Free CEN Practice Test: 50 Questions With Answers and Rationales

Answer: B. Synchronized cardioversion

Hypotension and new confusion caused by the rhythm make this an unstable tachyarrhythmia with a pulse. The 2025 AHA algorithm sends that patient straight to synchronized cardioversion, with sedation whenever feasible. The algorithm also notes that adenosine may be considered for a regular narrow rhythm, but it doesn't replace getting ready to cardiovert.

Why not the others?

• A. Vagal maneuvers sit on the stable pathway. Repeating them here delays treatment of a patient who is already in shock.
• C. Unsynchronized shocks are used for ventricular fibrillation and for polymorphic ventricular tachycardia, which cannot be reliably synchronized even when a pulse is present. This patient has an organized narrow-complex rhythm that the device can synchronize to.
• D. A calcium channel blocker belongs to the stable pathway, and these drugs lower blood pressure. It isn't the answer for a patient whose pressure is already 76/44.

Remember: Read the perfusion before the rhythm label. When this organized tachycardia causes instability, prepare synchronized cardioversion.

Sources: AHA 2025 Adult Tachyarrhythmia With a Pulse Algorithm, unstable branch and doses/details box; AHA 2025 Guidelines: Adult Advanced Life Support, polymorphic ventricular tachycardia; defibrillation and immediate CPR.

Answer: C. Give cycles of 5 back blows followed by 5 abdominal thrusts

She can't speak and can't cough effectively, so this is a severe obstruction. The 2025 AHA adult guideline calls for cycles of 5 back blows followed by 5 abdominal thrusts until the object is expelled or she becomes unresponsive. This is a change from earlier AHA teaching that started with abdominal thrusts.

Why not the others?

• A. Encouraging coughing is for a mild obstruction, when the person can still cough forcefully or speak. A silent, weak cough means air isn't moving well.
• B. Chest compressions start once she becomes unresponsive. While she's conscious, back blows and abdominal thrusts come first.
• D. Abdominal thrusts alone was the older sequence. The 2025 guidelines start each cycle with back blows.

Remember: Severe choking in a conscious adult: 5 back blows, then 5 abdominal thrusts, repeat.

Source: AHA 2025 Guidelines, Part 7: Adult Basic Life Support, adult foreign-body airway obstruction.

Answer: A. Lower the blood pressure to below 185/110 mm Hg before thrombolysis begins

The 2026 guideline keeps the pre-treatment target: blood pressure below 185/110 mm Hg before IV thrombolysis starts, then below 180/105 mm Hg for the first 24 hours afterward. Her current reading is above that line, so it has to come down first.

Why not the others?

• B. Thrombolysis with blood pressure above 185/110 isn't within the guideline's pre-treatment target. Pressure has to be controlled before the drug goes in.
• C. The pre-treatment target is below 185/110, not below 140. After IV thrombolysis, intensive systolic lowering below 140 has not improved outcomes in mild-to-moderate ischemic stroke; it is not the routine target.
• D. Waiting for a normal pressure isn't the standard and would burn time in a treatment that depends on speed.

Remember: Before IV thrombolysis: under 185/110. For 24 hours after: under 180/105.

Source: AHA/ASA 2026 Acute Ischemic Stroke Guideline, digital pocket guide, printed p. 20, section 4.3: Blood Pressure Management, recommendations 5, 7, and 10.

Answer: A. Prepare for endotracheal intubation to protect the airway

He is actively vomiting blood and his consciousness is falling. That combination puts him at high risk of aspiration. The ESGE guideline supports intubation before endoscopy for ongoing hematemesis with altered consciousness and inability to protect the airway.

Why not the others?

• B. Transfusion and resuscitation are guided by blood loss, hemodynamics, and the patient's condition, not a routine goal above 10 g/dL. They must proceed alongside airway protection, not postpone it.
• C. Nothing goes by mouth to a drowsy patient who is vomiting blood. The airway comes first.
• D. Sedating a drowsy patient who is vomiting blood, with no airway plan, raises the aspiration risk this situation is trying to prevent.

Remember: Variceal bleed plus falling consciousness plus active hematemesis: secure the airway before the scope.

Source: ESGE Guideline: Endoscopic diagnosis and management of esophagogastric variceal hemorrhage, main recommendations 5–6; sections 4.2 and 4.4.

Answer: D. Stop the magnesium infusion and prepare IV calcium gluconate

Loss of patellar reflexes and respiratory depression are warning signs of magnesium toxicity. Absent reflexes plus a respiratory rate of 10 means stop the infusion now. Calcium gluconate is the antidote to counter magnesium's effects, given per order and protocol. Call for urgent help, assess the airway and ventilation, and assist breathing as needed while the antidote is prepared.

Why not the others?

• A. More magnesium is the last thing she needs. These are signs of too much, not too little.
• B. Waiting an hour lets toxicity progress toward respiratory arrest.
• C. Naloxone reverses opioids. It does nothing for magnesium-induced respiratory depression.

Remember: On magnesium, lost reflexes and slow breathing mean stop the drip, support breathing, and prepare calcium gluconate.

Sources: Magnesium sulfate prescribing information: Overdosage, overdosage: loss of patellar reflex, respiratory paralysis, treatment; Magnesium sulfate prescribing information: Warnings and Precautions, section 5.2: magnesium toxicity.

Answer: C. Keep him in sight, remove potentially dangerous objects, and alert the provider for an urgent safety evaluation

A yes to current suicidal thoughts is an acute positive screen on the NIMH ASQ tool. That means imminent risk. The patient needs an urgent full mental health evaluation, can't leave until evaluated, should be kept in sight, and should have dangerous objects removed. His calm manner doesn't change the screen result.

