CPEN BCEN Timed #1
A 1-week old infant is brought in by caregivers with a two-day history of poor feeding and
"breathing funny". During the triage assessment, the infant becomes increasingly irritable and
the nurse notices cyanosis around the lips and mucous membranes. What should the nurse
suspect? - ANS-Tetralogy of Fallot
A 1-year-old presents unconscious and is being ventilated with a bag-mask device. Ventilation
has become progressively more difficult. Which of the following is the PRIORITY intervention? -
ANS-Place padding under the shoulders.
A 10-year-old presents with a de-gloving injury to the hand. Which of the following is the MOST
appropriate treatment? - ANS-Gently realign any remaining soft tissue and cover with sterile
dressing.
A 12-month-old presents with a 2-day history of nausea and vomiting. Vital signs include:
BP 80/60 mm HgHR 56 beats/minRR 12 breaths/min
The child is limp and ashen. Which of the following is the PRIORITY intervention? -
ANS-manual ventilations
A 12-year-old child with Asperger's syndrome presents to the emergency department with a
caregiver. The BEST approach for the nurse would be to - ANS-keep the triage assessment
brief.
A 12-year-old male presents after losing a tooth when he crashed his bike. Which of the
following can be done to preserve the tooth until emergency dental care is available? -
ANS-Rinse the tooth and place it back in the socket.
A 12-year-old patient presents to the ED with complaints of numbness and tingling to the left
side of their face, facial droop and inability to close their left eye. The nurse suspects that the
patient is likely having which condition? - ANS-Bell's palsy
A 12-year-old presents with low-grade fever and diffuse abdominal pain which increases with
coughing. These symptoms suggest - ANS-appendicitis.
A 13-year-old girl presents with severe intermittent lower back and abdominal pain associated
with urinary incontinence. She is unsure of her last normal menstrual cycle. Which of the
following findings is MOST concerning? - ANS-vaginal bleeding
A 14-year-old female accompanied by a caregiver presents to the emergency department with
complaints of abdominal pain. The nurse notes a tattoo on the abdomen with initials and
attempts to discuss the tattoo without success. The patient tries to hide the tattoo. The nurse
should be MOST concerned about - ANS-human trafficking.
A 14-year-old female reports a sudden onset of severe pelvic pain with guarding. Which of the
following is MOST concerning? - ANS-referred shoulder pain
A 14-year-old patient presents to the emergency department with complaints of right hip pain
without trauma for the past 4 days. The nurse observes that the patient is holding the leg in an
externally rotated position. What is the BEST nursing intervention? - ANS-Ensure that the
patient is non-weight bearing.
, A 16-year-old has overdosed on an unknown amount of a selective serotonin reuptake inhibitor.
Which cardiac arrhythmia should the nurse expect? - ANS-prolonged QT interval
A 2-month-old presents with difficulty breathing associated with tachypnea, mild retractions, and
copious amounts of nasal drainage. The MOST appropriate intervention is to - ANS-suction the
nares.
A 2-year-old presents with a left thigh deformity after tripping over a toy. Further assessment
and diagnostic studies show a left femur fracture, multiple healed fractures to bilateral legs, and
blue-tinted sclera. The nurse is suspicious for - ANS-osteogenesis imperfecta.
A 2-year-old with known cardiac history is brought in by ambulance for prolonged cyanosis
following a temper tantrum. Treatment for this child would include - ANS-morphine.
A 22-month-old presents after drinking windshield wiper fluid. Symptoms of this ingestion
include - ANS-vomiting, diarrhea, ataxia, and visual impairment.
A 3-week-old infant presents with a parental complaint of bilious vomiting, and a distended
abdomen. Which of the following is the MOST likely diagnosis for this infant? - ANS-malrotation
volvulus
These symptoms are consistent with malrotation volvulus. Intussusception would be colicky and
pain with blood in the stool. Pyloric stenosis does not have a distended abdomen.
