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

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 70: What is the most common cause of cardiac arrest in pediatric patients?

Primary ventricular fibrillation
Congenital heart disease
Electrolyte disturbances
Respiratory failure or shock leading to asystole (Correct answer)

Correct answer: Respiratory failure or shock leading to asystole

Unlike adults, pediatric cardiac arrests are rarely due to primary cardiac arrhythmia; they are most commonly caused by respiratory failure or shock that progresses to asystole.

Question 71: A trauma patient has a blood pressure of 70/40 mmHg with absent JVD and dullness to percussion at the left lung base. What injury is most likely?

Tension pneumothorax
Hemothorax (Correct answer)
Diaphragmatic rupture
Cardiac tamponade

Correct answer: Hemothorax

Hemothorax presents with hypotension, absent JVD (volume loss), and dullness to percussion due to fluid (blood) in the pleural space.

Question 72: Which sign, elicited on abdominal examination, is most specific for peritonitis?

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

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

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

Correct answer: Subarachnoid hemorrhage

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

Question 74: A patient arrives in rapid atrial fibrillation with a rate of 160 bpm and is hemodynamically unstable. What is the most appropriate immediate intervention?

Administer diltiazem 0.25 mg/kg IV
Administer amiodarone 150 mg IV over 10 minutes
Perform synchronized cardioversion (Correct answer)
Initiate rate control with metoprolol

Correct answer: Perform synchronized cardioversion

An unstable patient with tachyarrhythmia requires immediate synchronized cardioversion rather than pharmacological management.

Question 75: What is the antidote for organophosphate/cholinergic poisoning?

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

Correct answer: Atropine and pralidoxime (2-PAM)

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

Question 76: Which fracture pattern is associated with massive pelvic hemorrhage and hemodynamic instability?

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

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 77: A patient on heparin infusion develops a sudden drop in platelet count from 280,000 to 80,000 on day 7. The nurse suspects heparin-induced thrombocytopenia (HIT). What is the priority action?

Administer a platelet transfusion
Switch to low-molecular-weight heparin
Continue heparin and monitor platelet count daily
Discontinue heparin and begin an alternative anticoagulant (Correct answer)

Correct answer: Discontinue heparin and begin an alternative anticoagulant

HIT is a prothrombotic condition; all heparin must be immediately discontinued and a direct thrombin inhibitor (e.g., argatroban) started to prevent thrombosis.

Question 78: 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
Acute pancreatitis
Perforated peptic ulcer (Correct answer)
Small bowel obstruction

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 79: The patient has an anterior ST-elevation myocardial infarction (STEMI) and is transported to the emergency department. You are evaluating him to determine whether to administer fibrinolytics. The following conditions are a strict no-no for this therapy:

Symptoms began 36 hours before arrival. (Correct answer)
The patient had a previous MI 6 years ago.
The patient has received aspirin in the last 2 hours.
The patient's pain is not relieved by medications.

Correct answer: Symptoms began 36 hours before arrival.

In general, fibrinolytic therapy is NOT advised for patients whose symptoms started more than 12 hours prior to arrival. Unless a posterior MI is identified, fibrinolytics shouldn't be used if symptoms started more than 24 hours before to arrival. The MI was anterior in this instance.

Question 80: 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
Anticholinergic toxidrome
Serotonin syndrome (Correct answer)

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 81: A patient arrives after a high-voltage electrical injury. Beyond cardiac monitoring, what other system requires priority assessment?

Musculoskeletal and renal systems for rhabdomyolysis (Correct answer)
Neurological system for peripheral neuropathy only
Gastrointestinal system for bowel perforation
Integumentary system only

Correct answer: Musculoskeletal and renal systems for rhabdomyolysis

High-voltage injuries cause massive muscle destruction (rhabdomyolysis), releasing myoglobin that can cause acute renal failure; aggressive IV fluids and urine output monitoring are essential.

Question 82: When should cardiopulmonary resuscitation in a pregnant patient include lateral uterine displacement?

