CEN Certified Emergency Nurse Exam — Questions and Answers

Question 1: 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 2: Which sign is most specific for cardiac tamponade on physical examination?

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

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

Troponin I (Correct answer)
LDH
Myoglobin
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 4: Which assessment is CONTRAINDICATED in a patient with suspected placenta previa?

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

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 5: 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
Observation and repeat ultrasound in 24 hours
Emergency surgical consultation for ovarian torsion (Correct answer)

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

Eye opening, pupil reactivity, verbal response
Pupil reactivity, verbal response, motor response
Respiratory effort, eye opening, 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 7: Which ECG change is most characteristic of hyperkalemia when the serum potassium level is above 6.5 mEq/L?

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

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 8: 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.

Question 9: Which assessment is most important before administering thrombolytics (tPA) to a patient with ischemic stroke?

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

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

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

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 11: 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
Discontinue heparin and begin an alternative anticoagulant (Correct answer)
Switch to low-molecular-weight heparin
Continue heparin and monitor platelet count daily

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 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 labetalol IV
Administer calcium gluconate IV and stop magnesium (Correct answer)
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: Which trauma patient is most likely to benefit from permissive hypotension strategy (target MAP 50 mmHg) during resuscitation?

68-year-old with TBI and abdominal bleeding
Patient in septic shock
Patient with suspected spinal cord injury
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 14: What is the priority assessment in a patient with Guillain-Barré syndrome admitted to the emergency department?

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

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 15: 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
Clostridioides difficile (Correct answer)
Salmonella typhi
Campylobacter jejuni

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

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

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

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

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

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

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 19: Preload describes:

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
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)

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

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

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

Quantifying neurological deficits and guiding thrombolysis decisions (Correct answer)
Determining eligibility for surgery
Classifying hemorrhagic vs. ischemic stroke
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 22: Which finding in a febrile infant under 30 days old warrants a full sepsis workup including lumbar puncture?

Any temperature ≥38.0°C rectally (Correct answer)
Temperature ≥38.5°C with URI symptoms
Temperature of 37.9°C rectally with otherwise normal exam
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 23: Confirmation of endotracheal tube placement should be verified by which MOST reliable method?

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

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

pH 7.52, PaCO2 28, HCO3 22
pH 7.30, PaCO2 35, HCO3 16
pH 7.28, PaCO2 58, HCO3 24 (Correct answer)
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 25: Which drug and dose is correct for pediatric epinephrine administration during cardiac arrest via IV/IO route?

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

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

Dopamine
Amiodarone
Epinephrine
Atropine (Correct answer)

Correct answer: Atropine

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

Question 27: An obstruction of the sphincter of Oddi caused by a gallstone affects a customer. What is the most typical side effect of this illness?

hepatitis
appendicitis
pancreatitis (Correct answer)
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 28: 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:

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

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

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

Correct answer: Obstructive shock from cardiac tamponade

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

Question 30: A patient presents with sudden onset severe epigastric pain, a rigid 'board-like' abdomen, and absent bowel sounds. Which condition is most likely?

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

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 31: A patient with end-stage renal disease on hemodialysis presents with peaked T-waves on ECG, muscle weakness, and potassium of 6.8 mEq/L. What is the FIRST intervention?

Administer sodium polystyrene sulfonate (Kayexalate) orally
Begin emergency hemodialysis immediately
Administer calcium gluconate IV to stabilize the cardiac membrane (Correct answer)
Give insulin 10 units IV with D50W

Correct answer: Administer calcium gluconate IV to stabilize the cardiac membrane

Calcium gluconate is the first-line intervention because it immediately stabilizes the cardiac membrane and protects against life-threatening arrhythmias while other potassium-lowering measures take effect.

Question 32: What is the initial energy setting for defibrillation of ventricular fibrillation using a biphasic defibrillator?

360 J
50 J
200 J (Correct answer)
100 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 33: Which ventilator strategy is recommended to reduce lung injury in ARDS patients?

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

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 34: 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?

Atropine (Correct answer)
N-acetylcysteine
Naloxone
Flumazenil

Correct answer: Atropine

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

Question 35: A pregnant trauma patient at 28 weeks gestation is in hemorrhagic shock. Which positioning modification is essential during resuscitation?

Supine position only
Prone positioning
Left lateral uterine displacement to relieve aortocaval compression (Correct answer)
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 36: 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?

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

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

Gastroenteritis
Intussusception
Malrotation with midgut volvulus (Correct answer)
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 38: 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?

