CEN study guide for the July 2026 outline

A normotensive patient with PE has right ventricular dilation on echocardiography and an elevated troponin. Blood pressure is 118/72 mm Hg and heart rate is 112 beats/min. The nurse should anticipate

Use Check on the answer you favor. The verdict shows up with a short note on each choice.

1. immediate full-dose systemic alteplase.
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   Full-dose systemic alteplase is reserved for PE with hypotension; in a normotensive patient it adds major bleeding without a survival benefit.
2. anticoagulation with close monitoring.
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   Right ventricular strain with a positive troponin in a normotensive patient is intermediate-high-risk PE: heparin plus close watching for decompensation.
3. discharge on an oral anticoagulant.
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   Discharge on oral therapy fits only low-risk PE; RV dysfunction and a troponin rise call for a monitored bed.
4. a 2 L crystalloid bolus for right ventricular support.
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   A large crystalloid load dilates a strained right ventricle further, shifts the septum left and lowers output.

One hour after radial-access PCI, a patient's hand distal to the compression band is pale and cool with numb fingers. The pulse oximeter on that hand shows no waveform. The nurse should

1. document the findings as an expected effect of radial PCI.
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   A pale, cool, numb hand without a waveform is a complication of radial access, not an expected finding to document and leave.
2. elevate the arm and apply ice to the wrist.
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   Ice constricts vessels and elevation lowers arterial inflow, so both worsen the hand ischemia.
3. add a second compression device just above the radial band.
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   A second compression device deepens the ischemia already present; extra pressure treats bleeding, not a pulseless hand.
4. loosen the band per protocol and notify the provider.
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   Pallor, coolness, numbness and a lost pleth waveform mean the band is cutting off flow; releasing it stepwise while watching the site restores perfusion.

A 52-year-old whose chest pain resolved before arrival has deep, symmetric T-wave inversions in V2–V3. Troponin is minimally elevated and he is now pain-free. The nurse should recognize this pattern as

1. critical LAD stenosis needing urgent angiography.
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   Deep symmetric T inversions in V2–V3 after resolved chest pain are the Wellens pattern, a warning of critical proximal LAD narrowing and impending anterior MI.
2. an indication for a same-day stress test.
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   A same-day stress test in a patient with the Wellens pattern can provoke a large anterior infarction, so it is avoided.
3. acute pericarditis requiring NSAIDs.
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   Pericarditis gives diffuse ST elevation with PR depression and positional pain, not localized deep T inversions in V2–V3.
4. a benign early repolarization pattern.
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   Early repolarization shows J-point and ST elevation with upright T waves, the opposite of deep T-wave inversion.

An intubated patient with severe ARDS is to start a continuous cisatracurium infusion to improve ventilator synchrony. Before starting it, the nurse should ensure that

1. adequate sedation and analgesia are in place.
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   A paralytic removes movement but leaves awareness and pain intact, so deep sedation and analgesia must be running before the infusion starts.
2. the patient can follow commands during the infusion.
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   A paralyzed patient cannot move to follow commands; if commands were followed, the blocker would not be working.
3. the ventilator is switched to a spontaneous mode.
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   Spontaneous modes need patient effort, and under paralysis there is none, so a mandatory mode is required.
4. train-of-four monitoring will not be needed.
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   Train-of-four checks guide titration of a continuous blocker and help avoid excess paralysis, so they are planned, not skipped.

A 46-year-old with pulmonary arterial hypertension arrives with worsening dyspnea. SpO2 is 84% on room air, blood pressure is 104/66 mm Hg, and heart rate is 112 beats/min. Correcting the hypoxemia is a PRIORITY because hypoxemia

1. suppresses the hypoxic respiratory drive seen in chronic lung disease.
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   The hypoxic-drive worry concerns giving oxygen to CO2 retainers; it is not why low oxygen endangers a patient with PAH.
2. constricts pulmonary arteries and strains the right ventricle.
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   Low oxygen triggers hypoxic pulmonary vasoconstriction, raising the load on a right ventricle that is already failing against high pressures.
3. causes seizures long before it affects the heart.
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   In PAH the right ventricle fails at oxygen levels well above those that cause seizures, so the heart is at risk first.
4. dilates pulmonary arteries and floods the alveoli with fluid.
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   Hypoxemia narrows pulmonary arteries rather than dilating them, and pulmonary arterial hypertension does not flood the alveoli.