Hirschsprung's disease would demonstrate explosive diarrhea, fever, abdominal pain, and
vomiting.
A 3-year-old child presents following 36 hours of vomiting and diarrhea. Vital signs include:
BP 78/45 mm HgHR 150 beats/minRR 38 breaths/minTemp 100.4° F (38° C)O2 sat 94%
The highest PRIORITY intervention is: - ANS-intravenous volume replacement at 20 mL/kg.
A 3-year-old presents with bilateral hand and feet swelling, a red-colored tongue, and a high
fever for 7 days. The nurse knows that treatment is aimed at preventing: - ANS-Coronary
aneurysm
A 3-year-old presents with nausea, vomiting, and diarrhea for 5 days. The vital signs are:
BP 85/45 mm HgHR 136 beats/minRR 32 breaths/minT (rectal) 100.0o F (37.8o C)O2 sat 96%
on room air
The nurse should anticipate orders for: - ANS-oral rehydration
A 30-kg child has deep partial-thickness burns over 40% of total body surface area. Which of
the following findings would indicate adequate fluid resuscitation? - ANS-urine output of 30
mL/hr
A 4-week-old infant is brought to the emergency department by her father who states the infant
has been vomiting "forcefully" after each feeding but then wants to feed again immediately after.
The nurse suspects - ANS-pyloric stenosis.
A 4-year-old arrives via EMS after being hit by a car. An intraosseous needle (IO) has been
placed in the left tibia for fluid resuscitation. Inspection of the left lower leg reveals swelling and
tightness of the left calf. The MOST likely cause of this finding is - ANS-extravasation of the IO.
A 4-year-old patient presents with fever for 5 days, edematous hands, and dry, cracking lips.
Which of the following orders should the nurse question when delivering care? - ANS-low dose
corticosteroid therapy
A 5-day-old neonate is diagnosed with hyperbilirubinemia. If left untreated, the infant may have
long-term issues with - ANS-intellectual deficits.
A 1-week old infant is brought in by caregivers with a two-day history of poor feeding and
"breathing funny". During the triage assessment, the infant becomes increasingly irritable and
the nurse notices cyanosis around the lips and mucous membranes. What should the nurse
suspect? - ANS-Tetralogy of Fallot
A 1-year-old presents unconscious and is being ventilated with a bag-mask device. Ventilation
has become progressively more difficult. Which of the following is the PRIORITY intervention? -
ANS-Place padding under the shoulders.
A 10-year-old presents with a de-gloving injury to the hand. Which of the following is the MOST
appropriate treatment? - ANS-Gently realign any remaining soft tissue and cover with sterile
dressing.
A 12-month-old presents with a 2-day history of nausea and vomiting. Vital signs include:
BP 80/60 mm HgHR 56 beats/minRR 12 breaths/min
The child is limp and ashen. Which of the following is the PRIORITY intervention? -
ANS-manual ventilations
A 12-year-old child with Asperger's syndrome presents to the emergency department with a
caregiver. The BEST approach for the nurse would be to - ANS-keep the triage assessment
brief.
A 12-year-old male presents after losing a tooth when he crashed his bike. Which of the
following can be done to preserve the tooth until emergency dental care is available? -
ANS-Rinse the tooth and place it back in the socket.
A 12-year-old patient presents to the ED with complaints of numbness and tingling to the left
side of their face, facial droop and inability to close their left eye. The nurse suspects that the
patient is likely having which condition? - ANS-Bell's palsy
A 12-year-old presents with low-grade fever and diffuse abdominal pain which increases with
coughing. These symptoms suggest - ANS-appendicitis.
A 13-year-old girl presents with severe intermittent lower back and abdominal pain associated
with urinary incontinence. She is unsure of her last normal menstrual cycle. Which of the
following findings is MOST concerning? - ANS-vaginal bleeding
A 14-year-old female accompanied by a caregiver presents to the emergency department with
complaints of abdominal pain. The nurse notes a tattoo on the abdomen with initials and
attempts to discuss the tattoo without success. The patient tries to hide the tattoo. The nurse
should be MOST concerned about - ANS-human trafficking.
