CPEN Certified Pediatric Emergency Nurse Exam — Questions and Answers

Question 1: A child with a long bone fracture develops increasing pain, paresthesias, and a tense extremity 6 hours post-casting. What is the priority nursing action?

Elevate the extremity higher and apply ice
Bivalve or remove the cast immediately and notify the physician (Correct answer)
Obtain an X-ray to confirm fracture alignment
Administer additional analgesia and reassess in 2 hours

Correct answer: Bivalve or remove the cast immediately and notify the physician

Progressive pain, paresthesias, and extremity tightness under a cast are signs of compartment syndrome; the cast must be bivalved or removed immediately to relieve pressure.

Question 2: Which finding is most consistent with organophosphate poisoning in a pediatric patient?

Mydriasis and dry skin
Tachycardia and hyperthermia
Hypertension and diaphoresis
Miosis, bradycardia, and excessive secretions (Correct answer)

Correct answer: Miosis, bradycardia, and excessive secretions

Organophosphate poisoning causes a cholinergic toxidrome characterized by miosis, bradycardia, bronchospasm, and excessive secretions (SLUDGE).

Question 3: A 10-year-old with Crohn disease presents to the ED with severe right lower quadrant pain and a palpable tender mass. Imaging reveals a periappendiceal abscess. What is the initial management?

IV antibiotics and interventional radiology-guided drainage (Correct answer)
High-dose corticosteroids
Immediate appendectomy
Oral antibiotics and outpatient follow-up

Correct answer: IV antibiotics and interventional radiology-guided drainage

A periappendiceal abscess in pediatric patients is typically managed initially with IV antibiotics and percutaneous drainage, with interval appendectomy considered later.

Question 4: A 16-year-old is involved in a high-speed motor vehicle collision and arrives with BP 70/40, HR 138, distended abdomen, and decreasing GCS. The PRIORITY intervention is:

Fluid bolus of 60 mL/kg normal saline
Two large-bore IV lines and immediate type and crossmatch (Correct answer)
Foley catheter placement to monitor urine output
CT scan to identify the source of bleeding

Correct answer: Two large-bore IV lines and immediate type and crossmatch

Establishing large-bore IV access and obtaining blood for type and crossmatch is the immediate priority to prepare for blood product transfusion in this patient with signs of hemorrhagic shock.

Question 5: A 4-year-old is brought in after a near-drowning event in a backyard pool. Initial resuscitation is successful. The nurse should prioritize monitoring for:

Hyperglycemia
Immediate discharge if vital signs normalize
Hypertension and bradycardia
Delayed pulmonary edema and secondary drowning (Correct answer)

Correct answer: Delayed pulmonary edema and secondary drowning

Secondary drowning can occur hours after apparent recovery due to pulmonary edema from aspirated water, requiring at least 6-8 hours of observation.

Question 6: A 7-year-old is brought in after ingesting an unknown number of acetaminophen tablets 2 hours ago. Which antidote should be prepared for administration?

N-acetylcysteine (Correct answer)
Flumazenil
Naloxone
Activated charcoal alone

Correct answer: N-acetylcysteine

N-acetylcysteine (NAC) is the specific antidote for acetaminophen toxicity and is most effective when given within 8 hours of ingestion.

Question 7: Which type of fracture in a young child should raise suspicion for non-accidental trauma (NAT)?

Toddler's spiral tibial fracture from walking fall
Greenstick fracture of the radius
Classic metaphyseal lesion or posterior rib fractures (Correct answer)
Clavicle fracture from delivery

Correct answer: Classic metaphyseal lesion or posterior rib fractures

Classic metaphyseal lesions (bucket-handle fractures) and posterior rib fractures are high-specificity indicators of non-accidental trauma in young children.

Question 8: A 2-year-old presents with a serum ethanol level of 80 mg/dL after ingesting mouthwash. Which complication requires PRIORITY monitoring in young children with ethanol ingestion?

Metabolic acidosis with elevated anion gap
Hypoglycemia (Correct answer)
Hypertension
Respiratory alkalosis

Correct answer: Hypoglycemia

Young children are at high risk for ethanol-induced hypoglycemia because they have limited glycogen stores and ethanol inhibits gluconeogenesis.

Question 9: A 10-year-old presents with palpitations, heat intolerance, weight loss despite increased appetite, exophthalmos, and a visible neck mass. For which acute complication should the emergency nurse be alert?

Severe hypoglycemia
Thyroid storm (thyrotoxic crisis) (Correct answer)
Acute adrenal crisis
Hypercalcemic crisis

Correct answer: Thyroid storm (thyrotoxic crisis)

This presentation is classic for Graves' disease (hyperthyroidism). Thyroid storm is a life-threatening decompensation characterized by hyperthermia (>40°C), severe tachycardia, hypertension, vomiting, and altered mental status — often triggered by illness or missed doses. Treatment requires beta-blockers, thionamides (PTU/methimazole), iodine solution, and corticosteroids given in sequence.

Question 10: A 5-year-old is prescribed ibuprofen 10 mg/kg PO. The child weighs 20 kg and the suspension is 100 mg/5 mL. How many mL should be given?

20 mL
2 mL
5 mL
10 mL (Correct answer)

Correct answer: 10 mL

Dose = 10 × 20 = 200 mg; volume = (200 ÷ 100) × 5 = 10 mL.

Question 11: A 6-year-old sustained a brown recluse spider bite 72 hours ago. The wound now has a central necrotic eschar with surrounding erythema and a violaceous halo. What complication should the emergency nurse monitor for systemically?

Anaphylaxis from ongoing venom absorption
Septic shock from wound infection
Disseminated intravascular coagulation (DIC)
Acute hemolytic anemia and renal failure (Correct answer)

Correct answer: Acute hemolytic anemia and renal failure

Systemic loxoscelism from brown recluse venom can cause massive intravascular hemolysis, hemoglobinuria, and acute renal failure in severe cases.

Question 12: A 14-year-old fell into a frozen pond and was submerged for 8 minutes. He is now alert with core temp of 34°C and mild confusion. Frostbitten fingers are white and wooden. Which rewarming approach for the frostbitten fingers is CORRECT?

Apply dry heat pads directly to the affected fingers
Rub the fingers briskly to restore circulation
Do not rewarm the fingers until core temperature is fully corrected
Rewarm in water at 40–42°C for 15–30 minutes if there is no risk of refreezing (Correct answer)

Correct answer: Rewarm in water at 40–42°C for 15–30 minutes if there is no risk of refreezing

Rapid rewarming in water at 40–42°C is the standard treatment for frostbite, and should be performed only when refreezing is not a risk.

Question 13: Which feature of the Pediatric Assessment Triangle (PAT) is PRIMARILY evaluated by observing the child's muscle tone, interactivity, and consolability?

Level of consciousness
Work of breathing
Appearance (Correct answer)
Circulation to skin

Correct answer: Appearance

The Appearance component of the PAT includes the TICLS mnemonic: Tone, Interactivity, Consolability, Look/gaze, and Speech/cry.

Question 14: During assessment of a 4-year-old with abdominal pain, the nurse notes that pain worsens when the right thigh is extended while the patient is lying on the left side. This finding is most consistent with which diagnosis?

Intussusception
Appendicitis (psoas sign) (Correct answer)
Cholecystitis (Murphy sign)
Mesenteric ischemia

Correct answer: Appendicitis (psoas sign)

The psoas sign—pain on right hip extension—indicates inflammation adjacent to the iliopsoas muscle, classically seen with a retrocecal appendix in appendicitis.

Question 15: A 5-year-old is stung by a scorpion in Arizona. The child is drooling, has roving eye movements, and is agitated with abnormal limb movements. Which medication is MOST effective for severe scorpion envenomation in the US?

Midazolam for symptom control only
Calcium gluconate IV
Diphenhydramine IV
Antivenom (Anascorp) (Correct answer)

Correct answer: Antivenom (Anascorp)

Centruroides scorpion antivenom (Anascorp) rapidly reverses neurotoxic symptoms including cranial nerve dysfunction, excessive secretions, and motor abnormalities.

Question 16: Which approach best demonstrates mastery of neurological emergencies in CPEN practice?

Avoiding complex scenarios
Applying principles to novel situations with sound judgment (Correct answer)
Following procedures without understanding
Relying entirely on technology

Correct answer: Applying principles to novel situations with sound judgment

True mastery involves understanding underlying principles well enough to apply them to new and unfamiliar situations with professional judgment.

Question 17: Which finding on CT head is MOST concerning for non-accidental trauma in a 6-month-old with altered mental status?

Single linear skull fracture
Epidural hematoma
Subarachnoid hemorrhage
Bilateral subdural hematomas in different stages (Correct answer)

Correct answer: Bilateral subdural hematomas in different stages

Bilateral subdural hematomas in varying stages of evolution are a classic and highly concerning finding for non-accidental trauma (abusive head trauma).

Question 18: Which laboratory finding is MOST consistent with severe sepsis and tissue hypoperfusion?

Normal C-reactive protein with elevated procalcitonin
Elevated serum lactate level greater than 2 mmol/L (Correct answer)
Blood glucose above 200 mg/dL
White blood cell count below 5,000/mm³ only

Correct answer: Elevated serum lactate level greater than 2 mmol/L

Elevated lactate greater than 2 mmol/L indicates anaerobic metabolism from tissue hypoperfusion and is a key diagnostic and prognostic marker in severe sepsis.

