ENC(C) Review Questions
Camille Barr, RN, BN, ACCN, ENC(C) a , Tammy Nelson, RN, MN, ENC(C) b
, Heather McLellan, MEd, BN, RN, CEN,
CFRN, FAASTNc,d
a Alberta Health Services - University of Alberta Emergency Department
b Alberta Health Services - Clinical resource nurse
c Mount Royal University Advanced Studies in Critical Care Nursing
d Alberta Health Services – South Calgary Urgent Care
www.NENA.ca www.CJEN.ca
ISSN: 2293-3921 (print) | ISSN: 2563-2655 (online) | https://doi.org/10.29173/cjen515
Print publisher: Pappin Communications http://pappin.com | Online publisher: University of Alberta www.library.ualberta.ca/publishing/open-journals
1. A three-month-old is brought to triage by their parents with
complaints of nausea, vomiting and diarrhea. They just had
their three-month immunizations two days ago. The mom
states, “my baby just isn’t acting normal, she won’t wake up
to feed and didn’t take her bottle this morning.” The last time
the baby fed was eight hours ago. The child has a weak cry at
triage and sleeps through the vitals assessment. Vitals are as
follows:
• T - 38° C
• HR – 180
• BP – 72/42
• RR – 40
• SaO2 - 96% on room air
Which of the following actions is the most appropriate next
step?
A. Given acetaminophen orally to treat the fever as that will
help bring down the heart rate
B. Advise the parents that this is a typical reaction to
immunizations
C. Initiate a cool bath to reduce the fever
D. Check a glucose at triage
2. A 10-year-old with known Acute Lymphoblastic Leukemia
(ALL) presents to ER with his mom. His last chemotherapy
was two days ago and he awoke with a fever this morning. On
initial exam, you note that his cheeks are flushed, and he is
lethargic with dark circles under his eyes. He has an IVAD in
situ. His vital signs are as follows:
• T – 41.9° C
• HR – 156
• BP – 78/47
• RR – 24
• SaO2 – 94% on room air
Which of the following actions is the most appropriate?
A. Wait for the Maxilene (numbing cream) to take effect
prior to accessing his IVAD. Rationale – to optimize the
pediatric experience in ER
B. Administer a fluid bolus. Rationale – to manage
hypotension
C. Wait for blood and urine cultures to be drawn prior to
administering antibiotics. Rationale – to avoid jeopardiz-
ing culture results
D. Apply high flow oxygen. Rationale – to optimize oxygen
availability for this septic patient
3. An 18-month-old boy presents to triage with his mother.
She states her son has been having episodes of intermittent
abdominal pain. The patient at triage is alert and interacting
with mom, breathing is deep and easy with no increased work
of breathing and color is pink and cap refill is brisk. Mom
states that this abdominal pain has come and gone two times
lasting about 20 minutes and the child pulls his legs up and
starts crying. She also noted a bit of mucous and blood in his
stool. What condition might this child be experiencing?
A. Pyloric stenosis
B. Appendicitis
C. Intussusception
D. Constipation with anal fissure
4. A 26-year-old female presents to triage with generalized
swelling, mild right upper quadrant abdominal pain, head-
ache and nausea. The patient states that she is 28 weeks
and 3 days pregnant. What condition might this patient be
experiencing?
A. Pre-eclampsia
B. Pancreatitis
C. Liver cirrhosis
D. Cholestasis of pregnancy
Canadian Journal of Emergency Nursing · Vol. 48, No. 2, Summer 2025 97
5. A 53-year-old man presents to the emergency department
with complaints of weight gain, nausea and vomiting. His
creatinine level is measured at 353 micromoles/L (normal
values are 70–120 μmol/L). Which of the following is the
most likely cause of these assessment findings?
A. Hepatic toxicity
B. Pulmonary hypertension
