CEN Exam Review & Practice Test
The Board of Certification for Emergency Nursing (BCEN) offers the Certification Examination for Emergency Nurses. With a successful exam attempt, the candidate will be a Certified Emergency Nurse (CEN) for four years and may use the credential “CEN” for as long as the term is valid. To be eligible to take the exam, the candidate needs to have an up-to-date, unrestricted RN license or nursing certificate that is recognized in the USA. A BSN is not required. It is advisable to gain two years of experience in emergency nursing before taking the exam, but it is not mandatory.
The three-hour, computer-based CEN exam has 175 multiple-choice questions. Of these, 150 are scored. The remaining 25 are pre-trial questions to be used on future examinations. Candidates will receive their score immediately. If a candidate does not pass, the candidate may take the test again after three months have passed.
The subject areas of the Certification Examination for Emergency Nurses include:
- 21 questions on cardiovascular responsibilities
- 9 questions on gastrointestinal responsibilities
- 10 questions on genitourinary, gynecology and obstetrical responsibilities
- 6 questions on maxillofacial/ocular responsibilities
- 15 questions on neurological responsibilities
- 13 questions on orthopedic/wound responsibilities
- 6 questions on psychological/social responsibilities
- 18 questions on respiratory responsibilities
- 9 questions on patient care management responsibilities
- 11 questions on shock/multi-system responsibilities
- 15 questions on medical emergency responsibilities
- 7 questions on professional issue responsibilities
- 10 questions on substance abuse/toxicological/environmental responsibilities
CEN Practice Questions
1. Which dysrhythmia would be identified on an ECG/EKG six-second strip by a heart rate of 76 and a PR interval of 0.24?
A. sinus tachycardia
B. first-degree atrioventricular block
C. sinus bradycardia
D. junctional escape rhythm
2. Which blood test may indicate infection or inflammation and would need to be used as part of the clinical picture with diagnosing and treating abdominal pain?
A. white blood cell (WBC) count of 5.0
B. hematocrit (HCT) of 45
C. WBC count of 28.0
D. blood sugar (BS) of 74
3. A 30-year-old man comes to the emergency department with the acute onset of left flank pain radiating to the groin. Microscopic hematuria is present on urinalysis. What is the most likely diagnosis?
A. ureteral calcium oxalate calculus
B. ureteral cystine calculus
C. testicular torsion
4. Which of the following is NOT appropriate for screening for domestic violence by the emergency department nurse?
A. asking if the person has been hit, kicked, or otherwise hurt by someone in the past year; if so, by whom
B. asking, “Do you feel safe in your present relationship?”
C. avoid asking about intimate person violence if the patient is in the emergency department for a medical ailment, not trauma
D. asking if there is a partner from a previous relationship that makes the individual feel unsafe
5. A patient is intubated and on mechanical ventilation. The ventilator alarm rings and the airway pressure is found to be elevated. Possible causes include the following EXCEPT:
A. endotracheal tube obstruction with sputum
D. cuff leak
6. A 2-year-old is brought to the emergency department with mild fever, persistent restlessness, crying, and pulling his left ear. He has had a cold for about a week. Examination of the ear reveals a distorted light reflex and slight bulging of the tympanic membrane. What is the proper diagnosis and treatment?
A. otitis externa and antibiotics
B. otitis media and antibiotics
C. otitis media and myringotomy
D. acute labyrinthitis and antivertigo drug
7. A 75-year-old man has a history of several episodes of transient right-sided arm and hand weakness lasting an hour or two but with full recovery. He is diabetic and hypertensive and is taking medication for both conditions. This time the episode does not resolve and he is taken to the emergency department some 2 hours after the onset of symptoms. He is awake and able to answer questions and give a medical history. His chest is clear and no bruits are heard over the carotids. There is drift of the right arm on examination and his speech is slightly garbled. His blood pressure is 160/95 mm Hg and his pulse is irregular at 80 beats per minute. A CT of the brain reveals a small left-sided occlusion in a branch of the middle cerebral arterial circulation without hemorrhage. What should be the next step in his management?