Why not the others?

• A. A private restroom removes him from observation, which is the opposite of what an acute positive screen requires.
• B. A phone number is part of later safety planning, not a response to imminent risk in the ED.
• D. Delaying action until the next vital-sign check leaves an at-risk patient unwatched.

Remember: Current suicidal thoughts: keep the patient in sight, make the space safe, and get an urgent evaluation.

Source: NIMH Ask Suicide-Screening Questions (ASQ) Tool, acute positive screen / imminent-risk actions.

Answer: D. IM epinephrine in the anterolateral thigh

Hives plus wheezing plus hypotension after an exposure is anaphylaxis. CDC guidance for vaccine reactions says immediate intramuscular epinephrine is the treatment of choice when respiratory or cardiovascular signs are present, and there are no contraindications to epinephrine in anaphylaxis.

Why not the others?

• A. Antihistamines may be used as add-on treatment, but CDC says they should not be the initial or only treatment for anaphylaxis.
• B. Steroids act slowly and don't reverse airway swelling or shock in the first minutes.
• C. Albuterol may help the wheeze, but it doesn't treat the hypotension or the systemic reaction.

Remember: Anaphylaxis gets IM epinephrine first. Everything else is add-on.

Source: CDC: Preventing and Managing Adverse Reactions, anaphylaxis management; Table 5-2.

Answer: B. Notify the provider immediately for evaluation of acute compartment syndrome

Pain out of proportion to the injury that gets worse when the muscles are stretched is the classic early warning of acute compartment syndrome. AAOS describes acute compartment syndrome as a surgical emergency treated by fasciotomy, so this needs immediate escalation.

Why not the others?

• A. Analgesia is appropriate, but another dose is not a reason to postpone urgent compartment assessment for an hour.
• C. A palpable pulse does not exclude compartment syndrome. Loss of pulses is not an early finding.
• D. Waiting for sensory or motor loss risks further tissue damage. Escalating pain and pain on passive stretch already justify urgent assessment.

Remember: Pain out of proportion plus pain on passive stretch: escalate now, and don't let a pulse reassure you.

Sources: AAOS OrthoInfo: Compartment Syndrome, acute compartment syndrome: symptoms and treatment; BOASt: Diagnosis and Management of Compartment Syndrome of the Extremities, Standards for Practice: pain assessment, analgesia documentation, serial assessment and immediate decompression after diagnosis.

Answer: B. Begin copious irrigation immediately

Time to irrigation has the greatest influence on the outcome of a chemical eye injury. AAO's EyeWiki says irrigation should not be delayed to gather history, and it should continue while the ocular pH is checked.

Why not the others?

• A. Visual acuity matters, but it waits until irrigation is under way. Every minute of delay lets the alkali penetrate further.
• C. EyeWiki says to avoid acidic or alkaline solutions meant to neutralize the chemical. They can make the injury worse.
• D. Patching traps the chemical against the eye. Irrigation comes before referral.

Remember: Chemical exposure without signs of penetrating injury: start irrigation immediately while assessment continues.

Source: AAO EyeWiki: Chemical (Alkali and Acid) Injury of the Conjunctiva and Cornea, initial management / irrigation / ocular pH.

Answer: D. Apply 100% oxygen by non-rebreather mask and obtain a carboxyhemoglobin level by CO-oximetry

A standard pulse oximeter can't tell carboxyhemoglobin from oxyhemoglobin, so it gives a falsely reassuring reading. CO poisoning is confirmed with a CO-oximetry carboxyhemoglobin level, and treatment starts with 100% oxygen by non-rebreather mask.

Why not the others?

• A. The 99% reading is the trap. It doesn't rule out CO poisoning.
• B. Low-flow oxygen doesn't speed carbon monoxide removal the way 100% oxygen does, and a repeat SpO2 will be just as misleading.
• C. PaO2 measures dissolved oxygen, whereas an ordinary blood-gas saturation may be calculated from PaO2; neither reliably identifies carboxyhemoglobin. CO-oximetry measures the hemoglobin fractions. Waiting for a routine blood-gas result only delays oxygen.

Remember: Suspected CO: ignore the normal SpO2, give 100% oxygen, and get a CO-oximetry level.

Source: CDC: Clinical Guidance for Carbon Monoxide Poisoning, management; confirmation of diagnosis; conventional pulse oximetry limitations.

Answer: C. ESI 4

She isn't unstable or high risk, so she falls into the resource-based levels. Only the X-ray counts as an ESI resource. Oral medications, splints and wraps, and crutches don't count. One expected resource means ESI 4.

Why not the others?

• A. ESI 2 is for high-risk situations, new confusion, or severe pain or distress. A stable ankle injury with moderate pain doesn't qualify.
• B. ESI 3 needs two or more resource types. Counting the wrap and crutches as resources is the common mistake here.
• D. ESI 5 means no resources at all. The X-ray is one.

Remember: Count resource types, not items, and leave out oral meds, splints, and crutches.

Source: Emergency Nurses Association: Emergency Severity Index Handbook, 5th edition, ESI algorithm and resource table, printed p. 6 (PDF p. 12).

Answer: C. Give it as a rapid IV push, immediately followed by a normal saline flush

The patient is stable, so adenosine is a reasonable next step for a regular narrow rhythm after vagal maneuvers. The 2025 AHA algorithm specifies the first dose as 6 mg by rapid IV push followed by a normal saline flush. Adenosine is very short-acting, so it has to reach the heart as a fast bolus.