After 20 weeks gestation or when the uterus is palpable at the umbilicus (Correct answer)
Not indicated during CPR
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 83: A patient presents with bradycardia, miosis, excessive salivation, urination, and muscle fasciculations after working in an agricultural field. Which toxidrome is this?

Opioid toxidrome
Cholinergic toxidrome (organophosphate poisoning) (Correct answer)
Sympathomimetic 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 84: Which finding on a chest X-ray is most consistent with a massive pleural effusion?

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

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

Facilitate passage of the endotracheal tube
Improve visualization of the vocal cords
Prevent regurgitation and aspiration of gastric contents (Correct answer)
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 86: What is the first-line treatment for moderate croup (stridor at rest) in the emergency department?

Inhaled budesonide and observation
Oral or IM dexamethasone (Correct answer)
Inhaled racemic epinephrine only
Antibiotics and oxygen

Correct answer: Oral or IM dexamethasone

Oral or IM dexamethasone (0.6 mg/kg) is the first-line treatment for croup; it reduces airway inflammation and decreases the need for further interventions.

Question 87: 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)
Hypovolemic shock
Septic shock
Obstructive 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 88: 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
Administer a Fleet enema to stimulate passage
Position the patient in Trendelenburg
Insert a nasogastric tube and connect to low intermittent suction (Correct answer)

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 89: A patient presents with hypertension, tachycardia, hyperthermia, mydriasis, and agitation. Which toxidrome is this presentation consistent with?

Opioid toxidrome
Sympathomimetic toxidrome (Correct answer)
Sedative-hypnotic withdrawal
Cholinergic toxidrome

Correct answer: Sympathomimetic toxidrome

Hypertension, tachycardia, hyperthermia, dilated pupils, and agitation constitute the sympathomimetic toxidrome seen with cocaine or amphetamine use.

Question 90: A pregnant patient at 36 weeks presents with sudden painless bright red vaginal bleeding. Which condition is most likely?

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

Correct answer: Placenta previa

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

Question 91: Which assessment finding in a burn patient indicates the need for immediate endotracheal intubation?

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

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 92: A patient with known heart failure presents with severe dyspnea, pink frothy sputum, and an SpO2 of 82%. What is the priority intervention?

Apply CPAP or BiPAP (Correct answer)
Administer furosemide 40 mg IV
Insert Foley catheter
Obtain 12-lead ECG

Correct answer: Apply CPAP or BiPAP

Non-invasive positive pressure ventilation (CPAP/BiPAP) rapidly improves oxygenation in acute pulmonary edema and reduces the need for intubation.

Question 93: Which finding in a pediatric patient is the EARLIEST indicator of decompensated shock?

Mottled skin
Hypotension
Tachycardia (Correct answer)
Altered mental status

Correct answer: Tachycardia

Children compensate effectively for shock; tachycardia is the earliest sign, while hypotension is a late and ominous finding.

Question 94: A patient in anaphylaxis has received epinephrine 1:1,000 IM but symptoms persist. What is the next priority action?

Administer diphenhydramine 50 mg IV
Repeat epinephrine 1:1,000 IM in 5–15 minutes (Correct answer)
Administer methylprednisolone 125 mg IV
Place the patient in Trendelenburg position

Correct answer: Repeat epinephrine 1:1,000 IM in 5–15 minutes

A second dose of epinephrine IM can be given 5–15 minutes after the first if the patient does not improve, as epinephrine is the first-line treatment for anaphylaxis.

Question 95: ALL OF THE FOLLOWING ARE POSSIBLE CAUSES OF CARDIAC ARREST, EXCEPT:

Hypokalemia
Hypoxia
Hypervolemia (Correct answer)
Tension Pneumothorax

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 96: A patient with chest pain has a 12-lead ECG showing ST depression in V1–V4. Which condition should be considered first?

Anterior STEMI
Posterior MI (Correct answer)
Right ventricular infarction
Pericarditis

Correct answer: Posterior MI

ST depression in V1–V4 can represent a posterior MI, which appears as a mirror image; applying posterior leads (V7–V9) will reveal ST elevation.