Question 19: What does validity mean when selecting an assessment tool for CPEN certification purposes?

The tool is inexpensive
The tool is easy to administer
The tool is widely used
The tool measures what it claims to measure (Correct answer)

Correct answer: The tool measures what it claims to measure

Validity indicates that an assessment tool accurately measures the construct or ability it was designed to measure.

Question 20: Which statement is TRUE regarding the use of weight-based dosing in obese pediatric patients?

BMI is not considered when calculating pediatric drug doses
Some medications should be dosed on ideal body weight (IBW) to avoid toxicity (Correct answer)
All medications should be dosed on actual body weight without exception
Obese children always need lower doses regardless of the drug

Correct answer: Some medications should be dosed on ideal body weight (IBW) to avoid toxicity

Lipophilic drugs and some antibiotics must be adjusted to ideal or adjusted body weight in obese pediatric patients to prevent toxicity.

Question 21: Which professional attribute is most valued in environmental emergencies within the CPEN field?

Prioritizing personal convenience
Working in isolation
Avoiding challenging situations
Accountability and commitment to standards (Correct answer)

Correct answer: Accountability and commitment to standards

Accountability and commitment to professional standards build trust and ensure consistent, high-quality practice.

Question 22: A 4-year-old ingested a grandparent's clonidine tablet and is now bradycardic and difficult to arouse. Which opioid antagonist may be trialed for clonidine toxicity despite clonidine not being an opioid?

Flumazenil
Cyproheptadine
Physostigmine
Naloxone (Correct answer)

Correct answer: Naloxone

Naloxone is often trialed in clonidine toxicity because clonidine's CNS depression may involve endogenous opioid pathways, and some patients show partial reversal of sedation.

Question 23: A 6-year-old with sickle cell disease presents after prolonged sun exposure with priapism and fever of 38.8°C. Which environmental factor most likely precipitated this complication?

Dehydration-induced hemoconcentration and sickling (Correct answer)
Sunburn activating mast cell degranulation
UV radiation causing direct vascular endothelial injury
Hyperthermia causing direct hemolysis

Correct answer: Dehydration-induced hemoconcentration and sickling

Dehydration from heat exposure causes hemoconcentration, increased blood viscosity, and sickling, precipitating vaso-occlusive crisis including priapism.

Question 24: When calculating the estimated weight of a child aged 1–10 years using the Broselow formula, which formula is commonly used?

Weight (kg) = age × 3 + 7
Weight (kg) = age × 2 + 8 (Correct answer)
Weight (kg) = age × 4
Weight (kg) = (age + 4) × 2

Correct answer: Weight (kg) = age × 2 + 8

A commonly used formula for estimating weight in children 1–10 years is Weight (kg) = (age × 2) + 8.

Question 25: A 3-week-old infant presents with prolonged jaundice, poor feeding, hypotonia, and a bulging anterior fontanelle. TSH is elevated at >150 mIU/L and free T4 is undetectable. What is the diagnosis?

Inborn error of metabolism
Neonatal hypocalcemia
Neonatal sepsis
Congenital hypothyroidism (Correct answer)

Correct answer: Congenital hypothyroidism

Congenital hypothyroidism presents with prolonged jaundice, large fontanelles, poor feeding, hypotonia, and constipation. An extremely elevated TSH with undetectable T4 confirms the diagnosis. Early levothyroxine treatment is critical to prevent irreversible intellectual disability. This condition is targeted by newborn screening (heel-stick), but some infants present clinically before results return.

Question 26: A 7-year-old presents with acute limp and hip pain. Which condition requires urgent orthopedic evaluation due to risk of avascular necrosis?

Septic arthritis of the hip (Correct answer)
Minor muscle strain
Legg-Calvé-Perthes disease only
Toxic synovitis

Correct answer: Septic arthritis of the hip

Septic arthritis of the hip is a surgical emergency because elevated intra-articular pressure and bacterial enzymes can rapidly destroy the femoral head vascularity, causing avascular necrosis.

Question 27: When using the intranasal (IN) route for medication delivery in a pediatric patient, what device is preferred to atomize the medication?

Standard needleless syringe tip
Bulb syringe
Nebulizer mask
Mucosal Atomization Device (MAD) (Correct answer)

Correct answer: Mucosal Atomization Device (MAD)

The MAD atomizes the medication into fine particles that maximize mucosal absorption and minimize the risk of the child swallowing the dose.

Question 28: A tension pneumothorax in a pediatric patient is BEST initially treated with:

Chest X-ray confirmation before intervention
Immediate chest tube insertion
Needle decompression at the 2nd intercostal space, midclavicular line (Correct answer)
High-flow oxygen and observation

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

Tension pneumothorax is a clinical diagnosis requiring immediate needle decompression — do not delay for imaging.

Question 29: When administering medications through an intraosseous (IO) route, which of the following is the most important consideration?

Flush forcefully with saline before each medication to confirm placement and ensure delivery (Correct answer)
IO sites should not be used if IV access can eventually be obtained
Medications given IO are absorbed slower than IV and should be doubled in dose
IO route cannot be used for resuscitation medications

Correct answer: Flush forcefully with saline before each medication to confirm placement and ensure delivery

IO placement must be confirmed with a saline flush to ensure patency; medications reach systemic circulation at rates comparable to central IV access.

Question 30: A 3-year-old presents with bilateral black eyes (raccoon eyes) and clear fluid from the nose after a fall. What injury should be suspected?

Facial contusions
Nasal bone fracture
Basilar skull fracture (Correct answer)
Orbital cellulitis

Correct answer: Basilar skull fracture

Raccoon eyes and CSF rhinorrhea are classic signs of a basilar skull fracture.

Question 31: Which assessment finding would MOST suggest hypovolemic shock in a 3-year-old rather than cardiogenic shock?

Pulmonary crackles and hepatomegaly
S3 gallop on cardiac auscultation
History of vomiting and diarrhea with flat neck veins (Correct answer)
Bilateral rales and jugular venous distension

Correct answer: History of vomiting and diarrhea with flat neck veins

A history of fluid loss with flat (not distended) neck veins points toward hypovolemic shock rather than the fluid-overloaded state seen in cardiogenic shock.

Question 32: Which finding is most consistent with Beck's triad in a pediatric trauma patient?

Hypertension, bradycardia, irregular respirations
Tachycardia, hypotension, diaphoresis
Bradycardia, hypertension, widened pulse pressure
Hypotension, muffled heart sounds, distended neck veins (Correct answer)

Correct answer: Hypotension, muffled heart sounds, distended neck veins

Beck's triad (hypotension, muffled heart sounds, JVD) is the classic presentation of cardiac tamponade.

Question 33: Which position of comfort is typically seen in a child with septic arthritis of the hip?

Knee flexed with hip in neutral
Hip extended and internally rotated
Hip flexed, abducted, and externally rotated (Correct answer)
Hip fully adducted and extended

Correct answer: Hip flexed, abducted, and externally rotated

Children with septic arthritis of the hip hold the joint in flexion, abduction, and external rotation to maximize joint space volume and reduce intra-articular pressure.

Question 34: A 3-year-old is brought in after a seizure. During assessment, you note horizontal nystagmus and ataxia. Which ingestion should be HIGHEST on your differential?

Iron tablets
Acetaminophen
Ethanol or benzodiazepines (Correct answer)
Aspirin

Correct answer: Ethanol or benzodiazepines

Nystagmus and ataxia are classic signs of CNS depressant ingestion such as ethanol or benzodiazepines in the pediatric patient.

Question 35: An 8-year-old with selective mutism is brought to the ED for an unrelated injury. Which approach BEST facilitates communication during assessment?

Speak only to the parent and exclude the child from all interactions
Insist the child speak verbally so the assessment can proceed
Document the child as uncooperative and proceed without assessment
Allow the child to communicate through writing, drawing, or pointing (Correct answer)

Correct answer: Allow the child to communicate through writing, drawing, or pointing

Offering alternative communication methods such as writing, drawing, or pointing respects the child's condition and enables effective assessment.

Question 36: A 13-year-old football player collapses during summer practice with a rectal temperature of 40.8°C, diaphoresis, tachycardia, and altered mental status. Labs show Na 128 mEq/L. What fluid intervention is MOST appropriate?

Hypertonic saline (3%) at 1–2 mL/kg/hr (Correct answer)
1 L bolus of 0.9% NS rapidly IV
Restricted fluid intake until cooling is achieved
D5W at maintenance rate to correct hypernatremia

Correct answer: Hypertonic saline (3%) at 1–2 mL/kg/hr

Symptomatic hyponatremia with altered mental status in heat stroke requires cautious correction with hypertonic saline to prevent cerebral herniation from cerebral edema.

Question 37: When assessing hydration status in a 9-month-old, which finding BEST indicates severe dehydration (>10% fluid deficit)?

Heart rate at the upper limit of normal
Sunken anterior fontanelle and absent tears with mottled skin (Correct answer)
Slightly decreased urine output
Mildly dry mucous membranes

Correct answer: Sunken anterior fontanelle and absent tears with mottled skin

A sunken fontanelle, absent tears, and mottled skin together indicate severe dehydration requiring urgent fluid resuscitation.

Question 38: A 6-week-old presents with paroxysmal coughing episodes, post-tussive vomiting, and an apneic episode. The infant was born to an incompletely vaccinated mother. Which diagnosis is MOST likely?