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

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

Air-fluid levels in both lung fields
Tracheal deviation away from the affected side with opacification
Bilateral fluffy infiltrates
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 40: 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?

Right coronary artery (Correct answer)
Left main coronary artery
Left anterior descending artery
Left circumflex 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 41: Which finding best differentiates cardiogenic pulmonary edema from ARDS on chest X-ray?

Cardiomegaly and Kerley B lines in cardiogenic edema (Correct answer)
Bilateral infiltrates in cardiogenic edema vs. unilateral in ARDS
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 42: The 'lethal triad' in trauma refers to which three conditions?

Tachycardia, hypotension, and anemia
Hypothermia, acidosis, and coagulopathy (Correct answer)
Metabolic alkalosis, hyperkalemia, and hypothermia
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 43: A patient in the third trimester develops epigastric pain, nausea, thrombocytopenia, elevated LFTs, and hemolysis. What syndrome is present?

HELLP syndrome (Correct answer)
Hyperemesis gravidarum
Cholestasis of pregnancy
Acute fatty liver 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 44: A patient presents with a suspected aortic dissection. Which combination of findings is most classic?

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

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 45: 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
Cover with a moist, sterile dressing (Correct answer)
Push the bowel back into the abdomen
Clamp and ligate protruding bowel

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

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

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

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

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 48: 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 49: 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?

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

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 50: A patient is brought in post-lightning strike and is pulseless. Which finding is unique to lightning injury compared to other cardiac arrest etiologies?

PEA is the most common arrest rhythm
Torsades de pointes is the most common arrest rhythm
Asystole is the most common arrest rhythm (Correct answer)
V-fib is the most common arrest rhythm

Correct answer: Asystole is the most common arrest rhythm

Unlike most cardiac arrests, lightning strike most commonly causes asystole due to massive depolarization of cardiac cells.

Question 51: A patient has a suspected foreign body airway obstruction and becomes unconscious. What is the immediate next step?

Begin CPR and look for the object during ventilation attempts (Correct answer)
Administer high-flow oxygen via mask
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 52: Which of the following is a contraindication to administering IV tPA for acute ischemic stroke?

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

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 53: A patient on warfarin presents with an INR of 8.5 and is actively bleeding. Which is the fastest-acting reversal agent?

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

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

4-factor PCC provides the fastest reversal of warfarin by replacing all four vitamin K-dependent clotting factors, acting within minutes compared to hours for FFP or Vitamin K.

Question 54: 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?

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

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

Fomepizole (4-MP) (Correct answer)
Ethanol
N-acetylcysteine
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 56: Which formula is used to estimate the endotracheal tube size for a child between ages 1 and 10?

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

Correct answer: (Age / 4) + 4

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

Question 57: What is the initial fluid of choice for hemorrhagic shock in a trauma patient according to current guidelines?

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

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

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

Correct answer: Breathing and ventilation

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

Question 59: When performing pericardiocentesis for cardiac tamponade, the needle is inserted at which anatomical location?

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

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 60: 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)
Push the bowel back into the abdominal cavity
Cover with a dry sterile dressing
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 61: 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 100–120, decreased pulse pressure, mildly anxious
Heart rate >140, no palpable BP, unconscious
Heart rate <100, BP normal, slightly 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 62: Which finding on a 12-lead ECG is most consistent with cardiac tamponade?

Right bundle branch block
Prolonged QT interval
Electrical alternans (Correct answer)
ST elevation in all leads

Correct answer: Electrical alternans

Electrical alternans, where the QRS complex alternates in height with each beat, is a classic ECG finding in cardiac tamponade due to the heart swinging within the pericardial fluid.

Question 63: Which spinal injury pattern is most commonly associated with a diving accident causing cervical spine injury?

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

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 64: A 3-year-old presents with a temperature of 39.5°C, petechiae spreading rapidly, and altered mental status. What diagnosis requires immediate action?

Viral exanthem
Kawasaki disease
Immune thrombocytopenic purpura
Meningococcal septicemia (Correct answer)

Correct answer: Meningococcal septicemia

Rapidly spreading petechiae or purpura with fever and altered mental status is meningococcal septicemia until proven otherwise, requiring immediate IV ceftriaxone and ICU care.

Question 65: Magnesium toxicity in a preeclamptic patient on magnesium sulfate infusion is first evidenced by loss of which reflex?

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

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 66: 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?

Fentanyl patch application
Oral oxycodone every 4 hours
IV morphine titrated to effect
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 67: A 7-year-old is in anaphylaxis with urticaria, stridor, and hypotension. What is the priority intervention?

