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Certified Emergency Nurse (CEN) Exam Review
Jeff Solheim
At the completion of this section, the learner will be able to:
 Define shock
 Differentiate the signs of compensatory shock fro m deco mpensatory shock
 List the three forms of distributive shock
The CEN exam contains nine questions on shock which invol ve the following topics:
Card iogenic shock
Distributive shock (e.g. anaphylactic, septic, neurogenic shock)
Obstructive (e.g. pericardial tamponade, tension pneumothorax)
Shock (not specific)
 Shock (lack of oxygen to the tissues)
o Hypovolemic shock – Decreased cellular perfusion secondary to lack of circulating volu me
o Card iogenic shock – Decreased cellular perfusion secondary to failure of the central pu mp
o Distributive shock – Decreased cellular perfusion secondary to maldistribution of the o xygen to the periphery
o Obstructive shock – Decreased cellu lar perfusion secondary to obstruction of blood into or out of the ventricles (e.g.
pulmonary embolis m, pericard ial tamponade, tension pneumothorax)
 Obstructive shock
Type of obstruction
Tension pneumothorax
Card iac tamponade
Pulmonary embolism
Aortic aneurysm
Aortic stenosis
Excessive positive end exp iratory pressure
Treat ment
Roll the patient to her side
Chest tube/needle decompression
Surgical intervention
Surgical intervention
Readjust ventilator settings
 Hypovolemic shock
o Early (co mpensatory) shock
Sympathetic nervous system (adrenerg ic
Parasympathetic nervous system (cholinergic
Dry skin
 heart rate
 heart rate
 contractility
 contractility
 automaticity
 automaticity
 respiratory rate
 respiratory rate
Memory Tip – We have ONE heart and Beta-ONE receptors mainly affect the heart
(contractility, automaticity, heart rate, etc.). We have TWO lungs and Beta-TWO receptors
affect mainly the lungs (bronchodilation, respiratory rate, etc.)
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Certified Emergency Nurse (CEN) Exam Review
Definiti on:
Agonist – St imu lates a system
Antag onist – Diminishes the response of a system
Jeff Solheim
How would an alpha-adrenergic agonist affect the blood pressure?
How would an anticholinergic affect the pulse rate?
How would a beta-blocker affect the respiratory rate?
Late (deco mpensatory shock
 Inflammatory mediators are released in response to either foreign invasion of tissue or tissue damage. They
have three main courses of action:
Increased capillary permeability
Increased coagulation
Clinical manifestations of shock
Early (co mpensatory) shock
Late (deco mpensatory) shock
Blood pressure
Respiratory rate
Arterial blood gases
Skin condition
Urinary output
Treat ment
 Flu id replacement
 Crystallo ids
0.9% normal saline (NS)
Lactated Ringers solution (LR)
0.45% NS
0.2% NS
Dextrose 5% and water (D5 W)
Dextrose 5% in NS
Dextrose 10% in NS
Dextrose 10% in water
Dextrose 5% in 0.45 NS
Dextrose 20% in water
Isotonic crystalloids given at a 3:1 replacement ratio.
Generally, a bolus of 1 – 2 liters of crystalloid solution is ad ministered to a patient with
indications of hypovolemic shock.
Pediatric patients are given boluses at a rate of 20 mL/ kg.
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Certified Emergency Nurse (CEN) Exam Review
Jeff Solheim
Colloids (given at a 1:1 replacement ratio)
Dextran (co mes in
40, 70, and 75
mo lecular weight)
May cause anaphylaxis
Increases bleeding times
Carries a risk o f fluid overload
May increase serum amylase levels
May cause coagulopathies
Carries a risk o f fluid overload
May cause hypocalcaemia
Albumin (5% or
Is a human blood product
25% solutions
Can increase intravascular volume quickly so infuse cautiously and monitor for
indications of flu id overload
 Pro motes rapid expansion of blood volume and pro motes retention of volume in
Hypertonic saline
the vascular space.