Bacterial pneumonia from S. pneumoniae
Viral croup (laryngotracheobronchitis)
Respiratory syncytial virus bronchiolitis
Pertussis (whooping cough) (Correct answer)

Correct answer: Pertussis (whooping cough)

Pertussis in young infants presents with paroxysmal cough, post-tussive vomiting, and apnea; the classic inspiratory 'whoop' may be absent in neonates and young infants.

Question 39: Which combination of findings is MOST consistent with carbon monoxide (CO) poisoning in a child?

SpO2 95%, stridor, fever
SpO2 70%, gasping, hypotension
Normal SpO2, headache, altered mental status (Correct answer)
SpO2 88%, cyanosis, bradycardia

Correct answer: Normal SpO2, headache, altered mental status

Pulse oximetry cannot distinguish carboxyhemoglobin from oxyhemoglobin, so SpO2 reads falsely normal despite significant CO poisoning causing neurological symptoms.

Question 40: A 3-month-old is brought in with a 2-day history of vomiting, dehydration, and a palpable olive-shaped mass in the epigastrium. Which diagnostic finding on ultrasound confirms the diagnosis?

Pyloric channel length > 16 mm and muscle thickness > 4 mm (Correct answer)
Intraluminal target sign with layering
Dilated loops of small bowel with air-fluid levels
Free air under the diaphragm

Correct answer: Pyloric channel length > 16 mm and muscle thickness > 4 mm

Hypertrophic pyloric stenosis is confirmed on ultrasound when pyloric muscle thickness exceeds 4 mm and channel length exceeds 16 mm.

Question 41: Which pain assessment tool is MOST appropriate for a 4-year-old child who can understand simple instructions but cannot verbalize a numeric score?

FLACC scale
Numeric Rating Scale (NRS)
Wong-Baker FACES scale (Correct answer)
CPOT scale

Correct answer: Wong-Baker FACES scale

The Wong-Baker FACES scale is validated for children ages 3 and older who can point to a face representing their pain but cannot use numeric scales.

Question 42: Which radiographic finding on a lateral neck X-ray is MOST consistent with epiglottitis?

Thumb sign representing an enlarged, rounded epiglottis (Correct answer)
Steeple sign representing subglottic narrowing
Prevertebral soft tissue swelling below the C4 level
Retropharyngeal widening at the C2 level

Correct answer: Thumb sign representing an enlarged, rounded epiglottis

The 'thumb sign' on lateral neck X-ray represents the swollen, rounded epiglottis projecting posteriorly and is the classic radiographic finding of epiglottitis.

Question 43: A 10 kg toddler requires dopamine at 10 mcg/kg/min. Using a standard concentration of 400 mcg/mL, what is the infusion rate in mL/hr?

150 mL/hr
15 mL/hr (Correct answer)
1.5 mL/hr
0.15 mL/hr

Correct answer: 15 mL/hr

Rate (mL/hr) = (10 mcg/kg/min × 10 kg × 60 min) ÷ 400 mcg/mL = 6000 ÷ 400 = 15 mL/hr.

Question 44: A 6-year-old presents with a heart rate of 140 bpm, respiratory rate of 28, capillary refill of 3 seconds, and altered mental status. This constellation BEST describes which pediatric emergency state?

Hypertensive crisis
Decompensated shock (Correct answer)
Respiratory failure
Compensated shock

Correct answer: Decompensated shock

Decompensated shock is present when altered mental status accompanies tachycardia, tachypnea, and prolonged capillary refill, indicating failing compensatory mechanisms.

Question 45: In pediatric trauma, which intervention should be performed FIRST when tension pneumothorax is suspected?

Chest X-ray to confirm
IV fluid bolus
Chest tube insertion
Needle thoracostomy at the 2nd intercostal space midclavicular line (Correct answer)

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

Tension pneumothorax is a life-threatening emergency requiring immediate needle decompression before any confirmatory imaging.

Question 46: A 6-year-old is stung by multiple bees and develops urticaria, angioedema, and wheezing. His blood pressure is 70/40 mmHg. Which route of epinephrine administration is PREFERRED?

Intramuscular injection into the anterolateral thigh (Correct answer)
Sublingual administration
Subcutaneous injection
Intravenous bolus

Correct answer: Intramuscular injection into the anterolateral thigh

IM epinephrine into the anterolateral thigh is the preferred route for anaphylaxis as it provides the fastest absorption compared to subcutaneous injection.

Question 47: After being stung by a bee, a boy experiences acute facial edema, dyspnea, and hypotension, all of which indicate anaphylaxis. The most crucial intervention is:

diphenhydramine
prednisone
epinephrine (Correct answer)
oxygen

Correct answer: epinephrine

The symptoms of acute facial edema, dyspnea, and hypotension after a bee sting are classic signs of anaphylaxis, a severe, life-threatening allergic reaction. Epinephrine is the first-line and most crucial intervention for anaphylaxis because it rapidly reverses bronchospasm, vasoconstriction, and hypotension, directly addressing the life-threatening aspects of the reaction. While oxygen and diphenhydramine are supportive, epinephrine is the immediate life-saving medication.

Question 48: On a 12-lead ECG, a delta wave indicates:

Pre-excitation via an accessory pathway (Correct answer)
Prolonged QT interval
Hypokalemia
Right bundle branch block

Correct answer: Pre-excitation via an accessory pathway

A delta wave (slurred upstroke of the QRS) represents ventricular pre-excitation through an accessory pathway, characteristic of WPW.

Question 49: In a 9-month-old infant, the anterior fontanelle is bulging and tense at rest. This finding is MOST consistent with which condition?

Normal variant for age
Hypothyroidism
Dehydration
Increased intracranial pressure (Correct answer)

Correct answer: Increased intracranial pressure

A bulging, tense anterior fontanelle at rest in an infant suggests elevated intracranial pressure requiring urgent evaluation.

Question 50: A 4-year-old with a closed femur fracture is tachycardic and pale. Estimated blood loss from a femur fracture alone can be:

Up to 50 mL
Up to 500 mL (Correct answer)
Up to 1500 mL
Up to 100 mL

Correct answer: Up to 500 mL

A closed femur fracture can result in up to 30–500 mL of blood loss in children, depending on age and size.

Question 51: Racemic epinephrine administered to a child with croup requires a minimum observation period of how long after treatment?

1 hour
4 hours
30 minutes
2 hours (Correct answer)

Correct answer: 2 hours

Children must be observed for a minimum of 2 hours after racemic epinephrine due to the risk of rebound airway edema as the medication wears off.

Question 52: A child presents with pain and inability to bear weight after a fall. Which radiographic finding is unique to pediatric fractures?

Spiral shaft fracture only
Comminuted fracture pattern
Salter-Harris growth plate fracture (Correct answer)
Open fracture with bone exposure

Correct answer: Salter-Harris growth plate fracture

Salter-Harris fractures involve the physis (growth plate) and are unique to skeletally immature patients, with classification guiding prognosis and treatment.

Question 53: Which agent is used to treat TCA-induced wide-complex dysrhythmia and hypotension?

Sodium bicarbonate (Correct answer)
Calcium gluconate
Adenosine
Magnesium sulfate

Correct answer: Sodium bicarbonate

Sodium bicarbonate alkalinizes the blood and provides sodium load to overcome TCA sodium channel blockade, reversing QRS widening and dysrhythmias.

Question 54: A 7-year-old with celiac disease presents with severe abdominal pain, distension, and obstipation after being exposed to gluten. Which complication specific to celiac disease is most concerning?

Spontaneous bacterial peritonitis
Celiac crisis with refractory diarrhea and electrolyte imbalance (Correct answer)
Intussusception
Toxic megacolon

Correct answer: Celiac crisis with refractory diarrhea and electrolyte imbalance

Celiac crisis is a rare but life-threatening complication triggered by gluten exposure, characterized by severe diarrhea, dehydration, metabolic disturbances, and malnutrition.

Question 55: Which toxic ingestion is best treated with activated charcoal?

Hydrocarbon ingestion
Caustic alkali ingestion
Aspirin overdose within 1 hour (Correct answer)
Iron tablet ingestion

Correct answer: Aspirin overdose within 1 hour

Activated charcoal is most effective when given within 1 hour of aspirin ingestion, as it adsorbs salicylate and reduces systemic absorption.

Question 56: Which finding on physical exam suggests a pelvic fracture in a pediatric trauma patient?

Tenderness only over the ASIS
Instability on pelvic compression/distraction, perineal ecchymosis, or blood at the urethral meatus (Correct answer)
Isolated hip flexor tenderness
Posterior thigh pain with straight leg raise

Correct answer: Instability on pelvic compression/distraction, perineal ecchymosis, or blood at the urethral meatus

Pelvic ring instability, perineal or scrotal ecchymosis, and blood at the urethral meatus indicate significant pelvic fracture with potential urological and vascular injury.

Question 57: A 4-year-old is found apneic. After 2 rescue breaths fail to produce chest rise, the next step is:

Perform blind finger sweep of the mouth
Proceed directly to intubation
Begin chest compressions
Attempt to ventilate again with head repositioned (Correct answer)

Correct answer: Attempt to ventilate again with head repositioned

If initial rescue breaths do not produce chest rise, the head-tilt/chin-lift should be repositioned before a second attempt, as poor positioning is the most common cause.