Why not the others?

• A. A slow, diluted infusion lets the drug clear before it reaches the heart in an effective concentration.
• B. A slow push has the same problem. The algorithm calls for a rapid push.
• D. Adenosine is given IV for this indication, not IM.

Remember: Adenosine: fast push, fast flush.

Source: AHA 2025 Adult Tachyarrhythmia With a Pulse Algorithm, unstable branch and doses/details box.

Answer: D. Urgently assess and support ventilation, titrate oxygen to an SpO2 of 88–92%, and obtain a blood gas

BTS guidance recommends a target saturation of 88–92% for a patient with known COPD who is at risk of hypercapnic respiratory failure, pending blood-gas results. Rising drowsiness while receiving supplemental oxygen demands urgent airway and ventilation assessment; a saturation of 99% does not establish adequate ventilation. Escalate immediately for respiratory support as needed rather than waiting for the blood gas before responding to deterioration.

Why not the others?

• A. More oxygen pushes the saturation further above target and can worsen carbon dioxide retention.
• B. Stopping oxygen entirely risks dangerous hypoxemia. The goal is a target range, not zero.
• C. A saturation of 99% is above the target for this patient, and his falling level of consciousness is a warning sign.

Remember: COPD with worsening consciousness: assess ventilation urgently, titrate oxygen to 88–92%, and check a blood gas.

Source: British Thoracic Society: Emergency Oxygen guideline and target-saturation statement, Current BTS Guidelines; December 2019 review of 2017 recommendations.

Answer: B. A disabling deficit can warrant thrombolysis within 4.5 hours even when the NIHSS score is low

The 2026 guideline emphasizes rapid thrombolysis within the 4.5-hour window for eligible patients with disabling deficits, regardless of NIHSS score, without requiring advanced imaging. Aphasia that stops her from communicating is disabling even though it scores low. Full eligibility screening still applies.

Why not the others?

• A. There's no NIHSS cutoff that excludes a disabling deficit. The trials failed to show benefit for non-disabling deficits, such as isolated sensory symptoms, which is a different situation.
• C. IV thrombolysis is a treatment in its own right. It doesn't depend on thrombectomy.
• D. Within the 4.5-hour window, the guideline doesn't require advanced imaging to select patients with disabling deficits.

Remember: Judge the deficit, not just the score: a low NIHSS does not exclude thrombolysis for an otherwise eligible patient with a disabling deficit.

Source: AHA/ASA 2026 Acute Ischemic Stroke Guideline: Top Things to Know, disabling deficits, NIHSS, and the 4.5-hour IV thrombolysis window.

Answer: A. IV antibiotic prophylaxis started now, along with a vasoactive drug such as octreotide

The ESGE guideline recommends antibiotic prophylaxis for acute variceal hemorrhage in cirrhosis, even without signs of infection. When a variceal bleed is suspected, vasoactive drugs such as octreotide should start as soon as possible.

Why not the others?

• B. Waiting for a fever misses the point of antibiotic prophylaxis in this group.
• C. A hemoglobin target of 12 g/dL is not routine. Transfusion is individualized; ESGE recommends a restrictive strategy for hemodynamically stable patients without cardiovascular disease, not normalization of hemoglobin.
• D. Vasoactive drugs should begin as soon as a variceal bleed is suspected, not after endoscopy.

Remember: Cirrhosis plus upper GI bleed: antibiotics from admission, vasoactive drug early, restrictive transfusion.

Source: ESGE Guideline: Endoscopic diagnosis and management of esophagogastric variceal hemorrhage, main recommendations 5–6; sections 4.2 and 4.4.

Answer: C. A digital cervical examination

Sudden, painless bleeding after 20 weeks raises concern for placenta previa. If a previa is present, a digital cervical exam can trigger sudden, massive bleeding. That's why a digital vaginal or cervical exam should wait until ultrasound excludes previa. A speculum examination by an appropriate clinician is a separate assessment and is not the same as a digital examination.

Why not the others?

• A. Fetal monitoring is appropriate and safe.
• B. IV access is appropriate preparation for any antepartum bleed.
• D. A type and crossmatch is appropriate preparation in case she needs blood.

Remember: Bleeding after 20 weeks: no fingers in the cervix until ultrasound excludes previa.

Source: RCOG Green-top Guideline No. 63: Antepartum Haemorrhage, sections 7.2–7.3, printed p. 7: speculum and digital vaginal examination.

Answer: D. At 4 hours after the ingestion

The nomogram applies to acute ingestions with a known time, using a concentration drawn 4 to 24 hours after ingestion. A level drawn before 4 hours can't be used on the nomogram to decide treatment. If the 4-hour level falls on or above the treatment line, acetylcysteine is started.

Why not the others?

• A. A 2-hour level can't be plotted on the nomogram. Using it risks a false sense of safety.
• B. Liver enzymes rise late. Waiting for them delays acetylcysteine, which works best when started early.
• C. Waiting 24 hours throws away the window when treatment decisions matter most.

Remember: Acetaminophen: the nomogram starts at 4 hours after ingestion.

Source: Dart et al.: Management of Acetaminophen Poisoning in the US and Canada: A Consensus Statement, single acute ingestion; timing and interpretation of concentrations.

Answer: C. Begin potassium replacement and hold insulin until potassium is above 3.5 mmol/L

Insulin drives potassium into cells and can drop a low potassium dangerously fast. The 2024 consensus report says that if potassium is below 3.5 mmol/L at presentation, replacement should begin and insulin should be postponed until potassium rises above 3.5. Some older materials use a different threshold, so check the edition you study from.