Question 97: 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
Hyponatremia (Correct answer)
Hypercalcemia

Correct answer: Hyponatremia

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

Question 98: 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?

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

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 99: Which type of shock is most likely in a trauma patient with distended neck veins, muffled heart sounds, and hypotension without obvious external hemorrhage?

Obstructive shock from cardiac tamponade (Correct answer)
Hemorrhagic shock
Neurogenic shock
Distributive shock

Correct answer: Obstructive shock from cardiac tamponade

Beck's triad (hypotension, JVD, muffled heart sounds) in trauma indicates obstructive shock from pericardial tamponade.

Question 100: Cushing's triad, indicating severely elevated ICP, consists of which three findings?

Hypertension, tachycardia, hyperthermia
Tachycardia, hypotension, tachypnea
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 101: A patient with a history of heavy alcohol use presents with epigastric pain radiating to the back, nausea, and vomiting. Serum lipase is 1,800 U/L. What is the priority nursing intervention?

Prepare patient for emergent ERCP
Establish IV access and initiate aggressive fluid resuscitation (Correct answer)
Administer broad-spectrum IV antibiotics
Insert nasogastric tube for decompression

Correct answer: Establish IV access and initiate aggressive fluid resuscitation

Aggressive IV fluid resuscitation is the cornerstone of acute pancreatitis management to prevent hypovolemia, systemic inflammatory response, and organ failure.

Question 102: Which ABG result is most consistent with acute respiratory acidosis?

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

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 103: 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
large bore peripheral IV (Correct answer)
subclavian central line

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 104: 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?

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

Correct answer: Emergent surgical exploration (trauma laparotomy)

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

Question 105: 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?

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

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 106: 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?

Calcium channel blockers or beta-blockers (Correct answer)
Benzodiazepines
Antihistamines
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 107: Which finding on a 12-lead ECG most urgently requires immediate defibrillation?

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

Correct answer: Ventricular fibrillation

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

Question 108: The American Heart Association's ACLS guidelines state that applying cricoid pressure when intubating should:

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

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 109: 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?

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

Correct answer: Calcium channel blocker

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

Question 110: A patient with an open abdominal wound has loops of bowel eviscerated. Which nursing action is most appropriate?

Cover with a moist saline dressing and do not reinsert (Correct answer)
Cover with a dry sterile dressing
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 111: 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?

IV antibiotics for tubo-ovarian abscess
Laparoscopic cystectomy as scheduled surgery
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 112: 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 bag-mask device is faulty
Airway obstruction (Correct answer)
Cardiac tamponade
The patient has suffered an MI

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 113: Which Glasgow Coma Scale (GCS) score indicates the need for definitive airway management?

GCS 6 or less
GCS 8 or less (Correct answer)
GCS 10
GCS 12

Correct answer: GCS 8 or less

A GCS of 8 or less indicates severe brain injury with inability to protect the airway, requiring endotracheal intubation.

Question 114: 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:

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

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

Magnesium sulfate 4–6 g loading dose IV (Correct answer)
Lorazepam 2 mg IV
Diazepam 10 mg IV
Phenytoin 20 mg/kg 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 116: A patient in the third trimester develops epigastric pain, nausea, thrombocytopenia, elevated LFTs, and hemolysis. What syndrome is present?

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

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

Rebound tenderness at the right lower quadrant
Pain and inspiratory arrest during deep RUQ palpation (Correct answer)
Referred shoulder pain during splenic palpation
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 118: A 7-year-old is in anaphylaxis with urticaria, stridor, and hypotension. What is the priority intervention?

Methylprednisolone 1 mg/kg IV
Inhaled albuterol via nebulizer
IV diphenhydramine 1 mg/kg
Epinephrine 0.01 mg/kg IM (1:1000 solution) in the anterolateral thigh (Correct answer)

Correct answer: Epinephrine 0.01 mg/kg IM (1:1000 solution) in the anterolateral thigh

Epinephrine IM is the only drug proven to reverse anaphylaxis and is the first-line treatment; all other medications are adjuncts.