Question 58: A 2-year-old presents with refusal to use his right arm after being lifted by the arm. Which injury is most likely?

Shoulder dislocation
Supracondylar fracture
Nursemaid's elbow (radial head subluxation) (Correct answer)
Clavicle fracture

Correct answer: Nursemaid's elbow (radial head subluxation)

Nursemaid's elbow occurs when longitudinal traction on an outstretched arm causes subluxation of the radial head beneath the annular ligament, common in toddlers.

Question 59: During trauma assessment of a 5-year-old, the nurse notes paradoxical chest wall movement. This finding is MOST consistent with:

Simple pneumothorax
Flail chest (Correct answer)
Pulmonary contusion
Diaphragmatic hernia

Correct answer: Flail chest

Paradoxical movement—the chest segment moves inward during inhalation—is the hallmark of a flail chest caused by multiple rib fractures.

Question 60: Which approach is the MOST efficient for addressing the "emotional contagion hypothesis," which postulates that anxious parents might make their children more anxious during invasive procedures?

Tell the parents they should stop upsetting their child
Accompany the parents during the procedure
Prepare the parents in advance (Correct answer)
Keep the parents away from the child during the procedure

Correct answer: Prepare the parents in advance

The 'emotional contagion hypothesis' suggests that parental anxiety can be transferred to their children, increasing the child's distress during medical procedures. The most effective approach to mitigate this is to prepare the parents in advance. Providing clear, honest information about the procedure, what to expect, and how they can support their child empowers parents, reduces their anxiety, and enables them to be a calming and supportive presence for their child.

Question 61: Which antiepileptic drug is FIRST-LINE for infantile spasms (West syndrome)?

Phenobarbital
ACTH (adrenocorticotropic hormone) (Correct answer)
Carbamazepine
Levetiracetam

Correct answer: ACTH (adrenocorticotropic hormone)

ACTH is the first-line treatment for infantile spasms and has shown superior efficacy in reducing spasms and improving EEG in West syndrome.

Question 62: A 3-year-old presents with a mid-shaft tibia fracture and no history of trauma. Physical exam reveals bruising in multiple stages of healing. The nurse's most important action is to:

Order a bone density scan immediately
Initiate a child abuse evaluation and notify social work (Correct answer)
Splint the fracture and discharge with orthopedic referral
Reassure the parents and attribute the injury to toddler activity

Correct answer: Initiate a child abuse evaluation and notify social work

A tibia fracture in a non-ambulatory or very young child with unexplained or inconsistent history and multiple bruises is a red flag for non-accidental trauma requiring mandatory reporting and multidisciplinary evaluation.

Question 63: An 8-year-old with sickle cell disease presents with acute right upper quadrant pain, fever, and jaundice. Ultrasound shows gallstones and a distended gallbladder. Which complication is most concerning?

Biliary atresia
Simple cholelithiasis
Hepatic veno-occlusive disease
Acute cholecystitis with possible perforation (Correct answer)

Correct answer: Acute cholecystitis with possible perforation

Children with sickle cell disease are at high risk for pigment gallstones and acute cholecystitis, which can progress to perforation if not managed promptly.

Question 64: A 12-year-old male presents with knee pain and a visible bump just below the knee. He is an avid basketball player. What is the most likely diagnosis?

Septic arthritis of the knee
Patellar dislocation
Osgood-Schlatter disease (Correct answer)
Meniscal tear

Correct answer: Osgood-Schlatter disease

Osgood-Schlatter disease is caused by traction apophysitis at the tibial tubercle insertion of the patellar tendon, common in active adolescents during growth spurts.

Question 65: When assessing respiratory distress in a toddler, nasal flaring PRIMARILY indicates:

Impending respiratory failure
Normal breathing variant in children under 2
Upper airway obstruction only
Increased respiratory effort to maximize airflow (Correct answer)

Correct answer: Increased respiratory effort to maximize airflow

Nasal flaring is a compensatory mechanism in young children that dilates the nares to decrease airway resistance and increase airflow during respiratory distress.

Question 66: A child with epiglottitis is most likely to assume which position to maximize airway patency?

Supine with neck extended
Tripod (sniffing) position (Correct answer)
Prone position
Left lateral decubitus

Correct answer: Tripod (sniffing) position

Children with epiglottitis instinctively sit in the tripod (sniffing) position — leaning forward with neck extended — to open the supraglottic airway.

Question 67: Which sign differentiates obstructive shock from distributive shock in a pediatric patient?

Distended neck veins and muffled heart sounds (Correct answer)
Wide pulse pressure
Warm, flushed skin
Tachycardia

Correct answer: Distended neck veins and muffled heart sounds

Jugular venous distension and muffled heart sounds (Beck's triad) suggest obstructive shock from cardiac tamponade, distinguishing it from distributive shock.

Question 68: Which professional attribute is most valued in psychosocial emergencies within the CPEN field?

Accountability and commitment to standards (Correct answer)
Prioritizing personal convenience
Working in isolation
Avoiding challenging situations

Correct answer: Accountability and commitment to standards

Accountability and commitment to professional standards build trust and ensure consistent, high-quality practice.

Question 69: A 14-year-old obese male presents with left hip and knee pain after playing basketball. His left leg is externally rotated. Which diagnosis should the nurse prioritize?

Legg-Calvé-Perthes disease
Transient synovitis
Slipped capital femoral epiphysis (Correct answer)
Hip dislocation

Correct answer: Slipped capital femoral epiphysis

Slipped capital femoral epiphysis (SCFE) is most common in obese adolescents and presents with hip or referred knee pain and external rotation of the affected leg.

Question 70: When measuring blood pressure in a pediatric patient, which cuff size principle is MOST important for accuracy?

Cuff bladder should cover the entire upper arm
Cuff bladder should cover 50% of arm circumference
Use the largest cuff that fits on the arm
Cuff bladder width should be 40% of mid-arm circumference (Correct answer)

Correct answer: Cuff bladder width should be 40% of mid-arm circumference

The cuff bladder width should be approximately 40% of mid-arm circumference to ensure accurate blood pressure readings in children.

Question 71: A 6-year-old receives a medication that causes acute dystonia. Which drug is most commonly associated with this reaction in pediatric emergency patients?

Metoclopramide (Reglan) (Correct answer)
Lorazepam (Ativan)
Diphenhydramine (Benadryl)
Ondansetron (Zofran)

Correct answer: Metoclopramide (Reglan)

Metoclopramide is a dopamine antagonist and is the most common cause of drug-induced acute dystonia in children.

Question 72: A 7-week-old infant presents with a 2-week history of post-tussive emesis and inspiratory 'whoop.' The priority intervention is:

Obtain chest X-ray and observe
Place on contact and droplet precautions and start azithromycin (Correct answer)
Administer albuterol nebulization
Administer oral steroids

Correct answer: Place on contact and droplet precautions and start azithromycin

Pertussis in young infants is life-threatening; isolation (droplet precautions) and azithromycin are the priority interventions.

Question 73: A 12-year-old with known asthma presents with absent breath sounds on auscultation and SpO2 of 84%. This finding MOST likely indicates:

Normal auscultation for a large child
Pneumonia
Mild bronchospasm
Silent chest indicating severe obstruction (Correct answer)

Correct answer: Silent chest indicating severe obstruction

Absent breath sounds in asthma (silent chest) indicate severe airflow obstruction preventing audible air movement and is a sign of impending respiratory failure.

Question 74: A 13-year-old presents with a tick embedded in the scalp for an estimated 36 hours after a camping trip in North Carolina. Vital signs show T 39.1°C, HR 118, and the child has petechiae on the wrists and ankles. Which diagnosis requires IMMEDIATE antibiotic treatment?

Tick paralysis
Ehrlichiosis
Lyme disease with early dissemination
Rocky Mountain Spotted Fever (RMSF) (Correct answer)

Correct answer: Rocky Mountain Spotted Fever (RMSF)

Rocky Mountain Spotted Fever presents with fever, rash (petechiae on extremities), and tick exposure, requiring immediate doxycycline regardless of age due to the high mortality of untreated disease.

Question 75: A 5-year-old is brought in after ingesting a button battery. Which complication is the MOST serious concern if the battery is lodged in the esophagus?

Bowel obstruction
Aspiration pneumonia
Esophageal perforation from liquefactive necrosis (Correct answer)
Methemoglobinemia

Correct answer: Esophageal perforation from liquefactive necrosis

Button batteries lodged in the esophagus generate hydroxide ions via electrical current, causing rapid liquefactive necrosis that can perforate the esophagus within 2 hours.

Question 76: An 8-year-old ingested a large amount of acetaminophen 6 hours ago. The MOST important laboratory test to guide antidote therapy at this time is:

Serum acetaminophen level plotted on the Rumack-Matthew nomogram (Correct answer)
Serum creatinine
Complete blood count
Liver function tests (AST/ALT)

Correct answer: Serum acetaminophen level plotted on the Rumack-Matthew nomogram

The serum acetaminophen level drawn 4 or more hours post-ingestion and plotted on the Rumack-Matthew nomogram determines the risk of hepatotoxicity and the need for N-acetylcysteine.

Question 77: What is the most important professional competency for CPEN certification in psychosocial emergencies?

Speed of task completion
Memorization of all reference materials
Ability to work alone exclusively
Deep knowledge combined with practical application skills (Correct answer)

Correct answer: Deep knowledge combined with practical application skills

Professional competency requires both deep knowledge of the subject matter and the ability to apply that knowledge in practical situations.