A. start nitroprusside to reduce his blood pressure to normal
B. begin fibrinolytic therapy with alteplase (Activase)
C. begin warfarin
D. neurosurgical consultation for carotid endarterectomy
8. A chronically anemic patient is receiving a packed red blood cell (PRBC) transfusion. He suddenly develops fever and chills, tachypnea and dyspnea, and tightness in the chest. His urine flow is diminished and dark in color. What is the probable diagnosis and appropriate measures to take?
A. air embolus; stop infusion, administer oxygen, and turn patient on left side
B. hemolytic transfusion reaction; stop transfusion, send the untransfused blood and a patient blood sample to the C. blood bank, monitor urine flow and collect sample for the lab
D. pyrogenic transfusion reaction; stop transfusion and switch to leukocyte-poor PRBCs
E. circulatory overload; stop transfusion, consider diuretics
9. An elderly patient has recently taken a large dose of imipramine (Tofranil) in an apparent suicide attempt. He is confused and disoriented, hypotensive, and tachycardic with flushed skin and wide pupils. While being brought in by paramedics, he has a seizure. An ECG shows a sinus tachycardia with a prolonged QRS complex and QT-interval and T-wave abnormalities. Which of the following pharmacologic agents would NOT be appropriate?
A. lorazepam (Ativan)
B. sodium bicarbonate
C. phenytoin (Dilantin)
D. activated charcoal and sorbitol
10. Which of the following is NOT recommended for routine hemodynamic monitoring of patients in shock?
A. pulmonary artery catheter
B. central venous pressure
C. pulse oximetry
D. superior vena cava oxygen saturation (ScvO2)
11. A patient presents with a history of nausea, vomiting, and diarrhea for several days after a Caribbean cruise. In the emergency department, she is weak, moderately hypotensive, and dehydrated. An ECG shows bradycardia, mild ST depression, and a U wave with some ventricular ectopic beats. What is the most likely electrolyte abnormality?
12. The Emergency Medical Treatment and Active Labor Act (EMTALA) includes the following provisions EXCEPT:
A. participating hospitals have emergency departments and receive funding from Health and Human Services (HHS)
B. any patient who comes to the emergency department requesting examination or treatment must receive an appropriate medical screening exam to determine if an emergency situation exists
C. to transfer an unstable patient, the receiving hospital must accept him or her and the transferring doctor must D. sign a form stating that the benefits of the transfer outweigh the risks
E. verbal patient refusal of examination or treatment absolves the hospital from possible legal penalty
1. B: First-degree atrioventricular block is diagnosed partially by an EKG showing a PR interval of greater than 0.20 seconds.
2. C: An elevated WBC count would be indicative of infection or inflammation. The WBC count of 5.0 is normal. The HCT and BS levels listed would also be considered within normal limits.
3. A: Ureteral calculi are a quite common cause of acute emergency evaluation, usually causing flank pain with radiation to the back and/or groin. About 75% of these are calcium oxalate or phosphate; less common are struvite, uric acid, or cystine calculi. While KUB or ultrasound may show the stone, helical CT is now the preferred diagnostic method. Additional workup includes CBC, chemistry panel, urinalysis, and straining of urine to catch a passed stone for chemical analysis. Nursing attention should be directed to intravenous hydration with input and output recording and narcotic or narcotic plus NSAID (e.g., ketorolac) administration for pain. Some patients may be discharged with analgesics and instructions for hydration and calculus capture. Testicular torsion is most common in adolescents and usually presents with testicular and groin pain with abdominal radiation; increasing pain by lifting the scrotum to the level of the pubic symphysis causes exacerbation of the pain (Prehn sign). Cystitis may be infectious or drug-induced, but cystitis usually causes dysuria and pyuria and shows positive urine cultures.
