BCEN CPEN Exam Questions

Correct answer: Administer sedatives as ordered to keep the child calm and comfortable

All newly extubated children should be positioned upright to allow adequate draining of secretions and should receive humidified air and/or oxygen. Extreme caution should be taken with deep tracheal suctioning because it could induce laryngospasm. This procedure should be limited post-extubation. Pharmacologic management of the patient receiving mechanical ventilation is usually required; if the patient has been on narcotic or benzodiazepine therapy for longer than 5 to 7 days, withdrawal symptoms may occur with abrupt discontinuation. Therefore, patients should be weaned off these medications slowly.

No sedative agents should be administered post-extubation.

Correct answer: Ask the physician to exit the room and put on the appropriate PPE

You should reinforce infection practices, advocating for other patients in the ED who are not contaminated.

Reporting the incident does not advocate for the other patients. Ensuring proper hand hygiene and suggesting the physician change scrubs are not appropriate interventions to decrease infection.

Correct answer: Severe bradycardia

Digoxin is commonly used for the treatment of mild to moderate heart failure. The toxic effects of digoxin are exacerbations of therapeutic effects. Clinical effects of acute overdose occur in the gastrointestinal and cardiovascular systems (e.g., nausea, vomiting, hypotension, bradycardia, and dysrhythmias). Digoxin immune Fab (Digibind) is the antidote to digoxin and can be used in acute and symptomatic digoxin toxicity.

It is vital to educate the caregivers to assess the patient's heart rate prior to every dose administration to ensure it is greater than 60 beats per minute. In addition, the patient should receive frequent laboratory evaluations of serum levels, and the caregivers should be taught signs of digoxin toxicity (poor feeding or appetite, nausea, vomiting, and visual changes). Toxicity can occur even if the patient is within the therapeutic range.

Correct answer: Spleen

The most common mechanisms for injury in children are motor vehicle collisions and falls; other common causes include bicycle injuries and maltreatment/abuse. Blunt trauma occurs in 80% of injuries. The spleen is the most commonly injured abdominal organ in blunt abdominal trauma in children. This is primarily due to a lack of protection from the rib cage and the elasticity of the supportive ligaments.

The liver is second to the spleen as a major source of hemorrhage and is the most common cause of lethal hemorrhage. The pancreas is not frequently injured. The kidneys are often injured but not as frequently as the spleen in children.

Correct answer: Folic acid

When a patient is pregnant, they must consume enough nutrients to meet their needs and support the healthy growth and development of the fetus. Folate (also called folic acid when in supplement form) helps prevent neural tube defects (NTDs) and should be taken about one month before conception if possible and throughout at least the first trimester (3 months) of pregnancy.

Insufficient folic acid intake can increase the risk of spina bifida, which results from failure of differentiation and closure of the embryonic neural tube (occurring early in gestational development, from day 17 to 30). The most common parts of the spine affected by spina bifida are the lower thoracic lumbar and sacral areas. The degree of functional impairment depends on the extent of the defect and associated neural tissue.

Vitamin B12 and vitamin D are important during pregnancy to support the development of the fetus's nervous system and skeleton, respectively. Iron supplementation helps prevent anemia in the pregnant patient, as well as low birth weight in the infant.

Correct answer: 2 ng/mL

Digoxin is commonly used for the treatment of mild to moderate heart failure in pediatric patients. The toxic effects of digoxin are exacerbations of therapeutic effects (dysrhythmias, bradycardia, and heart block). Clinical effects of acute overdose occur in the gastrointestinal and cardiovascular systems, consisting of nausea, vomiting, hypotension, bradycardia, and dysrhythmias. Digoxin immune Fab (Digibind) is the antidote to digoxin and can be used in acute and symptomatic digoxin toxicity.

A toxic dose can be estimated by history, but laboratory evaluation of serum levels and careful evaluation of the patient are critical components to avoiding overdose. The therapeutic trough range is 0.5 to 2 ng/mL, and toxicity is usually seen at levels above 2 ng/mL (although toxicity can occur within this range, too).

Correct answer: Prevention of acute renal failure

Rhabdomyolysis is characterized by muscle breakdown, necrosis, and the subsequent release of intracellular muscle constituents into the circulation; it is a dangerous complication for multi-trauma victims. Although signs and symptoms are nonspecific, the classic triad includes muscle pain and cramping, weakness, and dark, reddish-brown urine. Laboratory findings reveal a marked elevation in CK and other serum muscle enzymes. Early complications may include hyperkalemia, hypocalcemia, hepatic inflammation, and cardiac arrhythmias.