Question 119: A patient is receiving CPR from the team. In response to an electrical shock, the beat will be:

SVT
Asystole
Ventricular fibrillation (Correct answer)
PEA

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 120: 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?

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

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

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

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

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

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 123: 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?

Escherichia coli O157:H7
Salmonella typhi
Campylobacter jejuni
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 124: 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 empiric antibiotics only
Perform lumbar puncture to assess for xanthochromia (Correct answer)
Administer IV analgesics and discharge

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 125: A patient presents with wide complex tachycardia. Which clinical feature most supports ventricular tachycardia over SVT with aberrancy?

Heart rate greater than 200 bpm
AV dissociation on ECG (Correct answer)
Response to vagal maneuvers
Abrupt onset with palpitations

Correct answer: AV dissociation on ECG

AV dissociation, where P waves and QRS complexes are independent, is a hallmark of ventricular tachycardia and helps distinguish it from SVT with aberrancy.

Question 126: A patient is brought in seizing continuously for 10 minutes. Lorazepam has been given twice without effect. What is the next drug to administer?

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

Correct answer: Levetiracetam or fosphenytoin IV

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

Question 127: A patient presents with a traumatic amputation of the right hand. What is the proper preservation method for the amputated part before replantation?

Wrap in wet saline gauze and pack directly in ice
Wrap in dry sterile gauze, place in a sealed bag, then place the bag on ice (Correct answer)
Apply pressure dressing to the amputated part and discard
Submerge directly in ice water

Correct answer: Wrap in dry sterile gauze, place in a sealed bag, then place the bag on ice

The amputated part should be wrapped in moist sterile gauze, placed in a sealed bag, and then placed over ice to prevent direct freezing and tissue maceration.

Question 128: A patient has a suspected foreign body airway obstruction and becomes unconscious. What is the immediate next step?

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

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 129: 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)
Intussusception
Gastroenteritis
Pyloric stenosis

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 130: 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?

Obtain a chest X-ray immediately
Start broad-spectrum antibiotics
Administer high-flow oxygen and prepare for needle thoracostomy (Correct answer)
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 131: A patient with known COPD presents in respiratory distress. ABG shows pH 7.28, PaCO2 72, PaO2 55. What is the correct interpretation?

Respiratory acidosis with hypoxemia (Correct answer)
Metabolic acidosis with hypoxemia
Respiratory alkalosis with hypoxia
Mixed metabolic and respiratory alkalosis

Correct answer: Respiratory acidosis with hypoxemia

Low pH with elevated PaCO2 indicates respiratory acidosis (CO2 retention), and PaO2 < 60 mmHg indicates hypoxemia.

Question 132: 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?

1000–1500 mL (Correct answer)
2000 mL
250 mL
500 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 133: Which assessment is CONTRAINDICATED in a patient with suspected placenta previa?

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

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 134: Which of the following is the most reliable early indicator of inadequate perfusion in a trauma patient?

Rising serum lactate (Correct answer)
Altered mental status
Decreased urine output
Falling blood pressure

Correct answer: Rising serum lactate

Elevated serum lactate reflects anaerobic metabolism and tissue hypoperfusion, often rising before overt hemodynamic changes become apparent.

Question 135: 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
Lumbar puncture for xanthochromia (Correct answer)
MRI brain with gadolinium
Repeat CT in 6 hours

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

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

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

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 138: A six-week-old male child with projectile vomiting that has gotten worse over many days is brought in by his parents. What congenital abnormalities needs to be taken into account?

pyloric stenosis (Correct answer)
appendicitis
toxic megacolon
anal atresia

Correct answer: pyloric stenosis

Pyloric stenosis, which is caused by a stenosis at the pyloric junction, affects men more frequently than women and typically manifests at six weeks. Projectile vomiting is a frequent symptom of this illness. Ultrasound is used to confirm the diagnosis.

