Emergency Nurse Practitioner ENP Ultimate Exam
1. Q: A 62-year-old male presents with crushing chest pain radiating to the left
arm. His BP is 88/52, HR 110, RR 24, SpO₂ 91% on room air. What is the priority
intervention? ANSWER Activate the cardiac catheterization lab and administer
aspirin 325 mg chewable. This patient is in cardiogenic shock with a suspected
STEMI. Immediate reperfusion therapy is critical.
2. Q: Which ECG finding is most specific for an acute inferior wall STEMI?
ANSWER ST-segment elevation in leads II, III, and aVF.
3. Q: A patient with atrial fibrillation has a rapid ventricular response at 160
bpm and is hypotensive (SBP 78). What is the immediate treatment? ANSWER
Synchronized cardioversion starting at 100–200 J (biphasic).
4. Q: What is the correct needle decompression site for a tension
pneumothorax? ANSWER Second intercostal space at the midclavicular line on
the affected side.
5. Q: In a patient with suspected aortic dissection, which two blood pressure
differentials are most concerning? ANSWER Systolic BP difference >20 mmHg
between arms, or pulse deficit between upper extremities.
6. Q: What is the classic triad for cardiac tamponade? ANSWER Beck's triad:
hypotension, jugular venous distension, and muffled heart sounds.
7. Q: A patient presents with tearing chest pain radiating to the back. BP is
190/110. What is the diagnostic test of choice? ANSWER CT angiography of
the chest/abdomen/pelvis.
8. Q: Which murmur is associated with hypertrophic cardiomyopathy (HOCM)?
ANSWER Systolic crescendo-decrescendo murmur that increases with Valsalva
and decreases with squatting.
,9. Q: What is the initial treatment for unstable supraventricular tachycardia
(SVT)? ANSWER Synchronized cardioversion with 50–100 J (biphasic) if
unstable; adenosine 6 mg IV rapid push if stable.
10. Q: A patient with end-stage renal disease presents with pericardial friction
rub, hypotension, and JVD. What is the diagnosis? ANSWER Uremic
pericarditis with tamponade physiology.
Respiratory Assessment
11. Q: What are the classic arterial blood gas findings in a COPD exacerbation?
ANSWER Respiratory acidosis with elevated PaCO₂ and decreased pH; may
have compensatory elevated bicarbonate.
12. Q: A patient has a tension pneumothorax. What is the immediate
intervention before chest X-ray? ANSWER Needle decompression with a 14-
gauge needle, 5 cm in length, at the 4th–5th intercostal space anterior axillary
line (or 2nd ICS midclavicular).
13. Q: What is the CURB-65 criteria for pneumonia severity? ANSWER
Confusion, Urea >7 mmol/L, Respiratory rate ≥30, BP (SBP <90 or DBP ≤60),
Age ≥65. Score ≥2 suggests hospitalization.
14. Q: A patient with asthma has a silent chest, altered mental status, and
PaCO₂ of 55. What does this indicate? ANSWER Impending respiratory failure;
the "silent chest" indicates severe bronchospasm with minimal air movement.
15. Q: What is the most common cause of hemoptysis in the ED? ANSWER
Acute bronchitis, though massive hemoptysis is most commonly due to
tuberculosis, bronchiectasis, or lung cancer.
16. Q: In a patient with suspected pulmonary embolism and hemodynamic
instability, what is the next step? ANSWER Bedside echocardiography to
assess for right heart strain; if confirmed and patient unstable, systemic
thrombolysis without waiting for CT.
17. Q: What is the Wells' criteria used for? ANSWER Clinical probability
assessment for pulmonary embolism.
18. Q: A patient presents with sudden-onset dyspnea, pleuritic chest pain, and
tachypnea after a long flight. What is the most likely diagnosis? ANSWER
Pulmonary embolism (Virchow's triad: stasis, hypercoagulability, endothelial
injury).