(7.5%) with
Frequently used to combat hypovolemia in the face of increased intracranial
Dextran 70
 Blood Products
o ABO Blood types
Woman with Rh antibodies may
pass those on to an Rh positive
fetus during pregnancy causing
hemolytic reactions in the fetus.
Care should be taken to prevent
exposure of wo man with Rh
negative blood who may become
pregnant to Rh positive blood to
prevent the development of Rh
Type A blood
Type B Blood
Type O blood
Type AB blood
O-negative blood is
considered the
“universal donor”
Hemolytic reactions
Early signs
Late signs
Nausea and Vo miting
Chest/Lumbar Pain
Heat along the vein receiv ing
the transfusion
Rh co mpatibility
 Rh positive blood is born with Rh antigens but no Rh antibodies and should
ideally receive Rh positive blood.
 Rh negative indiv iduals are born without Rh antigens and Rh antibodies. If they
receive Rh positive blood, they will develop Rh antibodies which will cause a
transfusion reaction in future transfusions.
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Certified Emergency Nurse (CEN) Exam Review
Blood component
Whole blood
Packed red blood
Fresh frozen
pl asma
Cryopreci pitate
Jeff Solheim
Types of blood components
Provides all blood components although clotting factors deteriorate if product is older
than 24 hours.
Must be ABO co mpatib le
Co mes in 500 mL volu mes
Give 20 mL/ kg in children
Elevates hemoglobin levels by 1 g/dL and hematocrit by 3% per unit
Best blood product to rapidly elevate o xygen carrying capacity
Must be ABO co mpatib le.
Co mes in 250 mL volu mes
Give 10 mL/ kg in children
The flu id portion of one unit of hu man blood that has been frozen solid within six hours
of collect ion to preserve clotting factors.
Useful for hypovolemia co mbined with hemorrhage caused by clotting deficiencies
Must be ABO co mpatib le.
Takes 20 minutes to thaw and must be used within 6 hours of thawing.
Does not need to be ABO co mpatible
Used for conditions such as hemophilia, von Willebrand disease, hypofibrinogenemia
and factor XIII deficiency.
Multiple units may be ordered (one unit fo r every 7 – 10 kg in children)
Prepared fro m plas ma and rich in Factor VIII, fibrinogen, von Willebrand factor, and
Factor XIII.
Is frequently given for bleed ing disorders such as hemophilia and disseminated
intravascular coagulation.
Must be ABO co mpatib le
End points to fluid resuscitation
Improvement in level of consciousness, condition of skin and capillary refill
Decreased pulse and increased blood pressure
Urinary output
o 0.5 mL/ kg/hour (adults)
o 1 – 2 mL/ kg/hour (infants)
Seru m pH and base excess levels returning to normal ranges
A stable or decreasing serum lactate level
 Distributive shock
Neurogenic shock (loss of sympathetic tone)
 Causes:
 Spinal cord in juries above T4 – T6
 Brain injury
 Spinal o r general anesthesia
 CNS depressants
 Hypoxia
 Lack of g lucose or excessive insulin (insulin
 Vasovagal syncope
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 Sympto ms
Jeff Solheim
 Vasodilation
 Gluconeogenesis
 Dry skin
 Bradycardia
 Decreased contractility
 Decreased automaticity
 Bradypnea
 Bronchoconstriction
 Treat ment
 1 – 2 Liter flu id bolus for hypovolemia, consider vasoconstrictor such as phenylnephrine
if bo luses ineffective
 Atropine for lo w heart rate
 Assist respirations as needed
o Septic shock
Hyperdynamic sepsis
Hypodynamic sepsis
Malaise, not feeling well,
Mentati on
Decreasing LOC, stupor and coma
tiredness, restlessness
Warm, flushed dry skin
Cold, clammy, pale, mottled skin
Heart Rate
Tachycardia, full bounding pulses
Tachycardia, weak, thready pulse
Respiratory Rate
> 20/ minute
Shallo w and tachypneic
Urine Output
Decreased or anuria
Co mbined metabolic and respiratory
Aci d-base values
Respiratory alkalosis
Fever/Shaking and chills
Hypothermic and mottled
Treat ment
Flu id resuscitation
 Crystallo id boluses
 Vasopressors
 Inotropes
Source control
 Identify and remove potential infected sources
 Wound cultures
Antimicrobial therapy
Consider Drotrecogin Alfa (Xigris)
Anaphylactic shock
Mil d symptoms (normal
BP, minimal respiratory
Give 0.2 – 0.3 mL
1:1,000 epinephrine SQ/IM
Repeat epinephrine
every 5 – 10 minutes
as needed
Maintai n ABC’s – oxygen,
intubation, surgical airway,
flu id boluses, positive
Severe symptoms
(hypotensive, respiratory
distress –Give 0.1 – 0.5 mL
1:10,000 ep inephrine IV
Secondary treatments
Antihistamines (e.g.