Question 78: Which ingestion requires whole bowel irrigation as a decontamination method?

Liquid antihistamines
Household bleach
Iron tablets or sustained-release medications (Correct answer)
Alcohol

Correct answer: Iron tablets or sustained-release medications

Whole bowel irrigation with polyethylene glycol is indicated for iron tablets and sustained-release drug ingestions not adsorbed by activated charcoal.

Question 79: In pediatric shock assessment, which clinical sign is the EARLIEST indicator of compensated hypovolemic shock?

Bradycardia
Absent peripheral pulses
Hypotension
Tachycardia (Correct answer)

Correct answer: Tachycardia

Tachycardia is the earliest compensatory response to hypovolemia as the body attempts to maintain cardiac output before blood pressure falls.

Question 80: What is the value of continuing education in environmental emergencies for CPEN professionals?

It replaces workplace experience
It is only needed for recertification
It keeps professionals current with evolving standards and practices (Correct answer)
It is primarily a social activity

Correct answer: It keeps professionals current with evolving standards and practices

Continuing education ensures professionals stay current with the latest developments, standards, and best practices in their field.

Question 81: A nurse accidentally administers a vesicant medication into a surrounding tissue rather than the vein. This is called:

Thrombosis
Phlebitis
Extravasation (Correct answer)
Infiltration

Correct answer: Extravasation

Extravasation is the inadvertent leakage of a vesicant or irritant solution into surrounding tissue, which can cause necrosis.

Question 82: A child struck by a ball presents with periorbital ecchymosis, numbness in the cheek and upper teeth, and diplopia on upward gaze. Which injury does this presentation most suggest?

Mandibular fracture
Zygomatic arch fracture
Orbital floor (blowout) fracture (Correct answer)
Nasal bone fracture

Correct answer: Orbital floor (blowout) fracture

An orbital floor (blowout) fracture occurs when blunt orbital trauma forces the orbital floor into the maxillary sinus. Entrapment of the inferior rectus muscle causes restricted upward gaze and diplopia. Infraorbital nerve involvement produces numbness along the cheek and upper dentition. CT of the facial bones confirms the diagnosis.

Question 83: What is the hallmark presentation of a toddler's fracture?

Obvious deformity of the femur with crepitus
Pathological fracture through a bone cyst
Complete fracture of the fibula after direct impact
Non-displaced spiral fracture of the tibia in a child beginning to walk, after minor twisting injury (Correct answer)

Correct answer: Non-displaced spiral fracture of the tibia in a child beginning to walk, after minor twisting injury

A toddler's fracture is a non-displaced spiral tibial fracture occurring in children 9 months to 3 years from trivial twisting forces as they learn to walk.

Question 84: A 5-year-old presents with abdominal pain, vomiting, and bloody diarrhea 3 days after eating undercooked hamburger at a cookout. Labs show thrombocytopenia, anemia, and elevated creatinine. Which complication is developing?

Appendicitis
Mesenteric adenitis
Intussusception
Hemolytic uremic syndrome (Correct answer)

Correct answer: Hemolytic uremic syndrome

The triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury following E. coli O157:H7 infection is diagnostic of hemolytic uremic syndrome (HUS).

Question 85: A 7-year-old presents 4 hours after last seizure with persistent confusion and no return to baseline. The MOST appropriate diagnosis to rule out immediately is:

Simple febrile seizure
Syncope with prolonged recovery
Post-ictal state (normal)
Nonconvulsive status epilepticus (NCSE) (Correct answer)

Correct answer: Nonconvulsive status epilepticus (NCSE)

Persistent altered consciousness beyond the expected post-ictal period requires EEG to exclude nonconvulsive status epilepticus, which is treatable but easily missed.

Question 86: A parent reports finding their 2-year-old with an open bottle of acetaminophen. The child has no symptoms currently. What is the recommended antidote?

Sodium bicarbonate
Naloxone
Flumazenil
N-acetylcysteine (NAC) (Correct answer)

Correct answer: N-acetylcysteine (NAC)

N-acetylcysteine replenishes glutathione stores and prevents hepatotoxicity from acetaminophen overdose; it is most effective when given within 8 hours.

Question 87: A nurse is caring for a child with a suspected spinal injury after a diving accident. Which cervical immobilization device is most appropriate for initial prehospital stabilization?

Halo brace
Soft cervical collar
Rigid cervical collar and backboard (Correct answer)
Manual inline stabilization only

Correct answer: Rigid cervical collar and backboard

A rigid cervical collar combined with spinal backboard immobilization provides the best initial stabilization for suspected cervical spine injury in the prehospital setting.

Question 88: A 3-month-old is brought in with a history of 'fussiness' and is found to have multiple rib fractures at different stages of healing. The nurse's priority action is to:

Document the findings and notify the provider for a child abuse evaluation (Correct answer)
Apply supplemental oxygen and arrange orthopedic consult
Reassure the family and discharge with follow-up
Obtain a detailed feeding history

Correct answer: Document the findings and notify the provider for a child abuse evaluation

Multiple rib fractures in different stages of healing in an infant are highly suspicious for non-accidental trauma (child abuse) and mandate immediate provider notification and abuse evaluation.

Question 89: A 4-year-old (18 kg) requires IV morphine for pain. The standard pediatric dose is 0.1 mg/kg. What is the correct dose?

0.9 mg
1.8 mg (Correct answer)
18 mg
0.18 mg

Correct answer: 1.8 mg

0.1 mg/kg × 18 kg = 1.8 mg is the correct weight-based dose.

Question 90: A 16-year-old presents with acute knee pain and swelling after pivoting during soccer. The Lachman test is positive. The nurse anticipates which diagnosis?

Patellar dislocation
Medial collateral ligament sprain
Anterior cruciate ligament (ACL) tear (Correct answer)
Posterior cruciate ligament tear

Correct answer: Anterior cruciate ligament (ACL) tear

A positive Lachman test (anterior tibial translation at 20–30° flexion) is the most sensitive clinical test for ACL tear.

Question 91: A neonate born at 28 weeks gestation requires surfactant therapy. The PRIMARY purpose of surfactant is to:

Reduce pulmonary vascular resistance
Decrease alveolar surface tension to prevent collapse (Correct answer)
Decrease CO2 production
Stimulate respiratory drive

Correct answer: Decrease alveolar surface tension to prevent collapse

Surfactant reduces alveolar surface tension, preventing alveolar collapse at end-expiration in premature infants with surfactant deficiency (RDS).

Question 92: When using the Broselow tape for a pediatric trauma patient, what does it primarily estimate?

Blood pressure by age
Weight-based drug doses and equipment sizes (Correct answer)
Expected blood volume
Glasgow Coma Scale score

Correct answer: Weight-based drug doses and equipment sizes

The Broselow tape uses the child's length to estimate weight and provide color-coded drug dosing and equipment size recommendations.

Question 93: A 14-year-old presents after ingesting 20 acetaminophen tablets. She states she 'just wanted to sleep.' Which initial nursing action is the priority?

Assess suicide intent using a validated tool such as the Columbia Suicide Severity Rating Scale (Correct answer)
Administer activated charcoal immediately
Obtain a psychiatric consult
Notify child protective services

Correct answer: Assess suicide intent using a validated tool such as the Columbia Suicide Severity Rating Scale

A structured suicide risk assessment using a validated tool is the priority to determine immediate safety needs and guide management.

Question 94: A 4-month-old infant presents with lethargy, bulging fontanelle, and high-pitched cry. Which diagnosis should be IMMEDIATELY considered?

Benign intracranial hypertension
Normal developmental variant
Bacterial meningitis (Correct answer)
Colic

Correct answer: Bacterial meningitis

The triad of lethargy, bulging fontanelle, and high-pitched cry in an infant is a classic presentation of bacterial meningitis requiring urgent assessment and treatment.

Question 95: A 13-year-old is brought in after a motor vehicle collision with suspected pelvic fracture and hemodynamic instability. The nurse anticipates which massive transfusion protocol ratio?

10:1 PRBCs to FFP
1:1:1 PRBCs to FFP to platelets (Correct answer)
PRBCs only until surgical intervention
3:1 PRBCs to FFP

Correct answer: 1:1:1 PRBCs to FFP to platelets

Massive transfusion protocols utilize a 1:1:1 ratio of packed red blood cells, fresh frozen plasma, and platelets to mimic whole blood and reduce coagulopathy.

Question 96: A child with known hemophilia A presents with acute abdominal pain and is found to have a retroperitoneal hematoma on imaging. What is the most appropriate initial treatment?

Start heparin therapy
Administer factor VIII concentrate (Correct answer)
Administer fresh frozen plasma alone
Emergency laparotomy

Correct answer: Administer factor VIII concentrate

In a child with hemophilia A, the priority is to restore factor VIII activity to stop the bleeding before any surgical consideration.

Question 97: A 14-year-old presents with chest pain, fever, and a friction rub. ECG shows diffuse ST elevation with PR depression in most leads. The most likely diagnosis is:

Pulmonary embolism
Acute MI from coronary vasospasm
Hypertrophic cardiomyopathy
Pericarditis (Correct answer)

Correct answer: Pericarditis

Diffuse saddle-shaped ST elevation with PR depression in most leads, plus a friction rub, is the classic presentation of pericarditis.