Why not the others?

• A. Starting insulin with a potassium of 3.2 risks severe hypokalemia and arrhythmia.
• B. A bolus pushes potassium into cells even faster, which is exactly the danger here.
• D. The 2024 consensus doesn't recommend routine bicarbonate. It's considered only for severe acidosis with a pH below 7.0, and this patient's pH is 7.14.

Remember: DKA with potassium under 3.5: potassium first, insulin after.

Source: Hyperglycaemic crises in adults with diabetes: a consensus report, potassium replacement; bicarbonate.

Answer: B. Wrap it in saline-moistened gauze, seal it in a watertight bag, and set the bag on ice without direct contact

AAOS guidance is to clean the part gently, wrap it in moistened gauze, seal it in a watertight bag, and place the bag on ice, never letting the part touch the ice. Keeping it cool slows tissue damage and keeps replantation possible.

Why not the others?

• A. Direct contact with ice can freeze and further damage the tissue.
• C. Soaking the tissue in water damages it. The part should be moist, not submerged.
• D. Room temperature speeds tissue breakdown. The part should be kept cool.

Remember: Amputated part: moist gauze, sealed bag, bag on ice, part never touching ice.

Source: AAOS OrthoInfo: Fingertip Injuries and Amputations, first aid for an amputated fingertip.

Answer: D. Treat it as a time-critical stroke-equivalent emergency and activate immediate stroke-center evaluation

Sudden, painless monocular vision loss in a patient with vascular risk factors suggests a retinal artery occlusion. The AHA scientific statement identifies central retinal artery occlusion as an acute ischemic stroke and calls for rapid triage to emergency assessment and treatment.

Why not the others?

• A. Tomorrow is too late. This is a time-sensitive stroke equivalent.
• B. Patching and discharge treats it as a surface problem and misses a vascular emergency.
• C. A 4-hour delay wastes the window when acute intervention might be considered.

Remember: Sudden painless loss of vision in one eye: suspect retinal ischemia and arrange urgent stroke-capable evaluation.

Source: AHA Scientific Statement: Management of Central Retinal Artery Occlusion — Top Things to Know, recognition, emergency triage and treatment considerations.

Answer: B. Immediate cold-water immersion with the head and airway supported above water

A core temperature above 40°C with central nervous system changes after exertion is exertional heat stroke, a true medical emergency. The NATA position statement prioritizes immediate rapid cooling, preferably cold-water immersion. Cooling should start on site rather than after transport. Activate EMS while cooling, support the head and airway above water, and continuously monitor breathing and the patient’s condition.

Why not the others?

• A. Delaying cooling for transport prolongs the time the body spends at a damaging temperature.
• C. Antipyretics don't work on heat stroke, because the problem isn't a reset thermostat.
• D. When cold-water immersion is available, it is preferred for rapid cooling in exertional heat stroke. Waiting 30 minutes to reassess a confused patient at this temperature is unsafe.

Remember: Exertional heat stroke: cool first, transport second.

Source: National Athletic Trainers’ Association Position Statement: Exertional Heat Illnesses, recommendation 38 and Table 4: exertional heat stroke treatment.

Answer: C. Immediate (red)

In START, a patient who can't walk moves on to the breathing check. A breathing patient with a respiratory rate above 30/min is triaged Immediate. There's no need to go on to perfusion or mental status for this patient.

Why not the others?

• A. Minor is for the walking wounded. He can't walk.
• B. Delayed requires a respiratory rate under 30, adequate perfusion, and the ability to follow simple commands.
• D. Expectant is for a patient with no respiratory effort after the airway is positioned. He is breathing.

Remember: START: can't walk, breathing over 30 means Immediate.

Source: HHS Radiation Emergency Medical Management: START Adult Triage Algorithm, adult START algorithm and linked text description.

Answer: C. Resume chest compressions right away

The 2025 AHA guidelines use a single-shock strategy: after one shock, compressions resume immediately instead of pausing for a pulse check or stacking more shocks. Shorter pauses around the shock improve hands-on time, which is linked to survival.

Why not the others?

• A. A pulse check right after the shock creates a long pause. The rhythm is rechecked after the next cycle of CPR.
• B. Stacked shocks mean longer interruptions in CPR. The single-shock approach improved survival to hospital admission and discharge in the studies the guideline cites.
• D. Drugs never replace or delay compressions. Antiarrhythmics come later if VF persists.

Remember: Shock, then straight back on the chest.

Source: AHA 2025 Guidelines: Adult Advanced Life Support, polymorphic ventricular tachycardia; defibrillation and immediate CPR.

Answer: D. These are signs of life-threatening asthma; escalate immediately and prepare for airway support

GINA lists drowsiness, confusion, and a silent chest as signs of life-threatening asthma that call for immediate escalation of care. Faint breath sounds here mean little air is moving, not that the bronchospasm has eased. He is close to respiratory failure.

Why not the others?

• A. A quiet chest with falling oxygen and drowsiness is a danger sign, not improvement.
• B. Drowsiness in this setting reflects failing ventilation. Letting him sleep delays the rescue he needs.
• C. GINA doesn't recommend routine chest X-rays for exacerbations, and imaging shouldn't delay escalation for a patient this sick.

Remember: In asthma, a quiet chest plus drowsiness means the patient is tiring out, not getting better.

Source: GINA 2026 Summary Guide for Asthma Management and Prevention, printed pp. 35–36: acute exacerbations and Figure 9.