, 19. Q: What is the primary treatment for anaphylactic shock? ANSWER
Epinephrine 0.3–0.5 mg IM (1:1000) in the anterolateral thigh, repeated every
5–15 minutes as needed.
20. Q: In acute respiratory distress syndrome (ARDS), what is the target tidal
volume for mechanical ventilation? ANSWER 6 mL/kg of predicted body
weight (lung-protective ventilation strategy).
Neurological Assessment
21. Q: What is the most sensitive indicator of increased intracranial pressure
(ICP) on physical exam? ANSWER Altered level of consciousness; papilledema
is a late finding.
22. Q: A patient presents with "the worst headache of my life." What is the
diagnostic test of choice? ANSWER Non-contrast head CT to evaluate for
subarachnoid hemorrhage.
23. Q: What are the three components of the Glasgow Coma Scale (GCS)?
ANSWER Eye opening (1–4), Verbal response (1–5), Motor response (1–6).
Total 3–15.
24. Q: In a stroke patient, what is the time window for IV tPA (alteplase)?
ANSWER 4.5 hours from symptom onset (or last known well) for eligible
patients.
25. Q: What are the absolute contraindications to IV thrombolysis in stroke?
ANSWER Active internal bleeding, intracranial hemorrhage on CT, recent
intracranial surgery, recent ischemic stroke within 3 months, suspected aortic
dissection.
26. Q: A patient has a blown pupil (fixed, dilated). What does this suggest?
ANSWER Uncal herniation with compression of the ipsilateral oculomotor
nerve (CN III).
27. Q: What is the most common cause of atraumatic subarachnoid
hemorrhage? ANSWER Rupture of a saccular (berry) aneurysm.
28. Q: In bacterial meningitis, what are the classic triad of symptoms?
ANSWER Fever, nuchal rigidity, and altered mental status.
29. Q: What is the first-line antibiotic for suspected bacterial meningitis in
adults? ANSWER Ceftriaxone 2 g IV q12h + Vancomycin (adjusted for renal
1. Q: A 62-year-old male presents with crushing chest pain radiating to the left
arm. His BP is 88/52, HR 110, RR 24, SpO₂ 91% on room air. What is the priority
intervention? ANSWER Activate the cardiac catheterization lab and administer
aspirin 325 mg chewable. This patient is in cardiogenic shock with a suspected
STEMI. Immediate reperfusion therapy is critical.
2. Q: Which ECG finding is most specific for an acute inferior wall STEMI?
ANSWER ST-segment elevation in leads II, III, and aVF.
3. Q: A patient with atrial fibrillation has a rapid ventricular response at 160
bpm and is hypotensive (SBP 78). What is the immediate treatment? ANSWER
Synchronized cardioversion starting at 100–200 J (biphasic).
4. Q: What is the correct needle decompression site for a tension
pneumothorax? ANSWER Second intercostal space at the midclavicular line on
the affected side.
5. Q: In a patient with suspected aortic dissection, which two blood pressure
differentials are most concerning? ANSWER Systolic BP difference >20 mmHg
between arms, or pulse deficit between upper extremities.
6. Q: What is the classic triad for cardiac tamponade? ANSWER Beck's triad:
hypotension, jugular venous distension, and muffled heart sounds.
7. Q: A patient presents with tearing chest pain radiating to the back. BP is
190/110. What is the diagnostic test of choice? ANSWER CT angiography of
the chest/abdomen/pelvis.
8. Q: Which murmur is associated with hypertrophic cardiomyopathy (HOCM)?
ANSWER Systolic crescendo-decrescendo murmur that increases with Valsalva
and decreases with squatting.
,9. Q: What is the initial treatment for unstable supraventricular tachycardia
(SVT)? ANSWER Synchronized cardioversion with 50–100 J (biphasic) if
unstable; adenosine 6 mg IV rapid push if stable.