Question 139: A 36-week pregnant patient presents with severe headache, visual disturbances, BP of 160/110 mmHg, and 3+ proteinuria. What is the diagnosis?

Severe preeclampsia (Correct answer)
HELLP syndrome
Eclampsia
Gestational hypertension

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 140: 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)
54%
36%

Correct answer: 45%

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

Question 141: A patient presents with chest pain and a widened mediastinum on CXR. BP in the right arm is 160/90 and in the left arm is 90/60. The nurse suspects aortic dissection. Which action is contraindicated?

Administer thrombolytics (Correct answer)
Administer IV morphine for pain
Obtain emergent CT angiography of the chest
Administer IV labetalol for rate and pressure control

Correct answer: Administer thrombolytics

Thrombolytics are absolutely contraindicated in aortic dissection as they would worsen hemorrhage and increase mortality.

Question 142: 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)
Prophylactic anticonvulsants
Immediate coronary angiography
High-dose epinephrine infusion

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 143: 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
Physostigmine IV
Sodium bicarbonate 1–2 mEq/kg IV bolus (Correct answer)
Magnesium sulfate 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 144: Which of the following is the correct sequence for synchronized cardioversion in a hemodynamically unstable patient with atrial flutter?

360 J monophasic only
200 J → 300 J → 360 J biphasic
50–100 J biphasic → increase if needed (Correct answer)
Adenosine 6 mg IV → cardioversion if no response

Correct answer: 50–100 J biphasic → increase if needed

Synchronized cardioversion for atrial flutter begins at 50–100 J biphasic and is increased stepwise if the initial attempt fails.

Question 145: Which intervention is the HIGHEST priority for a patient presenting with status epilepticus lasting more than 5 minutes?

Draw blood cultures before starting antibiotics
Administer IV benzodiazepine immediately (Correct answer)
Obtain a head CT
Start a phenytoin infusion

Correct answer: Administer IV benzodiazepine immediately

Benzodiazepines (lorazepam or diazepam) are the first-line treatment for status epilepticus, given as soon as possible to terminate the seizure.

Question 146: A patient presents after acetaminophen overdose 4 hours ago. The Rumack-Matthew nomogram is used to determine treatment. Which antidote is indicated?

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

Correct answer: N-acetylcysteine (NAC)

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

Question 147: Which finding best differentiates cardiogenic pulmonary edema from ARDS on chest X-ray?

Bilateral infiltrates in cardiogenic edema vs. unilateral in ARDS
Cardiomegaly and Kerley B lines in cardiogenic edema (Correct answer)
Pleural effusions only in ARDS
Air bronchograms in cardiogenic edema but not 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 148: What is the appropriate initial fluid bolus for a child in septic shock?

Colloid only
20 mL/kg NS or LR IV over 5–10 minutes, reassess after each bolus (Correct answer)
10 mL/kg D5NS over 30 minutes
40 mL/kg NS bolus without reassessment

Correct answer: 20 mL/kg NS or LR IV over 5–10 minutes, reassess after each bolus

PALS recommends 20 mL/kg of isotonic crystalloid (NS or LR) IV over 5–10 minutes for pediatric septic shock, reassessing after each bolus for response and fluid overload.

Question 149: A 3-year-old ingests an unknown number of iron tablets. Which finding indicates severe iron toxicity?

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

Correct answer: Hemodynamic instability and metabolic acidosis

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

Question 150: Damage control surgery (DCS) in trauma is characterized by which primary principle?

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

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 151: 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?

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

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

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

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

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

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

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

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 155: 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?

IV fluid resuscitation
Pericardiocentesis
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 156: A patient with asthma is in severe bronchospasm and is not responding to nebulized albuterol. What is the next most appropriate pharmacological intervention?

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

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

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

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

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

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 159: 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
Spontaneous bacterial peritonitis
Acute variceal hemorrhage

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

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

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 161: 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?