Answer: A. IM midazolam

A seizure lasting 5 minutes or more calls for a benzodiazepine. The American Epilepsy Society guideline lists IM midazolam, IV lorazepam, and IV diazepam as first-line options. For adults without IV access, it rates IM midazolam as more effective than IV lorazepam.

Why not the others?

• B. Nothing goes by mouth to a seizing patient, and levetiracetam is a second-phase drug.
• C. Phenytoin and similar drugs are second-phase therapy after a benzodiazepine, not a substitute for it.
• D. Treatment starts at 5 minutes. Waiting makes seizures harder to stop.

Remember: Seizing at 5 minutes with no IV: IM midazolam.

Source: American Epilepsy Society guideline: Treatment of Convulsive Status Epilepticus (Epilepsy Currents, 2016), initial therapy recommendations.

Answer: B. Arrange immediate removal; the recent meal is not a reason to delay

A button battery lodged in the esophagus can cause serious burns in as little as 2 hours, even in a child with no symptoms. The National Capital Poison Center guideline says to remove it immediately and not to delay removal because the patient ate recently.

Why not the others?

• A. Children with an esophageal battery can look well at first. Observing risks a severe burn or perforation.
• C. The guideline specifically says a recent meal is not a reason to delay removal.
• D. A battery stuck in the esophagus won't be moved by a laxative, and the damage is happening where it sits.

Remember: Button battery in the esophagus: remove now, meal or no meal.

Source: National Capital Poison Center: Button Battery Ingestion Triage and Treatment Guideline, recommendations on esophageal batteries and removal timing.

Answer: D. Begin positive-pressure ventilation

The 2025 AHA/AAP neonatal guideline says a newborn who isn't breathing within the first 60 seconds, or whose heart rate stays below 100/min despite the initial steps, should receive assisted ventilation. A rising heart rate is the main sign that ventilation is working.

Why not the others?

• A. Compressions start only if the heart rate stays below 60/min despite 30 seconds of ventilation that moves the chest.
• B. Epinephrine comes after effective ventilation and compressions have failed to raise a very low heart rate.
• C. More stimulation delays ventilation, and delaying ventilatory support in newborns increases the risk of death.

Remember: Newborn apneic or heart rate under 100 after initial steps: ventilate.

Source: AHA 2025 Guidelines: Neonatal Resuscitation, initial ventilation; indications for chest compressions.

Answer: A. Lithium toxicity

The lithium label warns that diuretics, NSAIDs, and renin-angiotensin system antagonists can raise lithium levels. Its listed signs of toxicity progress from tremor and poor coordination to ataxia and, in severe cases, confusion. A new thiazide followed by these symptoms points to lithium toxicity.

Why not the others?

• B. Mania doesn't explain the tremor, vomiting, and ataxia, and it ignores the new drug interaction.
• C. Gastroenteritis could explain the vomiting, but not the tremor, ataxia, and confusion.
• D. Hydrochlorothiazide isn't a serotonergic drug. Its danger here is raising the lithium level.

Remember: Lithium plus a new diuretic or NSAID plus neuro or GI symptoms: think toxicity.

Source: DailyMed: Lithium carbonate prescribing information, lithium toxicity; section 7.1, clinically important interactions — diuretics.

Answer: C. Immediately, ideally within 1 hour of recognition

The 2026 Surviving Sepsis Campaign guideline recommends giving antimicrobials immediately, ideally within 1 hour, for adults with possible, probable, or definite septic shock. This patient's hypotension after fluids makes septic shock likely, so antibiotics shouldn't wait for more results.

Why not the others?

• A. Waiting for imaging delays treatment. The guideline's timing is tied to recognition of shock, not confirmation of the source.
• B. A 3-hour window applies to possible sepsis without shock. A patient with shock gets antimicrobials within 1 hour.
• D. Culture results take a day or more. Waiting for them would be dangerous.

Remember: Possible septic shock: antimicrobials now, ideally within the hour.

Source: Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026, time to antimicrobials: possible, probable or definite septic shock.

Answer: D. Treat it as a surgical emergency and arrange urgent hand-surgery evaluation

High-pressure injection injuries are known for looking harmless at first. The injected material can spread far through the tissue behind a tiny entry wound. Published cases document extensive damage despite an initially small wound; this paint-injection injury warrants urgent hand-surgery assessment rather than observation at home.

Why not the others?

• A. Discharge based on the small wound is the classic mistake with this injury.
• B. Waiting a day delays the surgical assessment this mechanism requires.
• C. Closing the entry wound doesn't address the material already spread through the tissue and is not a substitute for surgical evaluation.

Remember: High-pressure injection: tiny wound, big injury, surgical emergency.

Source: High-Pressure Injection Injuries of the Hand: A Report of Three Cases Presenting With Acute Compartment Syndrome, abstract: apparently minor wounds, extensive injury and emergency management; DOI 10.7759/cureus.72786.

Answer: C. Keep the patient upright and calm, and prepare equipment for a difficult airway

These findings suggest epiglottitis with a threatened airway. Keeping the patient upright can make breathing easier; urgent airway expertise and equipment are needed. Let the patient stay in the position they've chosen while the team prepares for a difficult airway.

Why not the others?

• A. With drooling and stridor, a routine bedside throat examination should not take priority over a prepared airway assessment by the appropriate team.
• B. Forcing this patient to lie flat may worsen breathing and delays airway-focused care.
• D. Sending an unstable airway to radiology without monitoring is a recognized management error.

Remember: Suspected epiglottitis with obstruction signs: let the patient sit up and get the airway team ready.

Source: NHS: Epiglottitis, emergency action; staying upright; hospital airway treatment.