A 14-year-old female reports a sudden onset of severe pelvic pain with guarding. Which of the
following is MOST concerning? - ANS-referred shoulder pain
A 14-year-old patient presents to the emergency department with complaints of right hip pain
without trauma for the past 4 days. The nurse observes that the patient is holding the leg in an
externally rotated position. What is the BEST nursing intervention? - ANS-Ensure that the
patient is non-weight bearing.
, A 16-year-old has overdosed on an unknown amount of a selective serotonin reuptake inhibitor.
Which cardiac arrhythmia should the nurse expect? - ANS-prolonged QT interval
A 2-month-old presents with difficulty breathing associated with tachypnea, mild retractions, and
copious amounts of nasal drainage. The MOST appropriate intervention is to - ANS-suction the
nares.
A 2-year-old presents with a left thigh deformity after tripping over a toy. Further assessment
and diagnostic studies show a left femur fracture, multiple healed fractures to bilateral legs, and
blue-tinted sclera. The nurse is suspicious for - ANS-osteogenesis imperfecta.
A 2-year-old with known cardiac history is brought in by ambulance for prolonged cyanosis
following a temper tantrum. Treatment for this child would include - ANS-morphine.
A 22-month-old presents after drinking windshield wiper fluid. Symptoms of this ingestion
include - ANS-vomiting, diarrhea, ataxia, and visual impairment.
A 3-week-old infant presents with a parental complaint of bilious vomiting, and a distended
abdomen. Which of the following is the MOST likely diagnosis for this infant? - ANS-malrotation
volvulus
These symptoms are consistent with malrotation volvulus. Intussusception would be colicky and
pain with blood in the stool. Pyloric stenosis does not have a distended abdomen.
Hirschsprung's disease would demonstrate explosive diarrhea, fever, abdominal pain, and
vomiting.
A 3-year-old child presents following 36 hours of vomiting and diarrhea. Vital signs include:
BP 78/45 mm HgHR 150 beats/minRR 38 breaths/minTemp 100.4° F (38° C)O2 sat 94%
The highest PRIORITY intervention is: - ANS-intravenous volume replacement at 20 mL/kg.
A 3-year-old presents with bilateral hand and feet swelling, a red-colored tongue, and a high
fever for 7 days. The nurse knows that treatment is aimed at preventing: - ANS-Coronary
aneurysm
A 3-year-old presents with nausea, vomiting, and diarrhea for 5 days. The vital signs are:
BP 85/45 mm HgHR 136 beats/minRR 32 breaths/minT (rectal) 100.0o F (37.8o C)O2 sat 96%
on room air
The nurse should anticipate orders for: - ANS-oral rehydration
A 30-kg child has deep partial-thickness burns over 40% of total body surface area. Which of
the following findings would indicate adequate fluid resuscitation? - ANS-urine output of 30
mL/hr
A 4-week-old infant is brought to the emergency department by her father who states the infant
has been vomiting "forcefully" after each feeding but then wants to feed again immediately after.
The nurse suspects - ANS-pyloric stenosis.
A 4-year-old arrives via EMS after being hit by a car. An intraosseous needle (IO) has been
placed in the left tibia for fluid resuscitation. Inspection of the left lower leg reveals swelling and
tightness of the left calf. The MOST likely cause of this finding is - ANS-extravasation of the IO.
A 4-year-old patient presents with fever for 5 days, edematous hands, and dry, cracking lips.
Which of the following orders should the nurse question when delivering care? - ANS-low dose
corticosteroid therapy
A 5-day-old neonate is diagnosed with hyperbilirubinemia. If left untreated, the infant may have
long-term issues with - ANS-intellectual deficits.