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

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 68: 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 69: A pregnant patient at 36 weeks presents with sudden painless bright red vaginal bleeding. Which condition is most likely?

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

Correct answer: Placenta previa

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

Question 70: A patient with a tricyclic antidepressant (TCA) overdose presents with a wide QRS complex and hypotension. Which treatment is most appropriate?

Physostigmine IV
Sodium bicarbonate 1–2 mEq/kg IV bolus (Correct answer)
Activated charcoal via NG tube
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 71: Which of the following best describes distributive shock?

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

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

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

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

28–32 Fr or larger tube (Correct answer)
20–22 Fr small-bore tube
12–14 Fr pigtail catheter
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 74: During a rapid sequence intubation, succinylcholine is contraindicated in which of the following patients?

Patient with a crush injury 72 hours prior (Correct answer)
Patient with a suspected cervical spine injury
Patient with a full stomach
Patient with hypertension

Correct answer: Patient with a crush injury 72 hours prior

Succinylcholine is contraindicated in crush injuries (>24-48 hours), burns, and denervation injuries due to risk of life-threatening hyperkalemia from upregulated acetylcholine receptors.

Question 75: When calculating the Parkland formula for burn resuscitation, what fluid is used in the first 24 hours?

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

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

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

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

Encourage ambulation to improve circulation
Administer IV opioids promptly per protocol and ensure adequate hydration (Correct answer)
Obtain hemoglobin electrophoresis before pain management
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 78: Cushing's triad, indicating severely elevated ICP, consists of which three findings?

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

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 79: 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
Transverse myelitis
Myasthenia gravis
Guillain-Barré syndrome (Correct answer)

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 80: 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?

CBC
MRI
CT (Correct answer)
ultrasound

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

Congenital heart disease
Primary ventricular fibrillation
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 82: A patient has a zone II penetrating neck injury with active bleeding. Which is the priority intervention?

Immediate surgical exploration
Diagnostic angiography and embolization
Direct pressure and airway management (Correct answer)
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 83: Which type of traumatic brain injury is associated with a 'lucid interval' followed by rapid deterioration?

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

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 84: A patient presents with sudden onset severe right flank pain radiating to the groin, hematuria, and costovertebral angle tenderness. Which imaging study is the gold standard for diagnosis?

IV pyelogram (IVP)
Non-contrast CT scan of abdomen and pelvis (Correct answer)
Abdominal plain film (KUB)
Renal ultrasound

Correct answer: Non-contrast CT scan of abdomen and pelvis

Non-contrast CT scan is the gold standard for nephrolithiasis as it detects all stone types including radiolucent uric acid stones and provides precise anatomical detail without contrast risk.

Question 85: What is the emergency treatment for ovarian torsion?

Hormonal suppression therapy
IV antibiotics and observation
Emergent surgical detorsion (Correct answer)
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 86: 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?

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

Correct answer: Deep frostbite (third/fourth degree)

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

Question 87: 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?

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

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

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

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 89: What is the first-line treatment for moderate croup (stridor at rest) in the emergency department?

Oral or IM dexamethasone (Correct answer)
Inhaled racemic epinephrine only
Inhaled budesonide and observation
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 90: A patient with chest pain has a 12-lead ECG showing ST depression in V1–V4. Which condition should be considered first?

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

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 91: 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 92: A trauma patient has a GCS of 9 (E2V3M4). What does this GCS score indicate about the patient's airway?

Definitive airway management should be considered (Correct answer)
The patient requires only nasal airway adjunct
The airway is patent and self-maintained
GCS does not predict airway patency

Correct answer: Definitive airway management should be considered

A GCS ≤8 is a widely used threshold for considering definitive airway management due to inability to protect the airway.

Question 93: 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?

Volvulus
Intussusception
Pyloric stenosis (Correct answer)
GERD

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 94: 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
3% Hypertonic saline
Lactated Ringer's solution
0.9% Normal saline with potassium chloride (KCl) (Correct answer)

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 95: A nurse is caring for a patient restrained due to violent behavior. Which action is a priority to prevent positional asphyxia?

Ensure the patient is never placed prone and monitor breathing continuously (Correct answer)
Apply four-point restraints in the prone position for optimal control
Sedate the patient heavily to reduce movement
Apply wrist restraints only and allow the patient to self-position

Correct answer: Ensure the patient is never placed prone and monitor breathing continuously

Positional asphyxia occurs when a restrained person cannot breathe effectively, most commonly in the prone position; continuous monitoring and supine/lateral positioning are essential.