Answer: C. Contact precautions, with gloves and a gown

C. difficile spreads through contact with contaminated hands, surfaces, and equipment. CDC says healthcare professionals use precautions such as wearing a gown and gloves while caring for patients with C. difficile infection.

Why not the others?

• A. C. difficile isn't airborne.
• B. It isn't spread by respiratory droplets.
• D. CDC's hand hygiene fact sheet notes that alcohol-based hand sanitizer does not kill C. difficile, which is why glove use matters so much.

Remember: C. diff: gown and gloves, and don't rely on alcohol rub to kill spores.

Sources: CDC: Clinical Guidance for C. diff Infection Prevention in Acute Care Facilities, isolate and initiate contact precautions for suspected or confirmed infection; CDC: Clean Hands Count for Healthcare Providers, p. 1: alcohol-based hand sanitizer and C. difficile.

Answer: B. The medical screening examination can't be delayed to ask about payment or insurance

Under EMTALA's regulation at 42 CFR 489.24(d)(4)(i), a participating hospital may not delay an appropriate medical screening examination, or further examination and treatment, to ask about the person's method of payment or insurance status.

Why not the others?

• A. That is exactly the delay the regulation prohibits.
• C. Routine triage is not automatically an EMTALA medical screening examination. The examination must be performed by qualified personnel under the hospital's rules; billing cannot delay it.
• D. Sending him elsewhere because he's uninsured puts payment ahead of the screening exam the rule requires.

Remember: EMTALA: payment questions cannot delay screening or stabilizing care; reasonable registration is allowed when it does not delay or discourage care.

Source: 42 CFR 489.24: Special responsibilities of Medicare hospitals in emergency cases, paragraphs (a) and (d)(4)(i), (iv).

Answer: B. Hold nitroglycerin and immediately alert the treating team to the hypotension during STEMI care

The blood pressure is already 86/54 mm Hg. NITROSTAT’s prescribing information warns that even small doses can cause severe hypotension in patients who are already hypotensive and contraindicates use in acute circulatory failure or shock. Hold the drug and escalate immediately; a chest-pain protocol does not override this danger sign.

Why not the others?

• A. Nitroglycerin can lower an already dangerously low pressure further.
• C. Distended neck veins with clear lungs do not establish pulmonary edema or justify automatically giving a diuretic instead of evaluating the shock.
• D. Automatic fluid restriction does not address the hypotension. Fluid decisions require urgent hemodynamic assessment rather than an assumption that pulmonary edema is present.

Remember: A chest-pain protocol does not override hypotension: hold nitroglycerin and escalate.

Source: DailyMed: NITROSTAT prescribing information, sections 4.5 and 5.2: circulatory failure/shock and hypotension.

Answer: D. The child needs a few more hours of observation, because the epinephrine's effect wears off

Nebulized epinephrine works within minutes, but the Canadian Paediatric Society notes that its effect disappears after about 2 hours. Children can be discharged safely if croup symptoms don't come back 2 to 4 hours after treatment. Forty-five minutes is too early to know.

Why not the others?

• A. At 45 minutes the epinephrine is still working, so the improvement may not last.
• B. A single dose of dexamethasone is the standard. A second dose isn't needed before discharge.
• C. The CPS statement supports safe discharge after an observation period without recurrence. Admission isn't automatic.

Remember: After racemic epinephrine for croup: watch 2 to 4 hours before sending home.

Source: Canadian Paediatric Society: Acute management of croup in the emergency department, nebulized epinephrine; observation before discharge.

Answer: B. Droplet precautions

CDC lists Standard plus Droplet precautions for meningococcal disease until 24 hours after effective antimicrobial therapy begins. Start appropriate precautions when meningococcal disease is suspected, rather than waiting for confirmation.

Why not the others?

• A. Meningococcal disease isn't spread by the airborne route.
• C. Contact precautions don't address respiratory droplet spread.
• D. Waiting for the lumbar puncture leaves staff and other patients exposed while the diagnosis is being confirmed.

Remember: Suspected meningococcal disease: droplet precautions for the first 24 hours of effective antibiotics.

Source: CDC: Appendix A — Type and Duration of Precautions, Meningococcal disease: sepsis, pneumonia, meningitis.

Answer: A. Abdominal ultrasound

Episodic, inconsolable pain with the legs drawn up, vomiting, and lethargy between episodes is a classic intussusception pattern. Ultrasound is the diagnostic modality of choice. The "currant jelly" stool is a late finding that many children never have, so normal stools don't rule it out.

Why not the others?

• B. A stool culture looks for infection. It doesn't evaluate a bowel obstruction.
• C. Endoscopy doesn't evaluate ileocolic intussusception.
• D. Lethargy between episodes and vomiting are red flags. Calling it colic risks missing bowel ischemia.

Remember: Intermittent inconsolable pain plus lethargy in an infant: ultrasound for intussusception.

Source: ACEP Sonoguide: Intussusception, introduction and indications for ultrasound.

Answer: D. Begin bag-mask ventilation and give an opioid antagonist such as naloxone

He has a pulse but isn't breathing, which is respiratory arrest. The 2025 AHA guidelines say trained rescuers should provide breaths or bag-mask ventilation for suspected opioid overdose with respiratory arrest and a definite pulse, and that an opioid antagonist such as naloxone should be given.

Why not the others?

• A. Naloxone takes time to work. Holding ventilation while you wait lets oxygen levels fall.
• B. He has a definite pulse, so compressions aren't indicated right now. Ventilation is.
• C. The recovery position is for someone breathing adequately. He isn't breathing.

