BCEN CPEN Exam Questions

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61.

Which of the following chemical warfare agents used in mass casualty events causes blistering to the patient's skin?

  • Vesicants 

  • Nerve agents 

  • Cyanide 

  • Riot-control agents 

Correct answer: Vesicants

Chemical warfare agents are hazardous chemicals designed for use by the military to irritate, incapacitate, injure, or kill during wartime. Mass casualty events caused by chemical attacks may be combined with explosions and blast attacks to make dirty bombs. First responders must be cautious in these types of attacks as to not expose themselves. Children are more vulnerable because of their physiologic, developmental, and psychological differences.

Vesicants cause blistering; the most common vesicants are sulfur, mustard, and lewisite. They can cause damage to the eyes, skin, airways, and some internal organs. The other chemical agents listed do not cause blistering of the skin.

62.

You are triaging a 10-year-old child who presents to the emergency department (ED) with a compound fracture of the tibia. What initial nursing action is necessary for this type of fracture?

  • Cover the site with a sterile dressing

  • Elevate the leg above the level of the heart

  • Attempt bone reduction

  • Wrap the leg in a tight compression bandage

Correct answer: Cover the site with a sterile dressing

A compound fracture (also called an open fracture) carries an increased risk of neurovascular compromise, blood loss, and infection because the skin and tissue over the bone are no longer intact. You should immediately cover the fracture with a sterile bandage or dressing (if this hasn't yet been done). 

Bone reduction should never be attempted by an ED nurse but by a specialized orthopedic surgeon as indicated. Avoid tight compression bandaging due to the risk of tissue ischemia. The extremity should be immobilized and splinted until a further assessment is made by the physician. 

63.

How is the varicella virus most commonly transmitted? 

  • Respiratory droplets

  • Contact with inanimate reservoirs

  • Contact transmission 

  • Water-borne transmission 

Correct answer: Respiratory droplets

Varicella-zoster virus (VZV) causes the highly contagious, systemic disease commonly known as chickenpox; VZV infection typically presents with diffuse vesicular lesions that itch, fever, general malaise, and fatigue. The varicella virus is transmitted via respiratory droplets and contact with open lesions. Droplet transmission occurs more frequently. Chickenpox can be severe, especially for infants, adults, and those who are immunocompromised. Complications include infected skin lesions, pneumonia, sepsis, and encephalitis. 

Prior to the availability of the VZV vaccine, chickenpox was a prevalent childhood illness. The varicella vaccine is now widely used (since 1980) and routinely administered to children on or after their first birthday with a repeat dose usually given between ages 4 and 6 years. 

64.

You are performing an electrocardiogram (ECG) on a two-year-old with suspected hemolytic uremic syndrome (HUS). Which of the following ECG findings would you expect from this patient? 

  • Tall, peaked T waves

  • ST-segment elevation

  • Narrow QRS complexes 

  • Shortened PR interval 

Correct answer: Tall, peaked T waves

HUS leads to acute kidney injury (AKI) and hyperkalemia. Hyperkalemia presents on ECG with tall, peaked T waves, ST-segment depression, widened QRS complexes, prolonged PR interval, ventricular arrhythmias, asystole, and cardiac arrest. 

65.

An adolescent male is admitted to the emergency department with nausea and vomiting, a headache, dizziness, altered mental status, and left-sided hemiparesis. The physician suspects the teenager is experiencing a cerebrovascular accident (CVA).

The nurse begins intravenous hydration and expects which of the following initial studies to be ordered?

  • Non-contrast CT of the brain

  • Head MRI

  • Cranial ultrasound (CUS)

  • Doppler ultrasound

Correct answer: Non-contrast CT of the brain

The incidence of CNS events in children in the first 20 years of life is rare at approximately 0.7%. A CVA is an acute infarction in the brain, most commonly related to intracranial arterial stenosis or obstruction, which can lead to stroke. It may be ischemic or hemorrhagic. An affected child presents with any of the following symptoms: hemiparesis, headache, dizziness, emesis, lethargy, aphasia, focal seizures, gait and visual disturbances, and altered mentation or alertness.

Initial stabilization should be performed prior to radiographic evaluation. Once the child is stable, non-contrast CT of the brain is the initial study of choice.

MRI results may be normal initially because several days of evolution are necessary to detect an edematous infarcted area. CUS is indicated for suspected intraventricular hemorrhage (IVH), not CVA. Doppler ultrasound may be used for imaging and flow-velocity measurements.

66.

Which of the following factors does not place a patient at an increased risk of a fatal reaction from anaphylaxis? 

  • Delay in administering antihistamines 

  • Being a teenager

  • History of asthma 

  • Delay in administering epinephrine 

Correct answer: Delay in administering antihistamines 

Anaphylaxis can be a life-threatening event and should be treated with parenteral epinephrine. Antihistamines are considered second-line treatment but should not replace the use of epinephrine (first-line treatment). 