C. Acute renal failure
D. Prostatic hypertrophy
Answer Key with Rationale
1. Correct answer D
The three-month-old is presenting with concerning signs such
as lethargy, weak cry, poor feeding, and an inability to wake
up for feeding, along with fever (T 38°C), tachycardia (HR
180), and hypotension (BP 82/42). These signs may indicate
a serious underlying condition like hypoglycemia. Infants are
particularly vulnerable to hypoglycemia, especially if they hav-
en’t fed for several hours, as this baby hasn’t fed in 8 hours.
Hypoglycemia can cause lethargy, poor feeding, tachycardia,
and altered mental status. Therefore, the most appropriate next
step is to immediately check the infant’s glucose level to rule out
hypoglycemia, as it can be life-threatening if untreated (Logee,
2020). While fever can contribute to discomfort, it is not the
immediate concern here (Ward, 2024). The baby’s lethargy
and weak cry suggest a more urgent issue, such as hypoglyce-
mia, that needs to be addressed first Although immunizations
can cause mild fever or irritability, the baby’s lethargy, poor
feeding, and vital sign abnormalities (tachycardia, hypoten-
sion) are concerning and suggest a more serious condition that
requires immediate investigation, not reassurance. A cool bath
may help lower the fever, but the baby’s symptoms indicate a
possible systemic issue, such as hypoglycemia or infection, that
requires immediate attention, not just symptomatic treatment
for fever (Smitherman et al., 2025).
2. Correct answer B
Looking at the assessment findings for this patient we see that
they are hemodynamically compromised. The most appro-
priate initial action for this patient is to initiate a peripheral
IV if possible or IO if an IV cannot be accessed and admin-
ister. In this case, the patient likely has sepsis, indicated by
signs such as hypotension, potential infection, and overall
clinical presentation. One of the primary management steps
for sepsis in pediatric patients (and adults) is fluid resuscita-
tion to improve blood pressure and perfusion (Harley et al.,
2022). Hypotension in a septic patient often signifies a state
of circulatory shock, and immediate fluid bolus administration
(typically with normal saline or lactated Ringer’s) is critical to
stabilize the patient’s condition. While numbing cream may be
helpful in making the procedure more comfortable, it is not the
priority when a child is potentially in shock or septic (Lorenc,
2024). Immediate management of hypotension is more urgent.
In septic patients, early antibiotic administration is crucial and
should not be delayed even if cultures haven’t been obtained
yet. Waiting for cultures to be drawn can significantly harm the
patient, as early antibiotics are vital in managing sepsis (Weiss
& Fitzgerald, 2024). While oxygen may be important if the
patient is in respiratory distress or has low oxygen saturation,
the priority in managing septic shock with hypotension is fluid
resuscitation. Oxygen administration might be necessary, but
addressing hypotension with fluids takes precedence to stabi-
lize the circulatory system.
3. Correct answer C
Rationale – These symptoms are common with intussuscep-
tion which is a common condition that occurs with children
who are between three months and three years old (Cleveland
Clinic, 2024a). It presents with colicky abdominal pain that
is severe when the bowel telescopes inside of itself and then
pain free when it resolves. These episodes usually last 15-20
minutes and then it goes away. Other symptoms include red
jelly like stools, diarrhea, a swollen belly with a section that is
harder, and sometimes nausea and vomiting (Cleveland Clinic,
2024b).