Question 98: Following open reduction of a femur fracture, a 9-year-old develops severe pain with passive stretch of the toes and a tense, woody thigh. The nurse's priority is to:

Elevate the extremity above heart level
Apply ice packs to reduce swelling
Administer additional opioid analgesics
Notify the provider immediately for compartment syndrome evaluation (Correct answer)

Correct answer: Notify the provider immediately for compartment syndrome evaluation

The 6 Ps (pain, pressure, paralysis, paresthesia, pallor, pulselessness) indicate compartment syndrome, a surgical emergency requiring fasciotomy.

Question 99: Which of the following is the MOST reliable early sign of shock in a pediatric trauma patient?

Altered mental status
Decreased blood pressure
Tachycardia (Correct answer)
Decreased urine output

Correct answer: Tachycardia

Tachycardia is the earliest and most sensitive sign of shock in children because they compensate by increasing heart rate before blood pressure falls.

Question 100: Which medication should be available at the bedside whenever IV fentanyl is administered to a pediatric patient?

Flumazenil (Romazicon)
Atropine
Epinephrine
Naloxone (Narcan) (Correct answer)

Correct answer: Naloxone (Narcan)

Naloxone reverses opioid-induced respiratory depression and must be immediately available when opioids are administered.

Question 101: What is the best practice for documenting assessment results in CPEN practice?

Document results from memory at end of day
Document all findings objectively and completely (Correct answer)
Record only abnormal findings
Use subjective descriptions only

Correct answer: Document all findings objectively and completely

Best practice requires documenting all findings objectively and completely at the time of assessment for accuracy and legal protection.

Question 102: When a 4-year-old who swallowed a little toy has inspiratory stridor, the obstruction is probably:

in the subglottic area
at or above of the vocal cords (Correct answer)
within the primary bronchi
within the trachea

Correct answer: at or above of the vocal cords

Inspiratory stridor is a high-pitched, harsh sound heard during inspiration, typically indicating an obstruction in the upper airway. When a foreign body causes inspiratory stridor, the obstruction is most likely located at or above the vocal cords (larynx or pharynx). Obstructions lower in the airway, such as in the trachea or bronchi, usually produce different sounds like wheezing or diminished breath sounds, rather than stridor.

Question 103: Which electrolyte abnormality is MOST likely to precipitate ventricular arrhythmias in a pediatric patient?

Hypernatremia
Hypocalcemia
Hypokalemia (Correct answer)
Hypermagnesemia

Correct answer: Hypokalemia

Hypokalemia prolongs the QT interval and increases myocardial excitability, predisposing to ventricular arrhythmias including torsades de pointes.

Question 104: A 12-year-old gymnast presents with wrist pain after a backward fall. X-ray is negative. The anatomic snuffbox is tender. The nurse should anticipate which next step?

Apply a volar wrist splint and discharge without follow-up
Perform immediate MRI in the ED
Discharge with RICE therapy
Apply a thumb spica splint and arrange follow-up for possible scaphoid fracture (Correct answer)

Correct answer: Apply a thumb spica splint and arrange follow-up for possible scaphoid fracture

Anatomical snuffbox tenderness with a negative X-ray is highly suspicious for scaphoid fracture; a thumb spica splint and orthopedic follow-up are indicated as scaphoid fractures can be initially radiographically occult.

Question 105: A 7-year-old with known short bowel syndrome presents with high-volume watery diarrhea, fever, and abdominal cramping after starting a new enteral formula. What is the most appropriate first action?

Hold the enteral feed and assess for formula intolerance or infection (Correct answer)
Administer loperamide to slow GI transit
Increase IV fluid rate and continue enteral feeds
Order a barium enema

Correct answer: Hold the enteral feed and assess for formula intolerance or infection

High-volume diarrhea with fever in a child with short bowel syndrome warrants stopping enteral feeds and evaluating for infection (including C. difficile) or formula intolerance before resuming.

Question 106: During a rapid assessment, a pediatric nurse notes that a 3-year-old has grunting respirations. Grunting PRIMARILY serves to:

Expel secretions from the lower airways
Signal upper airway obstruction above the glottis
Indicate pain rather than respiratory compromise
Increase end-expiratory pressure to prevent alveolar collapse (Correct answer)

Correct answer: Increase end-expiratory pressure to prevent alveolar collapse

Grunting is produced by partial closure of the glottis during expiration to generate intrinsic PEEP and maintain alveolar patency in conditions like pneumonia or pulmonary edema.

Question 107: Sodium bicarbonate is administered for a pediatric TCA overdose with wide-complex dysrhythmia. What is the PRIMARY mechanism by which it helps?

It chelates the TCA molecule directly
It increases urinary excretion of the TCA
Alkalinization reverses sodium channel blockade and increases protein binding of the drug (Correct answer)
It stimulates beta-adrenergic receptors

Correct answer: Alkalinization reverses sodium channel blockade and increases protein binding of the drug

Sodium bicarbonate alkalinizes the serum, which increases protein binding of TCAs and partially reverses sodium channel blockade, reducing QRS widening and dysrhythmia risk.

Question 108: A 7-year-old with known VP shunt presents with headache and vomiting for 24 hours. His temperature is 38.8°C. What is the priority intervention?

Perform lumbar puncture to rule out meningitis
Start empiric antibiotics and discharge
Administer acetaminophen and observe
Obtain immediate neurosurgical consultation for shunt evaluation (Correct answer)

Correct answer: Obtain immediate neurosurgical consultation for shunt evaluation

Fever with VP shunt malfunction symptoms requires urgent neurosurgical evaluation because shunt infection or obstruction can be life-threatening.

Question 109: A 5-year-old presents with inspiratory stridor, a barky cough, and low-grade fever. Which condition does this presentation MOST suggest?

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

Correct answer: Croup (laryngotracheobronchitis)

The classic triad of barky cough, inspiratory stridor, and low-grade fever in a preschool-age child is diagnostic of croup caused by viral laryngotracheobronchitis.

Question 110: A 15-year-old student has a rapid onset of fever, chills, and headache along with signs of confusion and hallucinations. He displays nuchal stiffness and photophobia. The indications from Brudzinski and Kernig are encouraging. The key diagnostic procedure is:

cranial magnetic resonance imaging (MRI) scan
lumbar puncture and examination of the cerebrospinal fluid (Correct answer)
complete blood count and differential
blood culture

Correct answer: lumbar puncture and examination of the cerebrospinal fluid

The symptoms described, including rapid onset fever, chills, headache, confusion, nuchal stiffness, photophobia, and positive Brudzinski and Kernig signs, are classic indicators of meningitis. A lumbar puncture to collect and analyze cerebrospinal fluid (CSF) is the definitive diagnostic procedure for meningitis. This allows for the identification of the causative pathogen (bacterial, viral, or fungal) and guides appropriate, life-saving treatment.

Question 111: A 5-year-old develops fever, sore throat, and a diffuse 'sandpaper-like' rash after a positive rapid strep test. What is the MOST appropriate antibiotic treatment?

Amoxicillin for 10 days (Correct answer)
Cephalexin for 7 days
Clindamycin for 14 days
Azithromycin for 5 days

Correct answer: Amoxicillin for 10 days

Amoxicillin for 10 days (or penicillin) is first-line treatment for Group A Streptococcal pharyngitis/scarlet fever to eradicate the organism and prevent rheumatic fever.

Question 112: When calculating the PELOD-2 score in a pediatric patient with suspected sepsis, which parameter is included?

Body surface area involvement
Serum procalcitonin level
Glasgow Coma Scale score (Correct answer)
Erythrocyte sedimentation rate

Correct answer: Glasgow Coma Scale score

The PELOD-2 (Pediatric Logistic Organ Dysfunction-2) score includes Glasgow Coma Scale score as part of its neurological domain assessment.

Question 113: In CPEN practice, what is the best approach to quality improvement in cardiac emergencies?

Use data-driven methods with measurable outcomes (Correct answer)
Make changes without measuring results
Copy what other organizations do without analysis
Wait for problems to occur before acting

Correct answer: Use data-driven methods with measurable outcomes

Data-driven quality improvement with measurable outcomes ensures that changes actually produce the intended improvements and can be verified.

Question 114: An 8-month-old presents with bilious vomiting, inconsolable crying, and a 'currant jelly' stool. Which diagnosis should be IMMEDIATELY suspected?

Pyloric stenosis
Intussusception (Correct answer)
Hirschsprung disease
Mesenteric adenitis

Correct answer: Intussusception

Bilious vomiting, intermittent colicky pain, and currant jelly stool are the classic triad of intussusception, a surgical emergency.

Question 115: A 10-month-old is brought in after reportedly ingesting a small magnet set. X-ray confirms two magnets in separate loops of bowel. Why is this particularly dangerous compared to ingesting a single magnet?

Magnets in separate bowel loops attract each other, causing pressure necrosis and perforation (Correct answer)
Multiple magnets block the pylorus completely
Two magnets cause a stronger foreign body reaction
Multiple magnets cause toxic heavy metal poisoning

Correct answer: Magnets in separate bowel loops attract each other, causing pressure necrosis and perforation

When multiple magnets are in separate loops of bowel, they attract through the intestinal walls, causing pressure necrosis, fistula formation, and perforation.

Question 116: A child presents sitting upright and leaning forward in the 'sniffing position' with high fever, drooling, and severe respiratory distress. Epiglottitis is suspected. What is the MOST important immediate action?