Remember: Opioid respiratory arrest with a pulse: ventilate and give naloxone together.

Source: AHA 2025 Guidelines: Adult and Pediatric Special Circumstances of Resuscitation, opioid overdose recommendations.

Answer: A. Within 1 hour of triage

The ASCO/IDSA guideline recommends that patients with febrile neutropenia receive the first dose of empirical antibacterial therapy within 1 hour of triage, after fever is documented and pretreatment blood samples are collected. Looking well doesn't change that timing.

Why not the others?

• B. Cultures are drawn before the first dose, but the antibiotics don't wait for results.
• C. One documented fever with neutropenia is enough to act on.
• D. Neutropenic patients can deteriorate quickly, which is why the guideline sets a 1-hour target from triage.

Remember: Fever plus neutropenia: cultures, then antibiotics within 1 hour of triage.

Source: ASCO/IDSA: Outpatient Management of Fever and Neutropenia in Adults Treated for Malignancy, initial empirical antibacterial therapy within 1 hour of triage.

Answer: A. A tetanus-containing vaccine now; TIG is not needed

CDC guidance: for dirty or major wounds, a person with a complete primary series needs a tetanus vaccine if the last dose was 5 or more years ago. TIG for dirty wounds is reserved for unknown, incomplete, or absent vaccination, HIV, or severe immunodeficiency. None of those apply here.

Why not the others?

• B. TIG isn't indicated for someone with a complete primary series and no immune compromise.
• C. The 10-year interval applies to clean, minor wounds. A dirty puncture uses the 5-year interval.
• D. TIG alone isn't the plan, and he doesn't meet the criteria for it.

Remember: Dirty wound: booster if 5 or more years since the last dose; TIG only for incomplete or unknown series, HIV, or severe immunodeficiency.

Source: CDC: Clinical Guidance for Wound Management to Prevent Tetanus, dirty/major wounds; booster threshold; TIG indications.

Answer: C. 467 mL/h

Total for 24 hours: 2 × 70 × 40 = 5,600 mL. Half of that, 2,800 mL, is due in the first 8 hours after the burn. The clock starts at the time of injury, not arrival, so 2 of those 8 hours are already gone. 2,800 mL ÷ 6 hours = 466.7, or about 467 mL/h. This is a calculated starting rate, not a rate to leave unchanged for 6 hours. Reassess and titrate from the start to the patient's response, such as urine output, under the burn team's protocol.

Why not the others?

• A. 233 mL/h spreads the whole 5,600 mL evenly over 24 hours. It ignores the front-loading in the first 8 hours.
• B. 350 mL/h divides 2,800 mL by 8 hours. That starts the clock at arrival instead of at the burn.
• D. 700 mL/h divides the full 24-hour total by 8 hours, which would double the ordered first-8-hour volume.

Remember: Burn fluids: the first 8 hours count from the time of injury.

Source: American Burn Association Clinical Practice Guidelines on Burn Shock Resuscitation, PDF p. 17: starting at 2 mL/kg/%TBSA and subsequent titration.

Answer: C. Report the concerns promptly through the chain of command, following facility policy

The pattern raises concern for possible diversion and patient harm, but it is not proof that the colleague has diverted medication or has a substance use disorder. NCSBN emphasizes recognizing concerns and intervening through the appropriate reporting process. Document objective observations, report promptly through the facility's chain of command, and protect patients according to policy.

Why not the others?

• A. A private confrontation skips the facility process and leaves patients at risk while the problem continues.
• B. Reporting is based on concerns and warning signs. Waiting for proof delays protection for patients and help for the nurse.
• D. Spreading concerns among coworkers isn't a reporting process and can harm everyone involved.

Remember: Suspected diversion: report it through the proper channel, promptly.

Source: NCSBN: Substance Use Disorder in Nursing, recognition, intervention and reporting concerns.

Answer: A. An IV beta-blocker such as esmolol or labetalol

The 2022 ACC/AHA aortic disease guideline recommends IV beta-blockers as the initial treatment for acute aortic syndromes unless contraindicated. Vasodilators are added if blood pressure isn't controlled with beta-blockers. Targets are a systolic pressure below 120 mm Hg, or the lowest pressure that keeps organs perfused, and a heart rate of 60 to 80/min.

Why not the others?

• B. The guideline sequence is beta-blocker first, then a vasodilator if needed. A vasodilator alone isn't the starting point.
• C. Heparin treats clots, not a torn aortic wall. It isn't part of the guideline's initial medical therapy for dissection.
• D. A thrombolytic isn't part of dissection management and would add bleeding risk to a vascular injury.

Remember: Aortic dissection: beta-blocker first, then vasodilator if needed.

Source: ACC: 2022 Aortic Disease Guideline Key Perspectives, Part 2, acute aortic syndromes — initial medical management.

Answer: D. Immediate needle decompression or finger thoracostomy by the qualified provider

These findings strongly indicate tension pneumothorax with shock. WSES-AAST thoracic trauma guidance treats tension pneumothorax as a life-threatening condition requiring immediate treatment. Prepare for emergency decompression by a qualified provider, followed by definitive pleural drainage; do not delay treatment for imaging.

Why not the others?

• A. Waiting for an X-ray delays a lifesaving procedure in a patient who is already in shock.
• B. Sending an unstable patient to CT is even more dangerous.
• C. Oxygen is supportive, but it doesn't relieve the pressure that is collapsing his circulation.

Remember: Tension pneumothorax is a clinical diagnosis: decompress, don't image.