Question 96: A patient taking phenytoin presents with a seizure. Phenytoin level is therapeutic. Which electrolyte abnormality is the most common correctable cause of breakthrough seizures?

Hyponatremia (Correct answer)
Hypermagnesemia
Hypernatremia
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 97: 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?

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

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

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

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 99: 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?

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

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

10 mEq/hr (Correct answer)
20 mEq/hr
5 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 101: 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 102: 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?

Administer 2L normal saline IV
Order portable CXR
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 103: 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)
Obtain 12-lead ECG
Insert Foley catheter
Administer furosemide 40 mg IV

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 104: A postpartum patient (1 hour after delivery) develops heavy vaginal bleeding with a boggy, enlarged uterus. What is the priority intervention?

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

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

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

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 106: 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?

metabolic acidosis
respiratory alkalosis
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 107: 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)
Phenobarbital 20 mg/kg IV
Midazolam 10 mg IM
Propofol infusion

Correct answer: Levetiracetam or fosphenytoin IV

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

Question 108: Which medication is first-line for treatment of an acute hypertensive encephalopathy with a BP of 240/140 mmHg?

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

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 109: 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?

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

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 110: A patient with digoxin toxicity has a potassium level of 6.2 mEq/L and multiple PVCs. Which treatment is indicated?

Calcium gluconate IV
Digoxin-specific antibody fragments (Digibind/DigiFab) (Correct answer)
Atropine 0.5 mg IV
Magnesium sulfate IV

Correct answer: Digoxin-specific antibody fragments (Digibind/DigiFab)

Digoxin-specific Fab fragments directly bind and inactivate digoxin, reversing toxicity including dysrhythmias and hyperkalemia.

Question 111: 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:

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

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 112: 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
CT pulmonary angiography (CTPA) (Correct answer)
V/Q scan
Chest X-ray

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 113: Which size endotracheal tube is appropriate for a 5-year-old undergoing emergency intubation?

7.0 mm cuffed
4.5–5.0 mm cuffed or uncuffed (Correct answer)
6.0 mm cuffed
3.0 mm uncuffed

Correct answer: 4.5–5.0 mm cuffed or uncuffed

The formula (age/4 + 4) estimates uncuffed ETT size; for a 5-year-old, this gives 5.25, so a 4.5–5.0 mm tube is appropriate.

Question 114: A patient presents with wide complex tachycardia. Which clinical feature most supports ventricular tachycardia over SVT with aberrancy?

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

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

Phenylephrine
Dopamine
Epinephrine
Norepinephrine (Correct answer)

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

Diffuse sulcal effacement
Ring-enhancing lesion with surrounding edema
Hyperdense lesion in the basal ganglia (Correct answer)
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 117: 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?

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

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

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

Correct answer: Rising serum lactate

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

Question 119: A 2-year-old presents with sudden onset barky cough, inspiratory stridor, and low-grade fever. What is the most likely diagnosis?

Bacterial tracheitis
Croup (laryngotracheobronchitis) (Correct answer)
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 120: 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?

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

Correct answer: Hematemesis with hemodynamic instability

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

Question 121: 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?

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

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

Asystole
PEA
SVT
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 123: Which scoring system is used prehospital to predict which trauma patients need transfer to a trauma center?

Glasgow Coma Scale alone
Revised Trauma Score (RTS) (Correct answer)
APACHE II
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 124: 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)
Submerge directly in ice water
Apply pressure dressing to the amputated part and discard

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

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

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

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

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 127: 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 has no visible neck injury
Patient has midline cervical tenderness
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)

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

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

Correct answer: Perform synchronized cardioversion

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

Question 129: 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 130: 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
Anticholinergic toxidrome
Serotonin syndrome (Correct answer)
Malignant hyperthermia

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 131: Which ECG finding in a dialysis patient with missed sessions is most immediately life-threatening?

Peaked T waves with widened QRS (Correct answer)
U waves
Prolonged PR interval
ST segment depression

Correct answer: Peaked T waves with widened QRS

Peaked T waves with widened QRS indicate severe hyperkalemia with impending cardiac dysrhythmia, requiring immediate calcium gluconate administration.

Question 132: A patient at 38 weeks is admitted in active labor. After a prolonged deceleration, the baby's head is not descending despite pushing. The fetal heart rate drops to 60 bpm. Which maneuver is first-line for shoulder dystocia?