Pyloric stenosis is usually a condition associated with young
infants (3–5 weeks after birth) and it is a condition associated
a muscular valve that sits between the stomach and the small
intestine that prevents food from moving into the small intes-
tine (Mayo, 2022). Appendicitis is also one that this could be,
but pain is often persistent rather than intermittent. They will
usually have a low-grade fever, right lower quadrant abdomi-
nal pain, nausea and vomiting and loss of appetite (Cleveland
Clinic, 2024a). The last one is a possibility if the child has been
constipated and has been straining. An assessment should be
made to see if there is bleeding around the anus but generally
this would be frank red blood and not a darker blood mixed
with mucous as the bleeding is at the anus not higher (Mayo
Clinic, 2024a).
4. Correct answer A
Rationale – The most common cause of these symptoms is
pre-eclampsia. This condition commonly occurs after the 20th
week of pregnancy (August & Sibai, 2025). Common symptoms
associated with this condition include high BP, swelling, head-
aches, blurred vision, and protein in their urine (August & Sibai,
2025). Trending of blood pressures during pregnancy is import-
ant as it helps identify those women at higher risk for developing
pre-eclampsia. Blood pressures 140/90 and above are classified
as “mild” and severe are generally 160/110 (LeWine, 2023).
Recognition of this condition can prevent maternal morbidity/
mortality.
A pregnant patient might also have pancreatitis if they have had
a previous history of same but generally only occurs in 3 out of
10,000 pregnancies (O’Heney et al., 2021). Acute liver cirrho-
sis is also relatively uncommon with the incidence occurring
in about 3% of women (Garcia- Romero, 2019). Cholestasis of
pregnancy is associated with right upper quadrant pain, itchi-
ness, jaundice, nausea, pale colored oily stool as well as loss of
appetite (Mayo, 2022). Although the patient does have some of
these symptoms of each condition, she does have all the symp-
toms that are associated with pre-eclampsia.
5. Correct answer C
Rationale – The patient presents with weight gain, nausea, vom-
iting, and elevated creatinine levels (353 μmol/L, well above the
normal range of 70–120 μmol/L), indicating impaired kidney
98 Vol. 48, No. 2, Summer 2025 · Canadian Journal of Emergency Nursing
function. Hepatic toxicity typically affects liver function and
does not cause such a significant rise in creatinine (Larson,
2023). Pulmonary hypertension primarily leads to symptoms
like shortness of breath and fatigue, and lab studies will fea-
ture elevation in brain natriuretic peptide rather than creati-
nine (Rubin, 2024). Prostatic hypertrophy may cause urinary
retention but doesn’t directly lead to a sharp increase in creati-
nine levels (McVary, 2025). The most likely diagnosis is acute
renal failure (acute kidney injury), where the kidneys suddenly
lose their ability to filter waste, leading to elevated creatinine and
symptoms such as weight gain, nausea, and vomiting due to fluid
retention and toxin buildup (Palevsky, 2025).
REFERENCES
August, P., & Sibai, B. M. (2025). Preeclampsia: Clinical features and
diagnosis. UpToDate. https://www.uptodate.com/contents/
preeclampsia-clinical-features-and-diagnosis
Baxter, C. S. (2020). Renal and genitourinary emergencies. In V. Sweet
& A. Foley (Eds.), Sheehy’s emergency nursing: Principles and
practice (7th ed., pp. 271–279). Elsevier.
Burg, M. D. & Graber, M. N. (2015). Renal failure (acute kidney
injury). In J. Schaider, R. Barkin, S. Hayden, R. Wolfe, A. Barkin,
P. Shayne, & P. Rosen (Eds.), Rosen & Barkins 5-minute emergency
medicine consult (5th ed). Wolters Kluwer.