4. C: Domestic violence, nearly always perpetrated against women, is a major problem confronted by the emergency nurse. Screening for possible cases should include answers A, B and D. Interestingly, victims of intimate partner violence often present with a medical ailment, not trauma. These include back, abdominal, or pelvic pain, headaches, urinary infections, sexually transmitted disease, or symptoms consistent with posttraumatic stress disorder (PTSD). Sometimes evidence of old trauma such as healing fractures or cosmetically concealed bruises may point toward the presence of domestic violence. Many victims will deny it but sometimes compassionate questioning in a private setting will elicit a positive response. The nurse may then offer advice, refer to a social agency or shelter, or ask for a consultation by the hospital social worker.
5. D: Mechanical ventilation requires diligent observation of the patient and ventilator by the emergency nurse. Modern ventilators usually come with alarms that indicate high or low airway pressure. High pressure may be caused by endotracheal tube obstruction with sputum or kinks or inadvertent endobronchial displacement. The airway should be suctioned and tube placement checked. A chest x-ray is frequently helpful in determining the cause. Lung collapse, worsening of the underlying disease, and bronchospasm are also causes of elevated pressure. Leaks around the endotracheal tube cuffs will cause low airway pressure. Auto-positive end-expiratory pressure (auto-PEEP) is caused by premature inspiratory delivery before full expiration (as in asthma or COPD patients) and may lead to increased pressure and lung damage.
6. B: Ear infections may cause severe and persistent pain, especially in children in the 6-month to 3-year age group and are a frequent cause of emergency department visits. Loss or distortion of the light reflex and bulging of the tympanic membrane are cardinal signs of otitis media, usually caused by bacteria such as Streptococcus Influenza or Haemophilus Influenza. Sinusitis and purulent rhinitis may accompany the otitis. Antibiotics to cover these organisms, topical warmed otic analgesics, and antipyretics are the usual treatment modalities. Otitis externa or swimmer’s ear also causes otalgia and frequently follows swimming in contaminated water or a foreign body in the ear. Keeping the ear dry and using otic analgesics and antibiotics are indicated. Ear plugs while swimming or ear drying agents after swimming or showering are the usual preventive measures. Myringotomy is a surgical procedure to keep the middle ear draining in chronic otitis media and hopefully prevent such complications as mastoiditis, meningitis, ruptured tympanic membrane, or permanent hearing loss. Labyrinthitis is an infection of the inner ear and usually causes severe vertigo, most commonly in adults.
7. B: This patient had several transient ischemic attacks prior to his clear-cut signs of a stroke, shown to be nonhemorrhagic in nature. Such strokes may be caused by local thrombosis, especially in arteriosclerotic vessels, or by emboli arising in the carotid artery (usually at the bifurcation of the internal and external vessels) or the heart, most often in atrial fibrillation patients with clots in the atrial appendage. Because this patient arrived in the emergency department within 3 hours from the onset of symptoms, the current recommendation is to begin fibrinolytic therapy with recombinant tissue plasminogen activator (r-TPA). Some recent studies indicate benefit from this therapy may be achieved up to 4.5 hours after the onset of symptoms. Blood pressure management in stroke patients is tricky. Most would agree with slow reduction if the value is greater than 220 systolic or 120 diastolic or the stroke is hemorrhagic in nature. For patients treated with a fibrinolytic agent, significantly elevated blood pressure should be lowered to prevent reperfusion problems. If noninvasive carotid scanning shows marked stenosis, neurosurgical consultation for endarterectomy or angioplasty with stent placement is reasonable. Subsequent warfarin treatment may be appropriate if atrial fibrillation is present.