An adult with asthma uses a peak flow-based action plan. At home, the peak flow is 65% of personal best with cough and mild dyspnea. The nurse should teach that this reading means the patient should

1. take the added yellow-zone steps.
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   A peak flow of 50% to 79% of personal best with symptoms is the yellow zone: use the reliever and the extra steps written in the plan.
2. continue usual therapy without changes.
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   Usual therapy without changes is the green-zone instruction, for 80% or more of personal best.
3. stop the controller until it improves.
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   The controller treats the airway inflammation behind the drop; stopping it during a flare makes the attack worse.
4. call 911 and go to the nearest ED at once.
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   Calling 911 is the red-zone step, for a reading under 50% or severe distress; 65% has not reached that level.

A patient went to sleep at 22:00 appearing normal. They woke up at 06:00 with slurred speech and facial droop. Emergency services were called at 06:15 and arrived at the ED at 06:45. What time is the Last Known Well?

1. 06:45
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   06:45 is the arrival time at the ED and has no bearing on when symptoms began.
2. 22:00
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   A patient who wakes with deficits was last known well when last seen normal, which here is bedtime at 22:00.
3. 02:00
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   02:00 is a guessed midpoint of sleep; no one saw the patient normal at that hour, so it cannot be used.
4. 06:15
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   06:15 is when emergency services were called, after the deficits had already been found.
5. 06:00
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   06:00 is when the deficits were discovered, not when the patient was last normal; using it would wrongly widen the treatment window.

A patient with increased intracranial pressure exhibits cycles of crescendo-decrescendo breathing followed by apnea. This pattern is:

1. Agonal respiration
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   Agonal respiration is irregular gasping near death or in cardiac arrest, without a gradual build and fade.
2. Cheyne-Stokes respiration
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   Breaths that build in depth, taper off and then stop in repeating cycles are Cheyne-Stokes respiration, seen with bilateral hemispheric injury or rising ICP.
3. Biot's respiration
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   Biot's respiration is clusters of breaths of equal depth separated by apnea, without the waxing and waning.
4. Apneustic respiration
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   Apneustic respiration shows long pauses at full inspiration from a pontine lesion, not cycles of rising and falling breaths.
5. Kussmaul respiration
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   Kussmaul respiration is deep, rapid and regular, a compensation for metabolic acidosis, with no pauses.

A 20-kg child is in status epilepticus, and IV access is in place. No anticonvulsant has been given yet. Which first medication dose is most appropriate?

1. 4 mg lorazepam dose
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   A 4 mg lorazepam dose is 0.2 mg/kg for this child, twice the weight-based amount, with more risk of respiratory depression.
2. 10 mg diazepam dose
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   IV diazepam runs about 0.2 mg/kg, or 4 mg here; a 10 mg diazepam dose is the adult maximum and too much for 20 kg.
3. 20 mg/kg phenytoin dose
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   20 mg/kg is a valid phenytoin load, but phenytoin is a second-line drug used after benzodiazepines fail, so it is not the first dose.
4. 40 mg valproic acid dose
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   Valproic acid is also second line, and its load is about 40 mg/kg; a flat 40 mg would be far too little.
5. 2 mg lorazepam dose
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   First-line treatment is an IV benzodiazepine; lorazepam at 0.1 mg/kg gives 2 mg for a 20-kg child, under the 4 mg single-dose cap.

A 38-year-old patient is being discharged from the emergency department after an episode of uncomplicated biliary colic, with outpatient surgical follow-up. Which statement indicates the patient understands the discharge teaching?

1. "I can resume my usual high-fat meals right away."
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   High-fat meals make the gallbladder contract and set off attacks, so a lower-fat diet is advised until surgery.
2. "I will return if I develop a fever or yellow skin."
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   Fever or yellow skin signals cholecystitis, a duct stone or cholangitis, so naming them shows the patient knows when to come back.
3. "I only need follow-up if the pain happens again."
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   Surgical follow-up is kept whether or not pain recurs, because the stones keep causing attacks and complications.
4. "Pain lasting all night is expected with gallstones."
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   Colic usually settles within a few hours; pain lasting all night suggests cholecystitis and is a reason to return.

A postpartum patient with severe hemorrhage remains hypotensive (BP 78/40 mmHg) and tachycardic despite receiving 3 liters of crystalloid and oxytocin. What is the next most appropriate resuscitation step?