Acute renal failure (ARF) occurs in up to 15% of rhabdomyolysis cases, and it is the most serious of complications since it relates highly to morbidity and mortality. Therefore, nursing implications and treatment should be focused primarily on the prevention of ARF. Treating dehydration and pyrexia are appropriate interventions but secondary treatment measures to ARF prevention. Rhabdomyolysis does not generally result in infection.

Correct answer: Idiopathic facial paralysis 

Bell's palsy is unilateral facial paralysis caused by damage to the facial nerve (cranial nerve VII). It is also known as idiopathic facial paralysis (IFP) and is an acute condition that presents without other signs and symptoms. Symptoms can take weeks or months to resolve. 

Treatment includes antiviral medications and corticosteroids, although current evidence demonstrates questionable benefits from antivirals. The use of oral corticosteroids (e.g., oral prednisone) to treat new-onset Bell's palsy is backed by the American Academy of Neurology (AAN). Analgesics for pain, eye care, and facial massage are other therapeutic interventions. 

Correct answer: An abdominal X-ray

Obtaining an order for an abdominal X-ray should be the nurse's priority. Radiographic imaging has the greatest diagnostic power for NEC and is capable of identifying intestinal dilation, pneumatosis intestinalis, hepatobiliary gas, and pneumoperitoneum (if intestinal perforation has occurred). The diagnostic test of choice is a three-way abdominal X-ray series (i.e., flat, left lateral decubitus, and sometimes cross-table views).

Abdominal ultrasonography and associated bloodwork are utilized to confirm or support the diagnosis. An abdominal US is becoming increasingly important in determining when surgical intervention may be indicated and is more sensitive in detecting portal venous gas and intra-abdominal free fluid. CBC and serum electrolyte evaluations typically reveal thrombocytopenia, leukocytosis or leukopenia, and metabolic acidosis. CRP levels are increasingly obtained and appear to be a good marker of the onset, persistence, and subsequent resolution of NEC. Stool cultures provide a differential diagnosis for spontaneous intestinal perforation; however, this is not the nurse's priority at this time.

Correct answer: Syncope

Carbon monoxide toxicity secondary to smoke inhalation is evaluated by measuring the patient's arterial carboxyhemoglobin level. Elevated levels serve as indirect evidence for exposure to combustible products, and multiple signs and symptoms have been associated with these levels.

The normal value is 0%-5%. A patient with a carboxyhemoglobin level of 15%-20% will generally exhibit headaches, mild dyspnea, and confusion. If levels rise above 20% and up to 40%, the patient will often be disoriented, fatigued, and nauseous and may exhibit fainting spells (syncope). Levels greater than 50% will leave a patient comatose with seizure activity, respiratory failure, and even death.

Correct answer: Peripheral edema 

A bacterial infection stimulates a systemic immune and inflammatory response requiring mature functional neutrophils and other immune cells to fight the invading pathogens. Inflammation causes the capillary beds to be leaky, so the patient will be edematous as fluid shifts to the interstitial space, leading to peripheral edema. 

WBCs are increased with a shift to the left in septic shock. Respiratory symptoms develop only when shock progresses. Hypokalemia is not associated with septic shock. 

Correct answer: Maintaining a central cart with supplies

Keeping a cart stocked with supplies optimizes the use of proper tools, thus decreasing the risk of infection.

The internal jugular is contraindicated as an insertion site and may increase the risk of infection. The use of antibiotic-impregnated catheters may be effective in certain patients (particularly pediatric burn patients) but not all patients. Chlorhexidine for antisepsis before insertion is harmful in neonates and is approved for use in children over two years of age. Strict adherence to hospital and nationally established CLABSI-prevention bundles is imperative when managing patients with central venous catheters.

Correct answer: Respiratory distress

Spinal (neurogenic) shock is a distributive shock resulting in low systemic vascular resistance (SVR) and a generalized loss of vascular tone leading to severe vasodilation and hypotension. The sympathetic nervous system fails to increase heart rate, causing cardiac output and oxygen delivery to fall. In the initial stages, SVR decreases, and there is increased blood flow to the skin, also called warm-dry shock. This leads to warm, flushed skin and a capillary refill time of <2 seconds. 

Respiratory distress is not an early sign of spinal shock. 

Correct answer: Potassium level of 3.2 mEq/L

Digoxin is used for the treatment of mild to moderate heart failure, to decrease the ventricular response rate in fast atrial arrhythmias, and to treat fetal tachycardia in the absence of hydrops. Digoxin has inotropic effects from the inhibition of the sodium-potassium pump. The nurse should watch for hypokalemia (as evidenced by serum levels that fall below 3.5 mEq/L), hypercalcemia (as evidenced by serum levels that rise above 10 mg/dL), and hypomagnesia (as evidenced by serum levels that fall below 1.4 mEq/L). These levels may aggravate digoxin cardiotoxicity, even if the digoxin level is normal (the therapeutic trough range is 0.5 to 2 ng/mL).