10. Q: A patient with end-stage renal disease presents with pericardial friction
rub, hypotension, and JVD. What is the diagnosis? ANSWER Uremic
pericarditis with tamponade physiology.
Respiratory Assessment
11. Q: What are the classic arterial blood gas findings in a COPD exacerbation?
ANSWER Respiratory acidosis with elevated PaCO₂ and decreased pH; may
have compensatory elevated bicarbonate.
12. Q: A patient has a tension pneumothorax. What is the immediate
intervention before chest X-ray? ANSWER Needle decompression with a 14-
gauge needle, 5 cm in length, at the 4th–5th intercostal space anterior axillary
line (or 2nd ICS midclavicular).
13. Q: What is the CURB-65 criteria for pneumonia severity? ANSWER
Confusion, Urea >7 mmol/L, Respiratory rate ≥30, BP (SBP <90 or DBP ≤60),
Age ≥65. Score ≥2 suggests hospitalization.
14. Q: A patient with asthma has a silent chest, altered mental status, and
PaCO₂ of 55. What does this indicate? ANSWER Impending respiratory failure;
the "silent chest" indicates severe bronchospasm with minimal air movement.
15. Q: What is the most common cause of hemoptysis in the ED? ANSWER
Acute bronchitis, though massive hemoptysis is most commonly due to
tuberculosis, bronchiectasis, or lung cancer.
16. Q: In a patient with suspected pulmonary embolism and hemodynamic
instability, what is the next step? ANSWER Bedside echocardiography to
assess for right heart strain; if confirmed and patient unstable, systemic
thrombolysis without waiting for CT.
17. Q: What is the Wells' criteria used for? ANSWER Clinical probability
assessment for pulmonary embolism.
18. Q: A patient presents with sudden-onset dyspnea, pleuritic chest pain, and
tachypnea after a long flight. What is the most likely diagnosis? ANSWER
Pulmonary embolism (Virchow's triad: stasis, hypercoagulability, endothelial
injury).
, 19. Q: What is the primary treatment for anaphylactic shock? ANSWER
Epinephrine 0.3–0.5 mg IM (1:1000) in the anterolateral thigh, repeated every
5–15 minutes as needed.
20. Q: In acute respiratory distress syndrome (ARDS), what is the target tidal
volume for mechanical ventilation? ANSWER 6 mL/kg of predicted body
weight (lung-protective ventilation strategy).
Neurological Assessment
21. Q: What is the most sensitive indicator of increased intracranial pressure
(ICP) on physical exam? ANSWER Altered level of consciousness; papilledema
is a late finding.
22. Q: A patient presents with "the worst headache of my life." What is the
diagnostic test of choice? ANSWER Non-contrast head CT to evaluate for
subarachnoid hemorrhage.
23. Q: What are the three components of the Glasgow Coma Scale (GCS)?
ANSWER Eye opening (1–4), Verbal response (1–5), Motor response (1–6).
Total 3–15.
24. Q: In a stroke patient, what is the time window for IV tPA (alteplase)?
ANSWER 4.5 hours from symptom onset (or last known well) for eligible
patients.
25. Q: What are the absolute contraindications to IV thrombolysis in stroke?
ANSWER Active internal bleeding, intracranial hemorrhage on CT, recent
intracranial surgery, recent ischemic stroke within 3 months, suspected aortic
dissection.
26. Q: A patient has a blown pupil (fixed, dilated). What does this suggest?
ANSWER Uncal herniation with compression of the ipsilateral oculomotor
nerve (CN III).
27. Q: What is the most common cause of atraumatic subarachnoid
hemorrhage? ANSWER Rupture of a saccular (berry) aneurysm.
28. Q: In bacterial meningitis, what are the classic triad of symptoms?
ANSWER Fever, nuchal rigidity, and altered mental status.
29. Q: What is the first-line antibiotic for suspected bacterial meningitis in
adults? ANSWER Ceftriaxone 2 g IV q12h + Vancomycin (adjusted for renal