Beta-2-agonists (Albuterol)
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Certified Emergency Nurse (CEN) Exam Review
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Practice Questions
A patient sustaining mu ltip le trau matic in juries presents with a BP of 50/32 mm Hg, a pulse of 146/ minute, a capillary refill of 4
seconds, and no urinary output. Appropriate volume resuscitation is:
D5 W at a rate of 3 mL for every 1 mL o f blood loss
Hetastarch at a rate of 3 mL for every 1 mL of b lood loss
Blood replacement at a rate of 1 mL for every 1 mL of b lood loss
Lactated Ringers solution at a rate of 1 mL for every 1 mL of b lood loss
An overdose which results in profound central nervous system depression may result in :
Distributive shock
Obstructive shock
Card iogenic shock
Hypovolemic shock
Which of the follo wing assessment parameters is most consistent with early co mpensated hypovolemic shock?
Respiratory alkalosis and cool clammy skin
Hypoglycemia and decreased urinary output
Deep, rap id respirations and hyperactive bowel sounds
Near-normal systolic blood pressure and abnormally lo w diastolic blood pressure
Which of the follo wing parameters indicates that fluid resuscitation for hypovolemia has been effective in a 200 (90 kg) poun d
A declining seru m pH
A narrowing pulse pressure
A declining seru m lactate level
A urinary output of 30 milliliters per hour
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Certified Emergency Nurse (CEN) Exam Review
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 Disorders of the red blood cells
 Polycythemia (elevation in red blood cell count – often secondary to hypoxia)
 Co mmon causes:
Living or v isiting a high altitude
Prolonged physical activ ity associated with hypoxia (e.g. – running a marathon)
 Erythrocytosis – polycythemia secondary to hypoxic diseases such as COPD
Signs and symptoms
Bru ising
 Sensation of warmth in the limbs
Treat ment
Supportive therapy
 Treat underlying causes of erythrocytosis
Polycythemia vera (A condition with an overactive bone marrow resulting in high red blood cell, high white blood cell
and high platelet counts. Is a genetic disease which typically affects middle-aged Jewish men)
 Sympto ms: Elevated blood counts which may cause heart failure and hypoxia.
 Treat ment
Admin istration of radiat ion phosphorus
 Phlebotomy to remove who le blood and replace with normal saline.
 Anemia (A decreased red blood cell count)
 Treat ment
Type of
Treat ment
Blood Loss
Stem blood loss as well as fluid and blood replacement
• Oral iron therapy.
Iron is caustic to GI tract, may turn stools green or dark black
• Iron is constipating
• Take iron with acid ic substance, not with antacids
Vitamin B
This deficiency is usually secondary to lack of the intestinal en zy me needed to absorb it, therefore,
oral vitamin B is unlikely to be effective and subcutaneous vitamin B will be given
Folic acid
This is almost always secondary to nutritional deficits and patients should be encouraged to increased
fresh fruits and vegetables in their d iets and to take folic acid sup plements. (Note that cooking
vegetables cooks out the folic acid ).