Source: Thoracic trauma WSES-AAST guidelines, pleural injuries: pneumothorax, tension pneumothorax and emergency decompression.

Answer: B. 9

Eye opening to pressure = 2. Intelligible single words = 3 ("Words"). Normal flexion = 4. Total: 2 + 3 + 4 = 9. Record the components too, E2 V3 M4, because they carry more information than the total.

Why not the others?

• A. 8 scores the motor response as abnormal flexion (3). The stem describes normal flexion.
• C. 10 scores the verbal response as confused (4). Confused requires coherent conversation, and he only gives single words.
• D. 11 scores eye opening as to sound (3) and verbal as confused (4). Neither matches the stem.

Remember: GCS: score each component from exactly what you see, and report E, V, and M, not just the total.

Source: Glasgow Coma Scale: Assessment Aid, eye, verbal and motor response table.

Answer: A. Perforated appendix with generalized peritonitis

Worsening right lower quadrant pain that becomes diffuse, with high fever and a rigid abdomen, raises concern for perforation and generalized peritonitis. A ruptured appendix can spread infection into the abdominal cavity. He needs urgent surgical evaluation and resuscitation.

Why not the others?

• B. Uncomplicated gastroenteritis does not adequately explain this progression with marked peritoneal signs.
• C. Pain that has spread and a rigid abdomen mean the disease is worsening, not resolving.
• D. Constipation doesn't explain high fever, tachycardia, and peritoneal signs.

Remember: Appendicitis that turns diffuse, rigid, and febrile: think perforation.

Source: American College of Surgeons: Appendectomy, appendicitis, ruptured appendix and peritonitis.

Answer: B. Alcohol withdrawal delirium (delirium tremens); benzodiazepines

Disorientation with hallucinations and marked autonomic overactivity after abrupt cessation of prolonged heavy alcohol use fits alcohol withdrawal delirium. ASAM describes its usual onset as 72–96 hours after the last drink, though timing varies. ASAM's guideline names benzodiazepines as first-line treatment, and patients may need very large doses with close monitoring. This is an emergency: also evaluate for other causes of delirium rather than diagnosing it from the clock alone.

Why not the others?

• A. Minor withdrawal doesn't cause disorientation, fever, and a heart rate of 132.
• C. Nothing in the history points to opioids, and the timeline fits alcohol.
• D. Hallucinations alone don't explain his disorientation, fever, and tachycardia, and an antipsychotic alone doesn't treat alcohol withdrawal.

Remember: After abrupt cessation of prolonged heavy drinking, delirium with autonomic overactivity suggests severe withdrawal; benzodiazepines are first-line with close monitoring.

Source: ASAM Clinical Practice Guideline on Alcohol Withdrawal Management, withdrawal time course; Recommendation VI.13 on alcohol withdrawal delirium.

Answer: A. IV unfractionated heparin unless contraindicated, and emergent vascular evaluation

Sudden pain, pallor, and pulselessness in a patient with atrial fibrillation suggests acute limb ischemia from an embolus. The 2024 ACC/AHA peripheral artery disease guideline recommends systemic anticoagulation with unfractionated heparin on diagnosis unless contraindicated, along with rapid assessment of limb viability.

Why not the others?

• B. A stocking and elevation don't restore arterial flow, and they delay urgent treatment.
• C. Warmth doesn't restore flow, and a 2-hour wait costs limb viability.
• D. This is a limb-threatening emergency, not an outpatient problem.

Remember: Acute limb ischemia: urgent vascular evaluation and heparin unless contraindicated.

Source: AHA/ACC 2024 Lower Extremity PAD Guideline slide set, slide 120: anticoagulation for acute limb ischemia.

Answer: B. He has category E cardiopulmonary failure and needs urgent team-based assessment for advanced treatment

The 2026 AHA/ACC guideline uses clinical categories A through E. Persistent hypotension marks category E, cardiopulmonary failure. Advanced reperfusion therapies are reasonable for category E1, but the choice depends on the full clinical assessment, contraindications and available expertise. Activate urgent team-based care; hypotension is not an automatic instruction to give systemic thrombolysis to every patient.

Why not the others?

• A. Early discharge applies to asymptomatic or low-severity patients, not someone in shock.
• C. Persistent hypotension is the defining feature of the highest-risk category.
• D. Treatment decisions are based on the clinical category, not on the D-dimer level.

Remember: PE with persistent hypotension: urgent cardiopulmonary-failure management and assessment for advanced treatment.

Source: AHA/ACC 2026 Acute Pulmonary Embolism Guideline: Top Things to Know, clinical categories, advanced therapies and PE response teams.

Answer: A. A noncontrast head CT

A sudden, maximal-onset headache raises concern for subarachnoid hemorrhage. ACEP’s clinical policy supports noncontrast head CT as the initial test in a neurologically intact adult presenting within 6 hours of onset. Whether a negative CT completes the evaluation depends on the scan quality, interpretation and remaining clinical suspicion.

Why not the others?

• B. A week's delay risks rebleeding from a ruptured aneurysm, which is associated with worse outcomes.
• C. A response to medication doesn't rule out a bleed, and it delays the diagnosis.
• D. CT comes first in this scenario. Lumbar puncture is not reserved only for patients presenting after 6 hours: ACEP recommends LP or CT angiography when a patient remains at risk after a negative noncontrast CT, using shared decision-making.

Remember: Thunderclap headache: noncontrast CT first.

Source: ACEP Clinical Policy: Headache — official imaging webinar, slides 23 and 41: early noncontrast CT; LP or CTA when risk remains after negative CT.