Risk factors for fatal anaphylaxis include being a teenager, having asthma, and experiencing a delay in administering epinephrine. A lapse in the use of antihistamines is not associated with mortality. 

67.

Which of the following ethical principles is defined as doing good for others?

  • Beneficence

  • Fidelity

  • Nonmaleficence

  • Justice

Correct answer: Beneficence

Beneficence is an ethical principle defined as doing good or performing actions with the intent of benefiting another person.

Fidelity (or promise-keeping) refers to the obligation to provide care to the best of one's ability. Nonmaleficence simply means to do no harm, and justice refers to fair treatment without discrimination.

68.

An infant with a history of prematurity is admitted to the PICU with a grade II intraventricular hemorrhage (IVH). What is the severity of this child's bleeding?

  • The bleeding has extended into the ventricular system of the brain

  • The bleeding is mild and is found only in the periventricular germinal matrix of the brain

  • The bleeding has extended into the ventricular system and caused ventricular dilation

  • The bleeding has extended into the brain parenchyma

Correct answer: The bleeding has extended into the ventricular system of the brain

IVH is a major complication of prematurity, and the incidence increases with decreasing gestational age and birth weight. A classification system has been put into place to determine the severity and grading of IVH based on the presence and amount of blood in the germinal matrix and lateral ventricles of the brain.

  • Grade 1: germinal matrix hemorrhage only (mild bleed)
  • Grade 2: IVH without ventricular dilation (bleed extending into the ventricular system of the brain)
  • Grade 3: IVH with ventricular dilation
  • Grade 4: intraventricular and parenchyma hemorrhage

69.

A two-week-old infant presents to the emergency department (ED) with feeding intolerance, constipation, and decreased activity with a weak cry. An initial laboratory workup reveals a potassium level of 4.5, elevated thyroid-stimulating hormone (TSH), and a sodium level of 139. You suspect which of the following conditions? 

  • Hypothyroidism 

  • Hyperthyroidism 

  • Congenital adrenal hyperplasia 

  • Adrenal insufficiency 

Correct answer: Hypothyroidism 

Hypothyroidism in a neonate presents with poor feeding, hypotonia, hypothermia, constipation, weight loss, and decreased activity. Lab results of hypothyroidism will reveal elevated TSH and low free T4. The potassium and sodium levels in this infant are within normal limits. 

Treatment with levothyroxine should be started alongside consultation with pediatric endocrinology. Lack of treatment can lead to significant cognitive deficits. 

70.

A physician orders a hemoglobin level, complete blood count (CBC), reticulocyte count, and peripheral blood smear for a patient in the PICU with suspected anemia. What finding is considered consistent with anemia?

  • Hemoglobin less than two standard deviations below the mean for the normal population

  • Hemoglobin less than one standard deviation below the mean for the normal population

  • Hemoglobin less than three standard deviations below the mean for the normal population

  • Hemoglobin less than four standard deviations below the mean for the normal population

Correct answer: Hemoglobin less than two standard deviations below the mean for the normal population

Anemia is defined as a hemoglobin level two standard deviations below the mean for age. The most significant problems seen in PICU patients with anemia include altered tissue perfusion, altered fluid volume, and decreased oxygen-carrying capacity. Nursing assessment and management are targeted at these three critical issues.

71.

An infant is transitioning to end-of-life care and is being withdrawn from assisted ventilation life-support. The physician has ordered fentanyl to be given to reduce air hunger and pain. Fentanyl has a risk of causing some degree of respiratory depression.

What principle is being demonstrated?

  • Double effect

  • Futile medical treatment

  • Best-interest standard

  • Reasonable person standard

Correct answer: Double effect

The "double effect" theory states that an action may be considered beneficial if the intent of the action is of positive value, even if the secondary effects of the action might be considered harmful if undertaken as the primary goal. This theory is used frequently in ICU settings.

The reasonable person standard asks, "What would a reasonable person want in this circumstance?" It is part of informed consent. The best-interest standard seeks to accomplish valid moral decision-making in difficult cases and requires a balance of beneficence, nonmaleficence, and justice. Determination of the appropriateness of treatment should be based on medical benefit as determined by family goals for the patient, including physiologic, psychologic, social, and religious factors. Based on all these aspects of care, a determination of nonbeneficial vs. beneficial therapy can be made.

72.

What is the most common cause of acute ischemic stroke (AIS) in children?

  • Cardiac disease

  • Sickle cell disease (SCD)

  • CNS infections

  • Trauma of the head and neck

Correct answer: Cardiac disease

Stroke is relatively rare in children. AIS accounts for about half of all pediatric strokes and is caused by an occlusion of cerebral blood vessels. It is most often due to arterial occlusion but may also be caused by occlusion of cerebral veins and sinuses. The majority of AIS in children occurs in the distribution of the middle cerebral artery.