All anemias
Maximize o xygenation of t issue via oxygen administration
 Sickle Cell Disease (congenital hemolytic anemia that occurs mainly in those of West African descent)
 Factors which may precipitate sickling:
Low o xygen concentrations
 Exposure to cold
Clin ical manifestations
Sudden explosive abdominal, chest, back and joint pain
Splenic ischemia can lead to increased susceptibility to infection
Heart ischemia can lead to acute coronary syndromes
Ulcers of the lower ext remities and long thin extremities
7 |P age
Certified Emergency Nurse (CEN) Exam Review
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Treat ment
Treat the underlying cause (IV flu ids for dehydration, sodium bicarbonate for acidosis, antibiotics for infect ion,
High flow o xygen (may reverse as many as 80% of sickled cells)
Pain control
Support extremit ies on pillows
Oral hydro xyurea
Discharge Instructi ons for Sickle Cell Disease:
 Warm moist heat to affected areas to reduce pain and swelling
 Keep well hydrated and rested
 Exercise regularly
 Avoid high altitudes or flying in non-pressurized aircraft
 Limit exposure to the cold
 Seek medical help for shortness of breath, weakness, fatigue, chest, abdominal, or back pain, or swelling of the hands
and feet.
Disorders of the white b lood cells
Neutropenia (A decrease in the white blood cells responsible for protecting the body from bacteria)
 Co mmon causes:
Cancer treat ment such as chemotherapy or radiation
Immunosuppressive therapy after organ transplantation
Immunosuppressive diseases such as acquired immune deficiency syndrome
Nutrit ional deficits
Clin ical manifestations
Increased susceptibility to infect ion (especially g ram-negative bacteria)
 Blunted responses to infection (decreased redness, swelling, edema and pus formation.)
Treat ment considerations
Reverse Isolation
Avoid the use of indwelling catheters
Dilute IV med ications, administer slowly
Culture all potentially infected sites
Early init iation of antib iotics
Acetaminophen (Tylenol) alternated with ibuprofen (Motrin , Advil) every 2 – 3 hours to decrease fever and
drug toxicity.
Admin ister drugs to stimulate neutrophil p roduction:
The only sign of infection in a
neutropenic patient may be
fever. Therefore fever in the
neutropenic patient constitutes
a medical emergency.
Granulocyte colony-stimulat ing factor (Neupogen)
 Granulocyte-macrophage colony-stimulating factor (Leukine, Prokine)
Hu man Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) – (A retrovirus spread via
direct contact with an infected person’s blood or body secretions.)
 Sympto ms:
2 – 6 weeks post exposure: Sy mptoms similar to mononucleosis.
Onset of AIDS - Changes in level o f consciousness ranging fro m withdrawn to demented, indicat ions of
wasting, volume depletion and weakness. The comp lete blood count will likely show anemia, ly mphopenia and
thrombocytopenia. Indications of infections such as oral candidiasis, herpes zoster, tinea and other skin rashes.
8 |P age
Certified Emergency Nurse (CEN) Exam Review
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Diagnosis: ELISA test, Western Blot test (consider informed consent)
Treat ment: A variety of antiviral medications can significantly slow
down the progression of this disease, but it is not curable. Treat ment
is main ly symptomat ic.
Leukemia (Excessive production of abnormal, immature white blood cells.
Although the number of white blood cells increases, they do not function
normally and protection from infection diminishes.)
Signs and symptoms:
Weight loss
Bone pain
Elevated uric acid levels
Ly mph node enlargement
Hepatomegaly, and splenomegaly
Discharge teaching for
Disinfect all body fluid spills
with 10% solution of bleach
in water.