1. Start a norepinephrine infusion
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   Norepinephrine raises vascular tone, but the deficit is blood volume and red cells, so it is not the next step.
2. Rapid infusion of normal saline
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   More normal saline after 3 L dilutes clotting factors and worsens acidosis; crystalloid is limited in hemorrhage.
3. Initiate blood transfusion
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   Ongoing shock after 3 L of crystalloid in hemorrhage calls for blood transfusion, which restores oxygen-carrying capacity and clotting factors.
4. Administer 500 mL of albumin
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   Albumin expands volume briefly but carries no red cells or clotting factors for a bleeding patient.
5. Initiate a dopamine drip
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   A dopamine drip does not replace lost blood; in hemorrhagic shock pressors mask the deficit while bleeding continues.

A 15-year-old male presents with sudden onset severe scrotal pain that began 8 hours ago. The testicle is high-riding and swollen. Which disposition is appropriate?

1. Emergency urology consultation
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   A high-riding, swollen testis with sudden pain is torsion until proven otherwise; urology is called at once because salvage falls with every hour.
2. Pain control and observation
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   Observation lets ischemia continue, and the testis can be lost within hours.
3. Antibiotic therapy and discharge
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   Antibiotics treat epididymitis, which starts gradually; sudden pain with a high-riding testis is not an infection.
4. Manual detorsion and discharge
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   Manual detorsion can buy time, but surgical fixation is still needed, so discharge is unsafe.
5. Elective scrotal ultrasound
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   Elective scrotal imaging would delay surgery at 8 hours of ischemia; any scan must not hold up the urologist.

A patient with severe depression in the emergency department shows psychomotor retardation, poor eye contact, and very brief answers. Which communication approach is MOST effective?

1. Speak loudly and firmly to hold attention
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   Speaking loudly and firmly feels intimidating and does not help a slowed patient process questions.
2. Ask several questions at once to save time
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   Several questions at once overwhelm a patient whose thinking is slowed and produce incomplete answers.
3. Use short statements and wait for replies
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   Psychomotor retardation slows thinking and speech, so short statements and unhurried pauses let the patient answer.
4. Insist on eye contact throughout the interview
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   Insisting on eye contact adds discomfort for a withdrawn patient and gathers no better information.

A 58-year-old patient with CT-confirmed peritonitis has received 30 mL/kg of crystalloid. Which finding indicates the patient has progressed to septic shock?

1. White blood cell count of 22,000 cells/µL
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   A white cell count of 22,000 supports infection but is not part of the septic shock definition.
2. Heart rate of 128 beats/min with MAP of 72 mm Hg
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   A heart rate of 128 shows stress, but a MAP of 72 is holding above 65 without any vasopressor.
3. Temperature of 103.1°F (39.5°C) with shaking chills and rigors
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   A temperature of 103.1°F with rigors reflects the inflammatory response but says nothing about circulatory failure.
4. Vasopressor needed to keep MAP at 65 mm Hg with lactate 3.8 mmol/L
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   Septic shock is sepsis that needs a vasopressor to hold MAP at 65 mm Hg and has lactate above 2 mmol/L after adequate fluids; both are present here.

A patient weighing 80 kg is prescribed norepinephrine at 0.1 mcg/kg/min. The infusion bag contains 8 mg of norepinephrine in 250 mL of D5W. What is the infusion rate in mL/hr?

1. 30 mL/hr
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   30 mL/hr comes from using 16 mcg/mL, the strength of 8 mg in 500 mL, and doubles the dose.
2. 7.5 mL/hr
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   7.5 mL/hr delivers only 0.05 mcg/kg/min, half the order, the result of doubling the concentration to 64 mcg/mL.
3. 60 mL/hr
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   60 mL/hr comes from treating the bag as 8 mcg/mL, as if the 8 mg were in a liter, and gives four times the order.
4. 45 mL/hr
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   45 mL/hr would deliver 24 mcg/min, which is 0.3 mcg/kg/min, three times the ordered dose.
5. 15 mL/hr
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   0.1 mcg/kg/min × 80 kg = 8 mcg/min, or 480 mcg/hr; the bag holds 32 mcg/mL, so 480 ÷ 32 = 15 mL/hr.