The nurse should also assess the child's heart rate (HR) prior to each dose administered to verify it is greater than 60 bpm.

Correct answer: Create a group of staff members to discuss the current hospital policy

Utilizing the nurse competencies—which reflect the integration of nursing knowledge, skills, and experiences that are required to meet the patient's and family's needs and optimize their outcomes—a systematic, collaborative approach to problem-solving is necessary for this scenario. 

An alternative strategy to avoid interrupting typical patient sleep patterns may be identified by various team members working together.

Correct answer: Tetralogy of Fallot (TOF)

TOF consists of four defects: VSD, pulmonary stenosis (PS), right ventricular hypertrophy (RVH), and an overriding aorta. It is the most common form of cyanotic congenital heart disease, accounting for as much as 10% of CHD, and it occurs slightly more often in boys.

ASD, VSD, and PDA are acyanotic heart diseases.

Correct answer: Racemic epinephrine

Acute epiglottitis is a life-threatening medical emergency in which the epiglottis swells due to a bacterial infection, and the airway is compromised. Signs and symptoms include an abrupt onset of a high fever, a sore throat, dysphagia, drooling, a muffled voice, and stridor. Airway management with the placement of an endotracheal tube (ETT) is generally indicated, along with parenteral antibiotics (ceftriaxone, cefotaxime, or a combination of ampicillin and sulbactam, pending culture and susceptibility reports). Antibiotics should be given for 7 to 10 days. Antipyretics for fevers and comfort with intravenous fluids are also given; corticosteroids should be administered to reduce edema during the early treatment phase.

Racemic epinephrine is indicated for the treatment of acute laryngotracheobronchitis (LTB), not for acute epiglottitis. Croup is the general medical term that refers to this inflammatory process.

Correct answer: Droplet

Droplet transmission, a form of contact transmission, involves contact of the conjunctive or the mucous membranes of a susceptible person with large droplets (larger than 5 micrometers) containing microbes generated from the respiratory tract of a person who has clinical disease or is a carrier of the organism. Droplets are usually generated when the infected person coughs, sneezes, or talks or during procedures such as suctioning, endotracheal intubation, or bronchoscopy.

Pertussis, or "whooping cough" is an acute respiratory tract infection caused by Bordetella pertussis, and is transmitted by aerosol droplets from infected to susceptible humans. Droplet isolation precautions should be instituted in this patient until pertussis is ruled out (precautions would remain in place if confirmed). Droplet precautions include the care provider wearing a mask upon entering the patient's room, hand hygiene before and after all cares, a private room if possible, and masking the patient upon any transport or movement for medically-necessary purposes to and from the patient's room. Examples of common conditions requiring droplet isolation are influenza, mumps, diphtheria (pharyngeal), pertussis, and Neisseria meningitidis.

Correct answer: Shortness of breath, pallor, systemic edema, and hepatomegaly

A VSD is a birth defect characterized by an opening (or hole) in the septal wall, allowing communication between the right and left ventricles. VSDs account for up to 20% of all congenital heart defects and are more common in girls. Children are usually asymptomatic until at least 2 to 4 weeks of age when PVR falls. This drop in PVR allows shunting from the LV to the RV and creates pulmonary overcirculation. Signs and symptoms include shortness of breath, pallor, hepatomegaly, and systemic edema.

Coarctation of the aorta manifests with decreased or absent pulses in the lower extremities and cool lower extremities. Feeding intolerance, diaphoresis, tachypnea, acrocyanosis, and lethargy are associated with aortic stenosis. Transposition of the great arteries (TGA) reveals a patient with a decreased appetite, shortness of breath, and cyanosis.

Correct answer: An isolation room

Meningitis is an acute inflammation of the meninges, the lining of the brain and spinal cord. It can be either viral or bacterial in nature. Viral meningitis (aseptic) is usually self-limiting and resolves spontaneously with basic supportive care. Bacterial meningitis is more severe and can cause serious complications if not treated appropriately. Common pathogenic organisms for bacterial meningitis in the United States are Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis, and Listeria monocytogenes.

Patients should be placed in isolation initially until N. meningitidis is ruled out (or at least 24 hours after admission) and should be as close to the nurses' station as possible to allow for maximal observation. Patients suspected of having meningococcal meningitis should be placed in droplet precautions until they have received 24 hours of antibiotics.

Close contacts should receive antibiotic prophylaxis. Anyone exposed to the patient's oral secretions during this time should also be treated. Immunity to bacterial meningitis cannot be acquired. Although immunization against H. influenzae is effective, N. meningitidis vaccination confers immunity only against certain pathogen serotypes.