Congenital heart disease is the most common cause of AIS in children, accounting for one-third of all cases.

Hematologic disorders, such as SCD, contribute to AIS from the occlusion of small vessels. CNS infections can cause AIS from local vasculitis and thrombosis. Trauma of the head and neck is associated with dissection of the carotid or vertebral arteries and is less commonly the cause of AIS.

73.

Waddell's triad is the combination of injuries that a child often sustains when struck by a vehicle. Which of the following is not part of this triad?

  • Wrist injury

  • Chest injury

  • Head injury

  • Femur fracture 

Correct answer: Wrist injury

Waddell's triad is associated with high-velocity accidents, typically motor vehicle, auto-pedestrian, and bicycle collisions seen in pediatric patients. The triad includes injuries to the chest/abdomen, head, and femur. 

When a child is struck by a vehicle's bumper, their leg is generally struck, leading to femur fractures. When a child is struck by the hood of a vehicle, their head, chest, and abdomen are usually injured. If the child is small enough, they will be run over when struck by the hood of a vehicle, as children can go under the vehicle after they are knocked down.

74.

A 10-month-old infant is brought into the emergency department via ambulance and stops breathing. The nurse confirms the infant still has a pulse by checking the brachial artery in the infant's upper arm. The nurse ensures the infant is positioned correctly and immediately begins CPR.

When two rescuers are performing CPR, what technique should be used for compressions?

  • Two thumbs on the sternum with hands encircling the chest to deliver compressions

  • Two hands on the sternum using the heel of the hands to deliver compressions

  • Two fingers on the sternum to deliver compressions

  • One hand on the sternum using the heel of the hand to deliver compressions

Correct answer: Two thumbs on the sternum with hands encircling the chest to deliver compressions

External chest compressions consist of serial, rhythmic compressions of the chest to maintain circulation to the vital organs until the infant begins spontaneously breathing again, or advanced life support can be initiated.

For an infant, the fingers should be placed at a point on the lower sternum just below the intersection of the sternum and an imaginary line drawn between the nipples. Lone rescuers should use two fingers on the sternum to deliver compressions. The two-thumb encircling hands technique may be used when two rescuers are present.

75.

A pediatric patient with acute kidney injury (AKI) has a glomerular filtration rate (GFR) that is significantly decreased. Which of the following signs and/or symptoms would the nurse expect to observe in this patient?

  • Increased plasma creatinine and hypervolemia

  • Decreased plasma creatinine and hypokalemia

  • Decreased blood urea nitrogen (BUN) and hypokalemia

  • Hyperkalemia and hypovolemia

Correct answer: Increased plasma creatinine and hypervolemia

GFR is considered the best overall measure of a kidney's ability to carry out various functions (including filtration of blood). It is used clinically to assess the degree of kidney impairment and to follow the course of the disease. A GFR that is significantly decreased indicates renal damage, resulting in an ability to remove waste and excess water from the blood. Hypervolemia and increased BUN levels will manifest as a direct result of a decreasing GFR.

The patient will also experience hyperkalemia and increased plasma creatinine levels, as potassium and excess waste products cannot be removed sufficiently until kidney function returns to normal.

76.

A child exhibits differing blood pressures in the upper and lower extremities, systemic hypertension, and a short systolic ejection murmur that is best heard at the left sternal border (LSB). Their pediatric nurse suspects which of the following congenital heart defects?

  • Coarctation of the aorta

  • Tetralogy of Fallot (TOF)

  • Ventricular septal defect (VSD)

  • Tricuspid atresia

Correct answer: Coarctation of the aorta

Aortic coarctation is the congenital narrowing of the aorta, the main blood vessel that carries blood from the heart to the rest of the body. This deformity results in increased blood pressure proximally and decreased pressure distally. Coarctation occurs in about 8%-10% of cases of congenital heart disease and is more common in boys. It is frequently associated with PDA, VSD, aortic stenosis, aortic insufficiency, bicuspid aortic valve, mitral and tricuspid valve anomalies, and DiGeorge syndrome.

Examination of the infant reveals a heaving precordium, equally diminished pulses if the ducts are still open, and a nonspecific systolic murmur at the LSB. In a child, however, there is a blood pressure differential between the upper and lower extremities, systemic hypertension, and a short systolic ejection murmur at the LSB.

TOF is an obstructive heart defect with signs and symptoms that include irritability, cyanosis, loss of consciousness, seizures, and possible cardiac arrest. A VSD may lead to heart failure due to increased energy requirements, prompting fatigue and pulmonary hypertension (caused by increased blood flow to the lungs). Tricuspid atresia occurs when the tricuspid valve fails to form, resulting in increased pulmonary blood flow with clinical manifestations of congestive heart failure and fluid overload. Survival is contingent upon the placement of an obligatory right-to-left atrial shunt.