A 24-kg pediatric patient presents in diabetic ketoacidosis with moderate dehydration. The appropriate initial fluid bolus volume is:

1. Bolus of 720 to 960 mL
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   720 to 960 mL equals 30 to 40 mL/kg, more than the 10 to 20 mL/kg used for the first bolus in DKA.
2. Rapid bolus of 1000 mL
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   A 1000 mL bolus is over 40 mL/kg for this child, an adult-size volume well beyond the first-bolus dose.
3. Bolus of 100 to 150 mL
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   100 to 150 mL is only about 4 to 6 mL/kg, too little to restore circulation in moderate dehydration.
4. Continuous 50 mL/hr rate
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   A continuous 50 mL/hr rate is a maintenance-style infusion, not an initial bolus, and leaves moderate dehydration uncorrected at the start.
5. Bolus of 240 to 480 mL
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   Pediatric DKA guidance uses 10 to 20 mL/kg for the first bolus, which is 240 to 480 mL for 24 kg.

A patient with bilateral mandibular fractures and oral bleeding, cleared of spinal injury, is alert but becomes dyspneic when lying flat. The nurse should

1. insert a nasopharyngeal airway and lie flat.
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   Lying flat is what causes the obstruction, and a nasopharyngeal airway does not stop the tongue falling back.
2. keep the patient supine with a cervical collar.
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   The spine is cleared, so a cervical collar adds nothing, and supine positioning worsens the obstruction.
3. pack the mouth with gauze to stop the bleeding.
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   Gauze packed into the mouth of a patient with an unstable jaw adds obstruction and aspiration risk.
4. allow the patient to sit up and lean forward.
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   With bilateral mandible fractures the tongue loses its front support; sitting up and leaning forward lets the tongue and blood fall away from the airway.

A patient with facial trauma has a tense orbit but an irregularly shaped pupil and uveal prolapse. Which management strategy is appropriate?

1. Apply a pressure patch to the eye
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   A pressure patch on a ruptured globe can extrude its contents, so patching is avoided.
2. Measure intraocular pressure levels
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   Measuring intraocular pressure presses on the globe and is contraindicated once rupture is suspected.
3. Perform immediate lateral canthotomy
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   Lateral canthotomy treats orbital compartment syndrome with an intact globe; a suspected rupture is a contraindication.
4. Place a rigid protective eye shield
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   An irregular pupil with uveal prolapse means an open globe; a rigid shield keeps any pressure off the eye so its contents are not pushed out.
5. Initiate copious irrigation of eye
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   Copious irrigation is for chemical exposure; on an open globe it adds pressure and fluid to the injured eye.

A patient has a carboxyhemoglobin level of 30%. The half-life of CO is 320 minutes on room air and 60 minutes on 100% oxygen. On a non-rebreather mask (100% oxygen), how long will it take to reach 7.5%?

1. 240 minutes
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   240 minutes is four half-lives on oxygen and would bring COHb below 2%, well past 7.5%.
2. 120 minutes
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   On 100% oxygen each 60-minute half-life halves COHb: 30% to 15% at 60 minutes, then 7.5% at 120 minutes.
3. 180 minutes
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   180 minutes is three half-lives, reaching about 3.75%, one halving too many.
4. 320 minutes
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   320 minutes is one half-life on room air, the wrong condition, and it only halves the level once.
5. 60 minutes
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   60 minutes is a single half-life on oxygen and brings the level only to 15%.

A violent adult patient is placed in seclusion and is also in 4-point restraints because of ongoing danger. According to CMS regulations, how must this patient be monitored?

1. continuously, in person or by audio-video with staff nearby
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   When restraint and seclusion are used together, CMS requires continuous monitoring, face to face or by simultaneous audio and video with staff close by.
2. at the time of the 4-hour order renewal by the provider
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   The 4-hour order renewal governs provider reassessment, not how often staff watch the patient.
3. every hour, with a documented nursing assessment and vital signs
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   Hourly assessment is far too sparse for this combination, which carries risks of asphyxia and injury between checks.
4. every 15 minutes, through the window of the seclusion room
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   Checks every 15 minutes can suit some single interventions, but restraint plus seclusion requires watching at all times.

A patient with a subdural hematoma is being transferred to a neurosurgical center. When giving nurse-to-nurse report to the receiving facility, which information is MOST important to include?

1. the GCS and pupil trend with treatments given and planned
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   The receiving nurse needs the trajectory: serial GCS and pupil checks, therapies given or running, and what to expect in transport and on arrival.
2. the patient's complete past surgical history and home medications
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   A complete past surgical history matters less than current status; key items such as anticoagulants belong in the report, not the whole list.
3. the reason the sending hospital cannot care for the patient
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   The reason for transfer is settled between physicians and does not help the receiving nurse manage the patient.
4. the insurance information needed for the receiving admission
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   Insurance details are handled administratively and cannot be a condition of an emergency transfer.