8. B: Transfusion reactions may be of several types and some of the symptoms may overlap. In nearly every case, the transfusion should be stopped immediately and the line kept open with normal saline or other maintenance fluid. This patient’s symptoms and signs strongly suggest a hemolytic transfusion reaction due to ABO incompatibility. Type-specific blood that has been cross-matched is standard for blood and packed cell transfusions, but type O Rh negative (females and males) or type O Rh positive (males) may be given in severe emergencies. Hemolytic transfusion reactions are often severe and may be life-threatening so immediate supportive therapy is required. Pyrogenic reactions are mostly due to recipient antibodies to donor leukocytes and leukocyte-poor blood product is preferred. Air embolus is usually due to catheter manipulation (often by patient) or improper infusion technique. Circulatory overload, by overzealous or too-rapid transfusion, may produce symptoms of pulmonary edema; give diuretic and other appropriate treatment for this immediately.
9. C: Overdose of tricyclic antidepressants, often by elderly patients with suicidal intent, is less common now since the advent of SSRI drugs for depression but is still a fairly frequent medical emergency. More common is CNS dysfunction ranging from disorientation and confusion to seizures and frank coma; anticholinergic effects including flushed skin, dry mucous membranes, and mydriasis; and cardiac effects including conduction abnormalities and ventricular tachycardia. Phenytoin is contraindicated for seizures in these patients because it has sodium channel blocking activity and may worsen arrhythmias. The drugs are very well absorbed by activated charcoal; the combination of activated charcoal with sorbitol to overcome the anticholinergics effects on the bowel is useful. Sodium bicarbonate raises the blood pH and lowers the free drug concentration, improving some of the ECG abnormalities.
10. A: While observation of the patient’s heart and respiratory rates, mental status, and adequacy of peripheral circulation are clinical indicators of shock, several invasive and noninvasive methods for following effectiveness of treatment are available. Pulse oximetry is a simple and noninvasive technique to measure peripheral oxygen saturation but is subject to limitations in estimating circulation and hypoxia, especially with use of vasoactive medications or hypothermia. Central venous pressure is a useful measure of circulating volume, cardiac performance, and vascular tone. Values under the normal range of 4 to 10 cm H2O indicate a low circulating volume while values above this range may indicate excessive fluid administration, pulmonary edema, or vascular obstruction. ScvO2 is measured from a catheter in the superior vena cava and a value of 70% is used to guide therapy even if clinical signs show improvement. Pulmonary artery catheters (e.g., Swan-Ganz) are not recommended for routine hemodynamic monitoring.
11. C: Hypokalemia (potassium lower than 3.5 mEq/L) may result from gastrointestinal or renal loss, or from transfer from extracellular fluid to intracellular fluid. Drugs such as aldosterone, insulin, and beta2-agonists promote the latter. Gastrointestinal loss is the most likely cause in this patient and hypokalemia may be a feature of traveler’s gastroenteritis. Renal loss occurs with diuretics or kidney disease and low potassium may be a feature of diabetic ketoacidosis or excess steroids. The ECG findings described are typical of low potassium but do not necessarily correlate with the degree. Potassium administration should be through a large bore or central venous catheter (it is locally irritating) by an infusion pump at 40 mEq/L not to exceed 10 to 20 mEq per hour. For severe hypokalemia, a 5 to 10 mEq bolus may be given but serial potassium and cardiac monitoring is required to avoid hyperkalemia, ventricular dysrhythmias, and death. Low serum magnesium levels may accompany hypokalemia and should be checked.
12. D: EMTALA was passed by Congress in 1986 as part of COBRA. Its intent was to prevent “patient dumping” and “economic triage” by hospitals participating in Medicare and receiving federal funds. It applies to all patients seeking emergency treatment whether they are Medicare patients or not. Triage refers to the order in which patients are seen by the physician, not whether or not they require medical examination. The patient must receive a medical screening exam before any disposition is made and the lack of insurance or out-of-plan HMO status is not a basis for transfer or discharge of the patient without medical examination. For unstable patients being transferred to another facility, the receiving hospital must accept the transfer and the emergency physician ordering the transfer must sign an approval note outlining the benefits and risks of the transfer. While a patient may refuse examination and treatment, simple verbal refusal may not be legally sufficient and every attempt should be made to obtain a written refusal, including a statement that the benefits and risks have been explained.