77.

A seven-month-old infant is admitted to the PICU with sinus tachycardia secondary to infection and subsequent dehydration. The patient has a heart rate of 200 beats/min. The nurse expects which of the following findings on an electrocardiogram (ECG) tracing?

  • Rhythm originating in the SA node

  • Irregular heart rate

  • Prolonged pause between QRS complexes

  • P wave inversion

Correct answer: Rhythm originating in the SA node

Sinus tachycardia is recognized on ECG with a normal upright P wave (not inverted) preceding every QRS complex (P:QRS ratio of 1:1). The PR interval and QRS configuration are normal (with no prolonged pause), the rhythm is regular, the heart rate is increased (as high as 250 bpm, overlapping with rates of supraventricular tachycardia [SVT] in neonates), and the pacemaker is coming from the sinatrial (SA) node and not elsewhere in the atria.

Sinus tachycardia is usually the result of an underlying condition and is rarely a primary cardiac arrhythmia. Most commonly, treating the underlying cause will resolve this condition. The heart rate is increased but regular in sinus tachycardia. If there is an inverted P wave noted on ECG, this generally indicates an ectopic atrial rhythm not originating in the SA node (a non-sinus origin of the P waves).

78.

How soon after a potentially infectious bite should a child be treated for rabies?

  • Within 24 hours

  • Within 12 hours

  • Within 72 hours

  • Within 7 days

Correct answer: Within 24 hours

The first stage in the treatment of rabies is an injection of antibodies (human rabies immune globulin [HRIG]) and a rabies vaccine shot. The vaccine helps the body start making its own antibodies to the virus. Ideally, the HRIG and the first dose of rabies vaccine should be given on the same day as the possible exposure (within 24 hours). Even if the delay is longer than that, according to the CDC, the person should still be given treatment. 

The rabies shot is given 4 times over a 4-week period. Half of the HRIG is injected around the bite site, with the remainder in the upper arm muscle. Side effects of the vaccine may include swelling or redness at the injection site, headache, fever, nausea, muscle aches, and dizziness, per the CDC. Treatment for rabies must begin soon after exposure; once symptoms appear, nothing can be done to stop the progression of the disease. It is almost 100% fatal once the virus becomes established in a human.

79.

A nurse is caring for an infant with a diagnosis of transposition of the great arteries (TGA) who is scheduled for surgical repair. Which surgical treatment option provides a permanent solution to TGA and is usually performed within the first 2 weeks after birth?

  • Arterial switch procedure

  • Complete repair with a patch

  • Balloon atrial septostomy

  • Norwood operation

Correct answer: Arterial switch procedure

TGA is a congenital heart defect in which the pulmonary artery and aorta are switched positions: the left ventricle gives rise to the pulmonary artery, and the right ventricle gives rise to the aorta, resulting in parallel circulations. Systemic venous blood enters the right side of the heart normally but exits through the aorta, sending deoxygenated blood back to the body instead of the lungs. Pulmonary venous blood enters the left side of the heart normally but exits through the pulmonary artery, sending oxygenated blood to the lungs instead of the body.

Repair via arterial switch is permanent and should be performed by 2 weeks of age to avoid CHF and early development of PVOD. Balloon atrial septostomy is a temporary treatment option that expands the ASD and improves the oxygenation of the blood. Complete repair with a patch is a treatment option for tetralogy of Fallot (TOF). The Norwood operation is palliative reconstructive surgery for hypoplastic left heart syndrome (HLHS).

80.

A teenage patient is admitted to the emergency department in a shock state after a drug overdose. The patient is experiencing insufficient oxygen delivery to the tissues, resulting in anaerobic metabolism and lactic acid production. Their serum lactate level is 5 mmol/L. The patient is diaphoretic and clammy to the touch with diminished peripheral pulses.

What phase of shock is this patient experiencing?

  • Compensated

  • Uncompensated

  • Refractory

  • Initial

Correct answer: Compensated

A patient who is in shock will experience anaerobic metabolism secondary to hypoxia. The cells are no longer able to use oxygen for energy because of inadequate tissue perfusion. Cardiac output is low, and blood cannot get to the organs and tissues.

The body is attempting to compensate for this problem by switching from aerobic to anaerobic metabolism, resulting in increased lactic acid production (a waste product). Normal lactic acid levels are generally below 2 mmol/L. Vasoconstriction in this phase results in cool, pale, or mottled skin with delayed capillary filling time, diminished peripheral pulses, and narrow pulse pressure. Diaphoresis results in clammy, moist skin.