Cleveland Clinic. (2024a, Nov 12). Appendicitis in kids: Symptoms,
treatment & recovery. https://my.clevelandclinic.org/health/
diseases/10792-appendicitis-in-children
Cleveland Clinic. (2024b, Jan 24). What is intussusception? https://
my.clevelandclinic.org/health/diseases/10793-intussusception
García-Romero, C. S., Guzman, C., Cervantes, A., & Cerbón, M. (2019,
July 1). Liver disease in pregnancy: Medical aspects and their
implications for mother and child. Annals of Hepatology. 18(4),
553–562. https://doi.org/10.1016/j.aohep.2019.04.009
Harley, A., Schlapbach, L. J., Johnston, A. N. B., & Massey, D. (2022).
Challenges in the recognition and management of paediatric
sepsis – The journey. Australasian Emergency Care, 25(1), 23–29.
https://doi.org/10.1016/j.auec.2021.03.006
Harvard Health. (2023, June 27). Preeclampsia and
Eclampsia. https://www.health.harvard.edu/a_to_z/
preeclampsia-and-eclampsia-a-to-z
Larson, A. M. (2023). Drug-induced liver injury. UpToDate.
Retrieved April 4, 2025, https://www.uptodate.com/contents/
drug-induced-liver-injury
Logee, K. (2020). Pediatric emergencies. In V. Sweet & A. Foley (Eds.),
Sheehy’s emergency nursing: Principles and practice (7th ed., pp.
556–575). Elsevier.
Lorenc, J., Flaucher, N., Evans, E., & Schurman, J. V. (2024). Establishing
a plan to improve pediatric patient comfort during PIV insertions
and blood specimen collection: A quality improvement
effort. British Journal of Nursing (Mark Allen Publishing), 33(7),
S36–S42. https://doi.org/10.12968/bjon.2024.33.7.S36
Mayo Foundation for Medical Education and Research. (2024a,
December 10). Pyloric stenosis. Mayo Clinic. https://www.
mayoclinic.org/diseases-conditions/pyloric-stenosis/
symptoms-causes/syc-20351416
Mayo Foundation for Medical Education and Research. (2024a,
December 31). Anal fissure. Mayo Clinic. https://www.mayoclinic.
org/diseases-conditions/anal-fissure/symptoms-causes/
syc-20351424
Mayo Foundation for Medical Education and Research. (2022,
December 22). Cholestasis of pregnancy. Mayo Clinic. https://www.
mayoclinic.org/diseases-conditions/cholestasis-of-pregnancy/
symptoms-causes/syc-20363257
McLellan, H. (2025). Topic 4: Acute kidney injury. Mount Royal
University
McVary, K.T. (2025). Clinical manifestations and diagnostic evaluation
of benign prostatic hyperplasia. UpToDate. https://www.
uptodate.com/contents/clinical-manifestations-and-diagnostic-
evaluation-of-benign-prostatic-hyperplasia
O’Heney, J. L., Barnett, R. E., MacSwan, R. M., & Rasheed, A. (2021).
Acute and chronic pancreatitis in pregnancy. The Obstetrician &
Gynaecologist, 23(2), 89–93. https://doi.org/10.1111/tog.12725
Palevsky, P. (2025). Definition and staging criteria of acute kidney
injury in adults. UpToDate. https://www.uptodate.com/contents/
definition-and-staging-criteria-of-acute-kidney-injury-in-adults
Rubin, L. J. (2024). Clinical features and diagnosis of pulmonary
hypertension of unclear etiology in adults. UpToDate. https://
www.uptodate.com/contents/clinical-features-and-diagnosis-of-
pulmonary-hypertension-of-unclear-etiology-in-adults
Smitherman, H. F., Macias, C. G., & Mahajan, P. (2025). The
febrile infant (29 to 90 days of age): Outpatient evaluation.
UpToDate. https://www.uptodate.com/contents/
the-febrile-infant-29-to-90-days-of-age-outpatient-evaluation
Ward, M. A. (2024). Fever in infants and children: Pathophysiology and
management. UpToDate. https://www.uptodate.com/contents/
fever-in-infants-and-children-pathophysiology-and-management
Weiss, S. L., & Fitzgerald, J. C. (2024). Pediatric sepsis diagnosis,
management, and sub-phenotypes. Pediatrics, 153(1),
e2023062967. https://doi.org/10.1542/peds.2023-062967