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

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 162: 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)
Colloid solution (albumin) 500 mL
Dextrose 5% in water 1L
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 163: A patient presents with severe unilateral pelvic pain that started suddenly, and ultrasound shows an enlarged ovary with absence of blood flow on Doppler. What is the diagnosis?

Hemorrhagic ovarian cyst
Ovarian torsion (Correct answer)
Ruptured ectopic pregnancy
Tubo-ovarian abscess

Correct answer: Ovarian torsion

Absent ovarian blood flow on Doppler ultrasound combined with an enlarged ovary and acute onset pelvic pain confirms ovarian torsion.

Question 164: A cirrhotic patient presents with confusion, asterixis, and jaundice. The nurse anticipates which primary diagnosis?

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

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 165: When performing pericardiocentesis for cardiac tamponade, the needle is inserted at which anatomical location?

Fifth intercostal space, anterior axillary line
Second intercostal space, midclavicular line
Fourth intercostal space, left sternal border
Subxiphoid angle directed toward the left shoulder (Correct answer)

Correct answer: Subxiphoid angle directed toward the left shoulder

The subxiphoid approach, directing the needle at a 45-degree angle toward the left shoulder, is the safest route for emergency pericardiocentesis.

Question 166: A trauma patient arrives after a high-speed MVC. During the primary survey, the nurse identifies absent breath sounds on the left and tracheal deviation to the right. What is the priority action?

Order portable CXR
Administer 2L normal saline IV
Perform needle thoracostomy on the left side (Correct answer)
Apply a non-rebreather mask

Correct answer: Perform needle thoracostomy on the left side

Absent breath sounds with tracheal deviation indicate tension pneumothorax requiring immediate needle decompression without waiting for imaging.

Question 167: 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?

Necrotizing enterocolitis
Hirschsprung disease
Intussusception (Correct answer)
Pyloric stenosis

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 168: What is the antidote for acetaminophen toxicity, and within what timeframe is it most effective?

Activated charcoal, within 24 hours of ingestion
Flumazenil, within 1 hour of ingestion
Fomepizole, within 12 hours of ingestion
N-acetylcysteine (NAC), within 8–10 hours of ingestion (Correct answer)

Correct answer: N-acetylcysteine (NAC), within 8–10 hours of ingestion

NAC is most effective when given within 8 hours of acetaminophen ingestion but can still provide benefit if given later; it replenishes glutathione to prevent hepatotoxicity.

Question 169: 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?

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

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 170: What is the Pediatric Assessment Triangle (PAT) composed of?

GCS, AVPU, and pupil response
Heart rate, respiratory rate, and blood pressure
Appearance, work of breathing, and circulation to skin (Correct answer)
Oxygen saturation, temperature, and mental status

Correct answer: Appearance, work of breathing, and circulation to skin

The PAT assesses three components—Appearance (tone, interactivity), Work of Breathing, and Circulation to skin—to rapidly determine if a child is stable or critically ill.

Question 171: Which weight estimation formula is commonly used in pediatric emergencies when a scale is unavailable?

Weight (kg) = age in months / 2
Weight (kg) = (age in years + 4) × 2 (Correct answer)
Weight (kg) = age (years) + 4
Weight (kg) = age (years) × 3

Correct answer: Weight (kg) = (age in years + 4) × 2

The Broselow tape is preferred, but the formula Weight = (age + 4) × 2 is a common quick estimate for children aged 1–10 years.

Question 172: Which serum biomarker is most specific for myocardial necrosis and is elevated within 3–6 hours of an acute MI?

LDH
Myoglobin
Troponin I (Correct answer)
CK-MB

Correct answer: Troponin I

Cardiac troponin I is the most specific biomarker for myocardial necrosis, rising within 3–6 hours and remaining elevated for up to 14 days.

Question 173: 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 174: 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?

Transverse myelitis
Multiple sclerosis
Guillain-Barré syndrome (Correct answer)
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 175: 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?

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

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

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

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

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

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.

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%

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