An upright chest radiograph of a 45-year-old patient with severe epigastric pain shows a thin crescent of air beneath the right hemidiaphragm. Which nursing action is the PRIORITY?

1. Give an oral antacid and reassess the pain
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   An oral antacid can leak through the perforation into the peritoneum and delays surgical care.
2. Prepare the patient for an upper GI barium study
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   Barium leaking through a perforation causes severe peritonitis, and the free air has already made the diagnosis.
3. Encourage ambulation to relieve trapped gas
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   The air lies free in the abdominal cavity from a perforation; it is not trapped bowel gas that walking could move.
4. Keep the patient NPO and notify the surgeon
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   Air under the diaphragm on an upright film means a perforated hollow organ, so the patient stays NPO and the surgeon is notified at once, with IV access and fluids started.

A patient with bipolar disorder who takes valproic acid is brought to the emergency department with new lethargy, confusion, and vomiting. The valproate level is within the therapeutic range. Which laboratory result MOST likely explains these symptoms?

1. Platelet count of 118,000/µL
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   Mild thrombocytopenia is a common valproate effect, but a platelet count of 118,000/µL does not cause confusion or vomiting.
2. Lipase of 40 U/L
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   Valproate can cause pancreatitis, which would explain vomiting, but a lipase of 40 U/L is normal and argues against it.
3. Ammonia of 165 mcg/dL
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   Valproic acid can raise ammonia even when the drug level is therapeutic, and an ammonia of 165 mcg/dL, several times normal, explains new lethargy, confusion and vomiting.
4. Glucose of 102 mg/dL
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   A glucose of 102 mg/dL is normal, so neither hypoglycemia nor hyperglycemia explains the change in mental status.

A trauma patient presents with an open femur fracture and pulsatile bleeding. BP is 80/50 mmHg. What is the priority intervention?

1. Cover the wound with a saline-soaked dressing
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   A saline-soaked dressing protects tissue but does not stop arterial bleeding.
2. Align the limb and apply a traction splint
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   A traction splint is a later step and does not control active arterial bleeding from the wound.
3. Apply a tourniquet proximal to the injury
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   Pulsatile limb bleeding with shock is life-threatening hemorrhage, and stopping it with a tourniquet comes before anything else.
4. Initiate large-bore intravenous access
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   Large-bore access is needed, but fluid given into an open arterial leak is lost; hemorrhage control comes first.
5. Obtain ankle-brachial index measurements
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   An ankle-brachial index screens for hidden arterial injury; here the injury is obvious and bleeding.

A patient with a casted tibial fracture reports burning pain of 9/10 despite IV opioids. The toes are pink with 2+ pulses. What is the PRIORITY action?

1. Reassess pulses in 30 minutes
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   Pulses often stay normal until late, so waiting 30 minutes to reassess risks permanent muscle and nerve damage.
2. Apply ice packs to the cast
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   Ice packs on the cast cannot relieve rising compartment pressure and delay the real fix.
3. Give another dose of IV hydromorphone
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   Another opioid dose masks the warning pain while the muscle becomes ischemic.
4. Elevate the leg well above heart level
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   Raising the leg well above the heart lowers arterial inflow and worsens compartment ischemia; it is kept at heart level.
5. Notify the provider immediately
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   Burning pain out of proportion that opioids do not relieve is the earliest sign of compartment syndrome, so the provider is notified at once.

A 34-year-old has two deep puncture wounds on the back of the hand from the family's vaccinated pet cat 3 hours ago. The wounds have been irrigated. Which additional treatment should the nurse anticipate?

1. Cephalexin for 3 to 5 days
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   Cephalexin covers skin flora but misses Pasteurella multocida, the main organism in cat bites.
2. Rabies vaccine series and immune globulin
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   A healthy, vaccinated pet cat that can be observed for 10 days does not call for rabies vaccine or immune globulin.
3. Amoxicillin-clavulanate for 3 to 5 days
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   Deep cat bites to the hand carry a high infection risk, mostly from Pasteurella multocida, so a short prophylactic course of amoxicillin-clavulanate is given.
4. Suture closure of the punctures
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   Suture closure of deep hand punctures traps bacteria inside; these bites are left open to drain.
5. Topical mupirocin under a dressing
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   Topical mupirocin does not reach the deep tissue that cat teeth inoculate, so it does not prevent infection there.