Practice safe sex
Do not share drug
paraphernalia, razors, and
Avoid individuals who are ill.
The same precautions that were introduced for neutropenia should be
maintained for leukemia.
 Disorders of the clotting functions
 Idiopathic thrombocytopenia purpura (ITP) – (An autoimmune disorder that occurs most commonly in chidren between the
ages of 2 to 4 resulting in a decreased platelet count. The disease often occurs several weeks after a viral in fection or
immun izat ions.)
 Signs and symptoms: Indicat ions of bleeding such as bruising, petechiae, purpura, epistaxis, b leeding gums,
gastrointestinal bleeding, and hematuria.
 Treat ment:
 Many patients need nothing more than careful observation
 Severe cases may require glucocorticoids and immune globulins to elevate platelet co unts
 Thrombocytosis (abnormally elevated platele count which leads to an increased risk of spontaneous clot formation)
 Signs and symptoms
 May be asymptomat ic
 Burning sensation or redness in the extremities that may be relieved by aspirin
 Treat ment
 Monitor for pulmonary embolus, myocardial infarct ion, stroke and deep vein thrombosis.
 Aspirin
 Disseminated intravascular coagulation (DIC) - (DIC is not a disease, but rather an abnormal activation of the body’s
clotting system that signals severe underlying problems. It involves both abnormal clotting and abnormal bleeding).
 Abnormal clotting with signs such as metabolic acidosis, mottling, gangrene and organ failure.
 Abnormal anticoagulation with bleed ing such as bruising, petechiae, purpura, epistaxis, bleeding gums, gastrointestinal
bleeding, and hematuria.
Laboratory values with DIC:
Platelet count
Prothromb in time
Partial thro mboplastin time
Fibrinogen levels
9 |P age
Certified Emergency Nurse (CEN) Exam Review
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Treat ment
Treat the underlying cause
Control bleed ing
Limit venipuncture
Apply pressure dressings or sandbags to active bleeding sites
 Handle patient gently
Pharmacological interventions
Reco mbinant human activated protein C (rhAPC)
 Aminocaproic acid (A micar)
 Hemophilia
Name of disorder
Alternate name
Cause of disorder
Clin ical
man ifestations
Hemophilia A
Hemophilia B
Hemophilia C
Classic hemophilia
Christmas disease
Rosenthal’s syndrome
Variant form of Factor VIII Variant form of Factor IX
Variant form of Factor XI
Congenital sex-linked disorders that affect males
• Most commonly b leed into soft tissues, muscles or weight bearing joints (knees,
elbows and ankles)
• Can also bleed into oral/nasal mucosa, urinary system, GI tract and CNS (usually
following trauma)
Treat ment
 Hemoarthrosis or hemato ma
 Ice
 Co mpression dressing
 Immobilization
 Elevation
 Lacerat ions
 Topical thro mbin
 Observe for 4 hours post suturing
 Venipuncture - Ho ld pressure for a minimu m of 5 minutes
 Never give an IM in jection
 Purified factor VII, IX or XI
 Fresh frozen p lasma and cryoprecip itate
Practice Question
Which of the follo wing patients is at highest risk for developing idiopathic thrombocytopenia purpura (ITP)?
A 3-year-o ld whose last chicken po x has just disappeared
A 52-year-o ld patient who is on daily aspirin fo r heart disease
A 17-year-o ld with an infected laceration to the dorsum of the right hand
An 80-year-old with a fractured hu merus after falling down a flight of stairs
Which of the follo wing statements, made by a patient being discharged home with leukemia, indicates they have understood their
discharge instructions?
“I will avoid exercising to decrease stress on my body.”
“I will change my tampons at least hourly to prevent infection.”
“I will call the doctor if my temperature exceeds 100°F (38°C).”
“I will avoid taking aspirin or nonsteroidal anti-inflammatory drugs to decrease the risk of bleeding.”
Answers: A C
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