Obtain a lateral neck X-ray before any airway intervention
Perform oral examination with a tongue depressor to visualize the epiglottis
Minimize agitation, prepare for definitive airway management, and call for anesthesia/ENT backup (Correct answer)
Administer racemic epinephrine via nebulizer as first-line treatment

Correct answer: Minimize agitation, prepare for definitive airway management, and call for anesthesia/ENT backup

Epiglottitis can cause complete airway obstruction with any agitation; the priority is keeping the child calm and immediately mobilizing resources for controlled intubation or surgical airway.

Question 117: A 6-year-old with type 1 diabetes is found unresponsive with a blood glucose of 24 mg/dL. IV access cannot be established. What is the most appropriate intervention?

Apply oral glucose gel to the buccal mucosa
Administer glucagon intramuscularly or intranasally (Correct answer)
Insert an intraosseous line and infuse 10% dextrose
Perform rectal glucose administration

Correct answer: Administer glucagon intramuscularly or intranasally

For severe hypoglycemia with altered consciousness when IV access is unavailable, glucagon (IM or intranasal) is the priority intervention. It stimulates hepatic glycogenolysis to raise blood glucose rapidly. Oral glucose gel is contraindicated in an unresponsive child due to aspiration risk. IO dextrose is a valid alternative but requires more setup time than glucagon IM/IN.

Question 118: Which finding on echocardiography is MOST consistent with Kawasaki disease complication requiring immediate intervention?

Trivial tricuspid regurgitation
Giant coronary artery aneurysm (≥8 mm) (Correct answer)
Mild mitral valve prolapse
Small patent foramen ovale

Correct answer: Giant coronary artery aneurysm (≥8 mm)

Giant coronary aneurysms (≥8 mm) in Kawasaki disease carry high risk of thrombosis and myocardial infarction, requiring anticoagulation.

Question 119: A 2-year-old presents after ingesting a dishwasher detergent pod with oral burns, drooling, and refusal to swallow. Which action is CONTRAINDICATED in managing this caustic ingestion?

NPO status pending endoscopic evaluation
IV access and pain management
Airway assessment and intubation if needed
Induction of vomiting with syrup of ipecac (Correct answer)

Correct answer: Induction of vomiting with syrup of ipecac

Inducing vomiting after caustic ingestion is strictly contraindicated because it re-exposes the esophageal and oropharyngeal mucosa to the caustic agent, worsening burns and increasing perforation risk.

Question 120: A 5-year-old presents with sudden, severe periumbilical pain that migrates to the right lower quadrant, low-grade fever, and anorexia. The Rovsing sign is positive. Which diagnostic tool is preferred to confirm the diagnosis while minimizing radiation exposure?

CT scan of the abdomen and pelvis
MRI of the abdomen
Abdominal X-ray
Ultrasound of the right lower quadrant (Correct answer)

Correct answer: Ultrasound of the right lower quadrant

Ultrasound is the preferred first-line imaging for suspected appendicitis in children to avoid ionizing radiation, with CT reserved for indeterminate ultrasound results.

Question 121: Which professional attribute is most valued in neurological emergencies within the CPEN field?

Avoiding challenging situations
Accountability and commitment to standards (Correct answer)
Prioritizing personal convenience
Working in isolation

Correct answer: Accountability and commitment to standards

Accountability and commitment to professional standards build trust and ensure consistent, high-quality practice.

Question 122: Which behavior in a 10-year-old brought to the ED after a house fire is MOST consistent with acute stress disorder?

Refusing to answer questions
Crying and clinging to a parent
Repeatedly re-enacting the fire in play (Correct answer)
Complaining of stomach pain

Correct answer: Repeatedly re-enacting the fire in play

Repetitive trauma re-enactment in play is a hallmark dissociative/intrusive symptom of acute stress disorder in school-age children.

Question 123: A 7-year-old has a Glasgow Coma Scale (GCS) score of 8. Which airway intervention is MOST indicated?

Definitive airway management (intubation) (Correct answer)
Bag-mask ventilation
Jaw thrust maneuver only
Supplemental oxygen by nasal cannula

Correct answer: Definitive airway management (intubation)

A GCS of 8 or below is a widely accepted threshold indicating inability to protect the airway and the need for definitive airway management.

Question 124: In a pediatric patient with suspected increased intracranial pressure, which pupillary finding indicates uncal herniation?

Hippus (rhythmic pupil oscillation)
Bilaterally pinpoint pupils
Unilateral fixed and dilated pupil (Correct answer)
Bilateral sluggish but equal pupils

Correct answer: Unilateral fixed and dilated pupil

A unilateral fixed and dilated pupil (blown pupil) indicates compression of cranial nerve III from uncal herniation, a neurosurgical emergency.

Question 125: What is the most important professional competency for CPEN certification in gastrointestinal emergencies?

Deep knowledge combined with practical application skills (Correct answer)
Speed of task completion
Memorization of all reference materials
Ability to work alone exclusively

Correct answer: Deep knowledge combined with practical application skills

Professional competency requires both deep knowledge of the subject matter and the ability to apply that knowledge in practical situations.

Question 126: An 18-month-old presents with 3 days of fever and irritability. Examination reveals a bulging, erythematous tympanic membrane with loss of the light reflex. Which antibiotic is FIRST-LINE per AAP guidelines?

Trimethoprim-sulfamethoxazole
Azithromycin
Cephalexin
Amoxicillin (Correct answer)

Correct answer: Amoxicillin

Amoxicillin is the first-line antibiotic for acute otitis media per AAP guidelines due to its efficacy against S. pneumoniae, the most common causative organism.

Question 127: Twelve hours following the commencement of the symptoms, a 4-year-old sickle cell patient with a right-sided stroke and left hemiplegia is taken to the hospital. What medical procedure is recommended to lower the chance of having another stroke?

Hyaluronidase
Unfractionated heparin
Exchange transfusion (Correct answer)
Thrombolytics

Correct answer: Exchange transfusion

For a child with sickle cell disease experiencing an acute stroke, an exchange transfusion is the recommended medical procedure to reduce the risk of another stroke. This procedure rapidly reduces the percentage of sickled red blood cells and replaces them with healthy red blood cells, improving oxygen delivery and decreasing blood viscosity. This helps prevent further vaso-occlusion and subsequent neurological damage.

Question 128: Which is the preferred initial fluid resuscitation volume for hemorrhagic shock in a pediatric trauma patient?

40 mL/kg isotonic crystalloid
10 mL/kg isotonic crystalloid
5 mL/kg isotonic crystalloid
20 mL/kg isotonic crystalloid (Correct answer)

Correct answer: 20 mL/kg isotonic crystalloid

ATLS and pediatric trauma guidelines recommend 20 mL/kg of isotonic crystalloid as the initial fluid bolus for hemorrhagic shock.

Question 129: An infant is receiving a continuous IV infusion and the pump alarms for occlusion. What is the first nursing action?

Assess the IV site and tubing for kinks or positional occlusion (Correct answer)
Replace the IV catheter immediately
Increase the pump pressure limit
Notify the physician before doing anything

Correct answer: Assess the IV site and tubing for kinks or positional occlusion

Assessment of the IV site and tubing is the first step to identify and correct the most common, easily remedied causes of occlusion.

Question 130: A neonate requires phenobarbital for seizures. Which potential side effect requires the nurse to have resuscitation equipment at the bedside?

Respiratory depression and apnea (Correct answer)
Tachyarrhythmia
Hyperglycemia
Hypertensive crisis

Correct answer: Respiratory depression and apnea

Phenobarbital can cause significant respiratory depression, especially in neonates and when combined with other CNS depressants.

Question 131: A nurse receives a verbal order for a medication during a pediatric emergency. What is the safest practice after receiving the verbal order?

Repeat the order back and confirm with the ordering provider before administering (Correct answer)
Refuse to act on verbal orders unless written first
Have another nurse write it down and administer
Administer immediately without delay then document later

Correct answer: Repeat the order back and confirm with the ordering provider before administering

Read-back confirmation of verbal orders is a Joint Commission-required safety practice that reduces communication errors.

Question 132: Which pupillary finding is the EARLIEST sign of uncal herniation?

Bilateral fixed and dilated pupils
Pinpoint pupils bilaterally
Unilateral miosis with ptosis
Unilateral dilated and non-reactive pupil ipsilateral to the lesion (Correct answer)

Correct answer: Unilateral dilated and non-reactive pupil ipsilateral to the lesion

Uncal herniation compresses CN III, causing ipsilateral pupillary dilation that is non-reactive — this is an early and critical sign.

Question 133: During triage, a 9-month-old presents with a bulging anterior fontanelle, high-pitched cry, and petechial rash. What is the nurse's most urgent concern?

Benign intracranial hypertension
Roseola infantum
Bacterial meningitis with possible septicemia (Correct answer)
Vitamin K deficiency bleeding

Correct answer: Bacterial meningitis with possible septicemia

A bulging fontanelle, high-pitched cry, and petechial rash are classic signs of bacterial meningitis and meningococcemia, which require immediate antibiotics.

Question 134: Which assessment finding in a neonate (0–28 days) requires the MOST immediate intervention?

Respiratory rate of 45 breaths/min
Central cyanosis with respiratory rate of 70 breaths/min (Correct answer)
Heart rate of 140 bpm
Mild acrocyanosis of the hands

Correct answer: Central cyanosis with respiratory rate of 70 breaths/min

Central cyanosis with tachypnea (RR >60) in a neonate indicates significant cardiorespiratory compromise requiring immediate intervention.