## Références

August, P., & Sibai, B.M. (2025). Preeclampsia: Clinical features and diagnosis. UpToDate. Retrieved April 4, 2025, from https://www.uptodate.com/contents/preeclampsia-clinical-features-and-diagnosis

Baxter, C.S. (2020). Renal and genitourinary emergencies. In V. Sweet & A. Foley (Eds.), Sheehy’s emergency nursing: Principles and practice (7th ed., pp. 271-279). Elsevier.

Burg, M.D. & Graber, M.N. (2015). Renal failure (acute kidney injury). In J. Schaider, R. Barkin, S. Hayden, R. Wolfe, A. Barkin, P. Shayne & P. Rosen (Eds.) Rosen & Barkins 5-minute emergency medicine consult (5th ed). Wolters Kluwer

Cleveland Clinic. (2024a, Nov 12) Appendicitis in kids: Symptoms, treatment & recovery.. https://my.clevelandclinic.org/health/diseases/10792-appendicitis-in-children

Cleveland Clinic. (2024b, Jan 24). What is intussusception? https://my.clevelandclinic.org/health/diseases/10793-intussusception

C. S., Guzman, C., Cervantes, A., & Cerbón, M. (2019, July 1). Liver disease in pregnancy: Medical aspects and their implications for mother and child. Annals of Hepatology. 18(4), 553–562. https://doi.org/10.1016/j.aohep.2019.04.009

A., Schlapbach, L. J., Johnston, A. N. B., & Massey, D. (2022). Challenges in the recognition and management of paediatric sepsis — The journey. Australasian Emergency Care, 25(1), 23–29. https://doi.org/10.1016/j.auec.2021.03.006

Harvard Health. (2023, June 27). Preeclampsia and Eclampsia. https://www.health.harvard.edu/a_to_z/preeclampsia-and-eclampsia-a-to-z

Larson, A.M. (2023). Drug-induced liver injury. UpToDate. Retrieved April 4, 2025, https://www.uptodate.com/contents/drug-induced-liver-injury

Logee, K. (2020). Pediatric emergencies. In V. Sweet & A. Foley (Eds.), Sheehy’s emergency nursing: Principles and practice (7th ed., pp. 556-575). Elsevier.

J., Flaucher, N., Evans, E., & Schurman, J. V. (2024). Establishing a plan to improve pediatric patient comfort during PIV insertions and blood specimen collection: a quality improvement effort. British Journal of Nursing (Mark Allen Publishing), 33(7), S36–S42. https://doi.org/10.12968/bjon.2024.33.7.S36

Mayo Foundation for Medical Education and Research. (2024a, December 10). Pyloric stenosis. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/pyloric-stenosis/symptoms-causes/syc-20351416

Mayo Foundation for Medical Education and Research. (2024a, December 31). Anal fissure. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/anal-fissure/symptoms-causes/syc-20351424

Mayo Foundation for Medical Education and Research. (2022, December 22). Cholestasis of pregnancy. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/cholestasis-of-pregnancy/symptoms-causes/syc-20363257

McLellan, H. (2025). Topic 4: Acute kidney injury. Mount Royal University

McVary, K.T. (2025). Clinical manifestations and diagnostic evaluation of benign prostatic hyperplasia. UpToDate. Retrieved April 2, 2025, https://www.uptodate.com/contents/clinical-manifestations-and-diagnostic-evaluation-of-benign-prostatic-hyperplasia

J. L., Barnett, R. E., MacSwan, R. M., & Rasheed, A. (2021). Acute and chronic pancreatitis in pregnancy. The Obstetrician & Gynaecologist, 23(2), 89–93. https://doi.org/10.1111/tog.12725

Palevsky, P. (2025). Definition and staging criteria of acute kidney injury in adults. UpToDate. Retrieved April 4, 2025, https://www.uptodate.com/contents/definition-and-staging-criteria-of-acute-kidney-injury-in-adults

Rubin, L.J. (2024). Clinical features and diagnosis of pulmonary hypertension of unclear etiology in adults. UpToDate. Retrieved April 2, 2025, https://www.uptodate.com/contents/clinical-features-and-diagnosis-of-pulmonary-hypertension-of-unclear-etiology-in-adults

Smitherman, H.F., Macias, C.G., & Mahajan, P. (2025). The febrile infant (29 to 90 days of age): Outpatient evaluation. UpToDate. Retrieved April 4, 2025, https://www.uptodate.com/contents/the-febrile-infant-29-to-90-days-of-age-outpatient-evaluation

Ward, M.A. (2024). Fever in infants and children: Pathophysiology and management. UpToDate. Retrieved April 4, 2025, https://www.uptodate.com/contents/fever-in-infants-and-children-pathophysiology-and-management

Weiss, S. L., & Fitzgerald, J. C. (2024). Pediatric Sepsis Diagnosis, Management, and Sub-phenotypes. Pediatrics, 153(1), 1-. https://doi.org/10.1542/peds.2023-