Emergency C-section
Zavanelli maneuver
Fundal pressure (Kristeller maneuver)
McRoberts maneuver with suprapubic pressure (Correct answer)

Correct answer: McRoberts maneuver with suprapubic pressure

The McRoberts maneuver (hyperflexion of maternal hips) combined with suprapubic pressure is the first-line management for shoulder dystocia.

Question 133: Which of the following is the correct sequence for synchronized cardioversion in a hemodynamically unstable patient with atrial flutter?

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

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

Should only be done on children.
Is no longer recommended. (Correct answer)
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 135: A patient with increased intracranial pressure (ICP) is being managed. Which intervention is most appropriate as a temporizing measure?

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

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

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

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 137: 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 88–92% via controlled oxygen delivery (Correct answer)
SpO2 95% via simple face mask

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 138: 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
Tubo-ovarian abscess
Ruptured ectopic pregnancy
Ovarian torsion (Correct answer)

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 139: 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 140: Which sign is associated with cardiac tamponade in addition to hypotension and muffled heart sounds?

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

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

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

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 142: 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
Protamine sulfate IV
Naloxone 0.4 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 143: 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?

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
Remove the object carefully and apply pressure

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 144: 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?

Mucus plug in the right bronchus
Pulmonary edema
Right mainstem intubation (Correct answer)
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 145: A patient presents after acetaminophen overdose 4 hours ago. The Rumack-Matthew nomogram is used to determine treatment. Which antidote is indicated?

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

Correct answer: N-acetylcysteine (NAC)

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

Question 146: During a mass casualty incident, which triage category is assigned to patients with survivable injuries requiring immediate intervention?

Green (minor)
Black (expectant)
Red (immediate) (Correct answer)
Yellow (delayed)

Correct answer: Red (immediate)

Red tag (immediate) is assigned to patients with life-threatening but survivable injuries who need urgent treatment within 60 minutes.

Question 147: Which Glasgow Coma Scale (GCS) score indicates severe traumatic brain injury requiring airway management consideration?

GCS 13–15
GCS 8 or below (Correct answer)
GCS 9–12
GCS 6–8 with stable vitals

Correct answer: GCS 8 or below

A GCS score of 8 or below indicates severe TBI, and the inability to protect the airway is the standard threshold for endotracheal intubation.

Question 148: 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?

toxic megacolon
anal atresia
appendicitis
pyloric stenosis (Correct answer)

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 149: 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?

Administer broad-spectrum IV antibiotics
Establish IV access and initiate aggressive fluid resuscitation (Correct answer)
Prepare patient for emergent ERCP
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 150: 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
Colorectal carcinoma
Internal hemorrhoids (Correct answer)
Anal fissure

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 151: 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?

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

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 152: 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
The patient has suffered an MI
Airway obstruction (Correct answer)
Cardiac tamponade

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

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

Correct answer: Sympathomimetic toxidrome

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

Question 154: 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
Insert a chest tube at the fourth intercostal space
Start broad-spectrum antibiotics

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 155: 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
Pyloric stenosis
Intussusception (Correct answer)

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 156: 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
Gestational hypertension
Severe preeclampsia (Correct answer)
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 157: A hiker presents with core temperature of 28°C, absent shivering, and loss of consciousness. What is the correct classification of this hypothermia?

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

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 158: 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?

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

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

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

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

Hepatic encephalopathy (Correct answer)
Acute portal vein thrombosis
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 161: Which finding in a pediatric patient is the EARLIEST indicator of decompensated shock?

Tachycardia (Correct answer)
Mottled skin
Altered mental status
Hypotension

Correct answer: Tachycardia

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

Question 162: A patient with bacterial meningitis should receive which treatment combination as soon as possible?

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

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 163: 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 164: 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?

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

Correct answer: Serotonin syndrome

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

Question 165: 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?

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

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 166: 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:

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

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

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

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 168: 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?

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

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

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

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 170: 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?

IV alteplase (tPA) within the 3–4.5 hour window (Correct answer)
Aspirin 325 mg and admit for observation
Emergent carotid endarterectomy
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 171: 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?

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

Correct answer: Hydroxocobalamin (Cyanokit)

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

Question 172: 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 173: A patient presents with altered mental status, fever, muscle rigidity, and clonus after starting a new antidepressant. What condition should be suspected?

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

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 174: 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?

Metformin
Calcium channel blocker (Correct answer)
Digoxin
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 175: 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)
Lower extremity Doppler ultrasound
V/Q scan
D-dimer level

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 176: 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?

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

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

Hypovolemic shock
Septic shock
Neurogenic shock (Correct answer)
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.

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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