Question 135: A 10-year-old post-cardiac arrest is receiving targeted temperature management. The target core temperature range is:

32–34°C for 24–48 hours
33–34°C for 12 hours only
36–37.5°C (normothermia) for 72 hours (Correct answer)
30–32°C for 6 hours

Correct answer: 36–37.5°C (normothermia) for 72 hours

Current pediatric post-arrest guidelines support targeted temperature management at 36–37.5°C (normothermia prevention of fever) for at least 72 hours.

Question 136: A 5-year-old sustains a partial-thickness sunburn to both arms after a day at the beach. Parents ask about home wound care. Which recommendation is CORRECT?

Apply butter or petroleum jelly to cool and protect the skin
Pop blisters with a sterile needle to prevent infection
Apply topical diphenhydramine cream for itch relief
Cover with cool, moist cloths and use ibuprofen for pain; do not break blisters (Correct answer)

Correct answer: Cover with cool, moist cloths and use ibuprofen for pain; do not break blisters

Cool compresses, oral NSAIDs, hydration, and leaving blisters intact are the correct management for partial-thickness burns from sunburn.

Question 137: A 6-year-old develops ascending weakness starting in the legs 3 weeks after a GI illness. Reflexes are absent. The MOST likely diagnosis is:

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

Correct answer: Guillain-Barré syndrome

Guillain-Barré syndrome presents with ascending flaccid paralysis and areflexia following a triggering infection, typically weeks prior.

Question 138: A 3-year-old ingested iron supplement tablets. Which early clinical sign is MOST associated with iron toxicity in the gastrointestinal phase?

Seizures and altered mental status
Hematemesis and bloody diarrhea (Correct answer)
Metabolic alkalosis
Bradycardia and hypotension

Correct answer: Hematemesis and bloody diarrhea

Iron is directly corrosive to the GI tract, causing hematemesis, bloody diarrhea, and abdominal pain in the initial GI phase of toxicity.

Question 139: What is the key benefit of evidence-based decision making in CPEN management?

It speeds up all processes
It eliminates all risk
It reduces reliance on data
It improves accuracy and reduces bias in decisions (Correct answer)

Correct answer: It improves accuracy and reduces bias in decisions

Evidence-based decision making uses data and research to improve the accuracy of decisions and reduce the influence of personal bias.

Question 140: A 15-year-old with inflammatory bowel disease presents with fever, abdominal distension, and a markedly dilated transverse colon on X-ray (> 6 cm). He appears toxic. Which diagnosis is most likely?

Toxic megacolon (Correct answer)
Large bowel obstruction from stricture
Paralytic ileus
Sigmoid volvulus

Correct answer: Toxic megacolon

Toxic megacolon is defined by colonic dilation greater than 6 cm with systemic toxicity and is a life-threatening complication of inflammatory bowel disease requiring urgent intervention.

Question 141: What is the CORRECT pediatric dose of lorazepam for an actively seizing child?

0.5 mg/kg IV, max 10 mg
0.01 mg/kg IV, max 0.5 mg
1 mg/kg IV, max 20 mg
0.05–0.1 mg/kg IV, max 4 mg per dose (Correct answer)

Correct answer: 0.05–0.1 mg/kg IV, max 4 mg per dose

Lorazepam 0.05–0.1 mg/kg IV (max 4 mg per dose) is the first-line benzodiazepine for acute pediatric seizure management.

Question 142: A teenager ingests a large amount of acetaminophen 8 hours ago. Which lab value is the priority assessment?

Serum lipase
Serum acetaminophen level and liver function tests (Correct answer)
Serum electrolytes
Complete blood count

Correct answer: Serum acetaminophen level and liver function tests

Serum acetaminophen level plotted on the Rumack-Matthew nomogram and LFTs are essential to determine toxicity risk and need for NAC treatment.

Question 143: A 9-year-old with a traumatic brain injury (TBI) has a GCS of 7, HR 52, BP 160/90, and irregular respirations. This triad is known as:

Cushing's triad (Correct answer)
Charcot's triad
Beck's triad
Virchow's triad

Correct answer: Cushing's triad

Cushing's triad (hypertension, bradycardia, irregular respirations) indicates dangerously elevated intracranial pressure and impending herniation.

Question 144: A 6-year-old presents with drooling, tripod positioning, and refusal to swallow. The nurse should FIRST:

Attempt to visualize the oropharynx with a tongue blade
Keep the child calm and prepare for definitive airway management (Correct answer)
Administer nebulized epinephrine immediately
Obtain a lateral neck X-ray before any intervention

Correct answer: Keep the child calm and prepare for definitive airway management

Drooling, tripod positioning, and dysphagia suggest epiglottitis; agitating the child by examining the throat can precipitate complete airway obstruction.

Question 145: A 13-year-old runner presents with anterior knee pain that worsens with stair climbing and kneeling. There is tenderness over the tibial tubercle apophysis. Which condition is most likely?

Prepatellar bursitis
Chondromalacia patellae
Osgood-Schlatter disease (Correct answer)
Patellar tendinopathy

Correct answer: Osgood-Schlatter disease

Osgood-Schlatter disease is traction apophysitis of the tibial tubercle caused by repetitive quadriceps stress during adolescent growth spurts.

Question 146: Which finding is MOST consistent with toxic shock syndrome (TSS) caused by Staphylococcus aureus in a pediatric patient?

Petechial rash beginning on the trunk
Painless ulcer at the primary inoculation site
Vesicular lesions on palms and soles
Desquamation of palms and soles 1-2 weeks after illness onset (Correct answer)

Correct answer: Desquamation of palms and soles 1-2 weeks after illness onset

Desquamation of the palms and soles occurring 1–2 weeks after the acute illness is a hallmark feature of staphylococcal toxic shock syndrome.

Question 147: In pediatric trauma, which radiographic view is included in the primary survey imaging for hemodynamically unstable patients?

Full skeletal survey
CT of the head, chest, and abdomen with contrast
MRI of the spine
Chest X-ray, pelvis X-ray, and FAST exam (Correct answer)

Correct answer: Chest X-ray, pelvis X-ray, and FAST exam

In hemodynamically unstable pediatric trauma patients, the primary survey imaging includes chest X-ray, pelvis X-ray, and FAST exam to identify life-threatening hemorrhage without delaying resuscitation.

Question 148: The 'steeple sign' on anteroposterior neck X-ray in a child with stridor is characteristic of:

Foreign body aspiration
Epiglottitis
Retropharyngeal abscess
Croup (laryngotracheobronchitis) (Correct answer)

Correct answer: Croup (laryngotracheobronchitis)

The steeple sign represents subglottic narrowing on AP X-ray, which is the classic radiographic finding in viral croup.

Question 149: A 13-year-old with penetrating abdominal trauma has tachycardia and peritoneal signs. The MOST appropriate next step is:

Immediate surgical consultation for exploratory laparotomy (Correct answer)
FAST exam followed by observation
Diagnostic peritoneal lavage
CT scan of the abdomen with contrast

Correct answer: Immediate surgical consultation for exploratory laparotomy

Peritoneal signs (rigidity, rebound tenderness) after penetrating trauma indicate the need for emergent surgical consultation and likely operative intervention.

Question 150: Which of the following vital sign parameters is MOST age-appropriate for a healthy 1-year-old?

Heart rate 100–160 bpm, RR 25–35 (Correct answer)
Heart rate 140–160 bpm, RR 40–60
Heart rate 60–80 bpm, RR 12–20
Heart rate 80–100 bpm, RR 18–24

Correct answer: Heart rate 100–160 bpm, RR 25–35

Normal vital signs for a 1-year-old include a heart rate of approximately 100–160 bpm and respiratory rate of 25–35 breaths per minute.

Question 151: When using the Pediatric Early Warning Score (PEWS), which three domains are typically assessed?

Temperature, heart rate, and oxygen saturation
Skin color, capillary refill, and pupil response
Level of consciousness, urine output, and blood pressure
Behavior, cardiovascular status, and respiratory status (Correct answer)

Correct answer: Behavior, cardiovascular status, and respiratory status

PEWS assesses Behavior, Cardiovascular status, and Respiratory status to identify early clinical deterioration in hospitalized children.

Question 152: A 2-year-old is ordered acetaminophen 15 mg/kg PO. The liquid is available as 160 mg/5 mL. The child weighs 12 kg. How many mL should be given?

2.8 mL
5.6 mL (Correct answer)
11.3 mL
7.5 mL

Correct answer: 5.6 mL

Dose = 15 × 12 = 180 mg; volume = (180 ÷ 160) × 5 = 5.625 ≈ 5.6 mL.

CPEN Certified Pediatric Emergency Nurse Exam

The CPEN® exam, administered by the Board of Certification for Emergency Nursing (BCEN), certifies nurses in pediatric emergency care across six clinical domains including respiratory, cardiovascular, neurological, trauma, and psychosocial emergencies.

150

Questions

180 min

Time Limit

75%

To Pass

Checking for saved progress...

Exam Rules

You can skip questions and return to them later
Flag questions for review before submitting
No feedback shown until you submit the entire exam
Unanswered questions count as wrong — answer everything
10 pretest questions are mixed in and don't affect your score
Timer auto-submits when time runs out
Your progress is auto-saved every 30 seconds