Pediatric CCRN Exam — Questions and Answers

Question 1: A newborn with transposed great arteries is hospitalized. 46% is the SpO2 value. Which of the following medications should the nurse anticipate being given as a temporary solution until a balloon septostomy can be performed?

Tolazoline (Priscoline)
Alprostadil (PGE1) (Correct answer)
Digoxin (Lanoxin)
Indomethacin (Indocin)

Correct answer: Alprostadil (PGE1)

In a newborn with transposed great arteries and low SpO2 (46%), Alprostadil (PGE1) is administered as a temporary measure. PGE1 maintains the patency of the ductus arteriosus, which is crucial for mixing oxygenated and deoxygenated blood in this condition. This allows for improved systemic oxygenation until a definitive surgical intervention like a balloon septostomy or arterial switch can be performed.

Question 2: A 2-year-old with RSV bronchiolitis has an SpO2 of 89% on room air. Which intervention has the strongest evidence for improving outcomes?

Nebulized albuterol every 4 hours
Supplemental oxygen to maintain SpO2 ≥ 90–92% (Correct answer)
Systemic corticosteroids to reduce inflammation
Hypertonic saline nebulization with airway suctioning

Correct answer: Supplemental oxygen to maintain SpO2 ≥ 90–92%

Supportive care with supplemental oxygen to maintain adequate saturation is the only consistently evidence-based intervention for RSV bronchiolitis; bronchodilators and steroids are not routinely recommended.

Question 3: A 5-year-old is noted to have subtle lip smacking and eye blinking lasting 90 seconds followed by confusion. This event is BEST classified as:

Focal impaired awareness seizure (complex partial seizure) (Correct answer)
Myoclonic seizure
Generalized tonic-clonic seizure
Absence seizure

Correct answer: Focal impaired awareness seizure (complex partial seizure)

Repetitive automatisms (lip smacking, eye blinking) with impaired awareness followed by post-ictal confusion characterize focal impaired awareness seizures originating in the temporal lobe.

Question 4: A 5-year-old is admitted for hypertensive urgency. The drug of choice for acute, controlled reduction of blood pressure in a PICU setting is:

IV furosemide bolus dosing
IM hydralazine every 6 hours
Continuous IV nicardipine or labetalol infusion (Correct answer)
Oral nifedipine (sublingual administration)

Correct answer: Continuous IV nicardipine or labetalol infusion

Continuous IV nicardipine or labetalol allows precise, titratable blood pressure control, preventing the dangerous overcorrection associated with bolus agents.

Question 5: A child with aortic stenosis has a peak-to-peak gradient of 75 mmHg on cardiac catheterization. This finding indicates:

Moderate aortic stenosis
Normal variant in pediatric patients
Mild aortic stenosis requiring monitoring only
Severe aortic stenosis requiring intervention (Correct answer)

Correct answer: Severe aortic stenosis requiring intervention

A peak-to-peak gradient ≥70 mmHg across the aortic valve is classified as severe aortic stenosis and typically warrants balloon valvuloplasty or surgical intervention.

Question 6: A 3-month-old presents with poor feeding, weak cry, constipation, and decreased muscle tone. The nurse suspects infant botulism. What is the most appropriate initial intervention?

Start broad-spectrum IV antibiotics
Administer BabyBIG (botulism immune globulin) and prepare for respiratory support (Correct answer)
Administer botulism antitoxin (HBAT) immediately
Initiate activated charcoal to bind toxin

Correct answer: Administer BabyBIG (botulism immune globulin) and prepare for respiratory support

BabyBIG (heptavalent botulism immune globulin) is the specific treatment for infant botulism, and respiratory support should be anticipated due to progressive weakness.

Question 7: A PICU patient's grandmother, who is the legal guardian, is making care decisions that the primary nurse believes are not in the child's best interest. The nurse's FIRST action should be to:

Carry out the grandmother's decisions without question
Consult with the interdisciplinary team and document the concern (Correct answer)
Override the grandmother's decisions citing nursing judgment
Contact law enforcement to report medical neglect

Correct answer: Consult with the interdisciplinary team and document the concern

When a nurse has concerns about guardian decision-making, the appropriate first step is to consult the interdisciplinary team, including social work and the attending physician, and document the concern before escalating.

Question 8: A 4-year-old with burns over 40% TBSA on day 2 of hospitalization has brown urine, rising creatinine, and serum CK of 25,000 U/L. The PRIORITY intervention is:

Aggressively increase IV fluid rate to maintain urine output >1–2 mL/kg/hr (Correct answer)
Initiate emergent dialysis for myoglobinuric renal failure
Administer furosemide to increase urine output
Add sodium bicarbonate to IV fluids to alkalinize urine and protect kidneys

Correct answer: Aggressively increase IV fluid rate to maintain urine output >1–2 mL/kg/hr

Myoglobinuria from rhabdomyolysis requires aggressive IV fluid resuscitation to achieve urine output of 1–2 mL/kg/hr to flush myoglobin from the tubules and prevent acute kidney injury.

Question 9: A 3-year-old with bacterial meningitis develops a petechial rash, hypotension, and purpura fulminans. Which organism is most likely responsible?

Haemophilus influenzae
Neisseria meningitidis (Correct answer)
Streptococcus pneumoniae
Listeria monocytogenes

Correct answer: Neisseria meningitidis

Neisseria meningitidis is classically associated with purpura fulminans and septic shock due to its endotoxin-mediated cascade.

Question 10: A 26-week neonate receiving surfactant therapy exhibits a sudden drop in oxygen requirement from FiO2 0.60 to 0.35 following administration. The MOST important next nursing action is:

Obtain arterial blood gas in 4 hours
Notify the physician of improvement
Wean ventilator settings to avoid hyperoxia (Correct answer)
Increase PEEP by 2 cmH2O

Correct answer: Wean ventilator settings to avoid hyperoxia

Rapid improvement in oxygenation after surfactant requires immediate ventilator weaning to prevent oxygen toxicity and volutrauma.

Question 11: A 6-year-old on ECMO develops sudden loss of the ECMO flow waveform, circuit chattering, and hypotension. The nurse's first action should be:

Increase vasopressor support immediately
Increase ECMO RPM to restore flow
Clamp the ECMO circuit and notify the ECMO specialist (Correct answer)
Administer an IV fluid bolus of 20 mL/kg

Correct answer: Clamp the ECMO circuit and notify the ECMO specialist

Circuit chattering with flow loss suggests volume deficit or suction events; clamping the circuit and alerting the ECMO specialist prevents air entrainment and allows safe assessment.

Question 12: A family whose child has cerebral palsy and will be receiving a baclofen (Lioresal) pump to treat spasticity is receiving patient education from the nurse. Which of the following should the nurse emphasize in the conversation?

Parents must bring the child back to the clinic to have medicine added to the pump. (Correct answer)
Parents can be taught to regulate the dosage based on symptoms.
Gamma-aminobutyric acid (GABA), a neurotransmitter, is inhibited by the drug.
The child will have a normal gait after insertion of the pump.

Correct answer: Parents must bring the child back to the clinic to have medicine added to the pump.

Intrathecal baclofen pumps deliver medication directly into the spinal fluid, requiring specialized knowledge and sterile technique for refills. Parents cannot regulate the dosage or refill the pump themselves due to the complexity and risk of infection or overdose. Therefore, regular clinic visits for pump refills by trained professionals are essential for safe and effective management of spasticity.

Question 13: A 2-year-old who is on a ventilator has spent her entire life in a hospital. The patient will be sent home in a week with a gastrostomy and tracheostomy, according to the doctor. As a way to assess the discharge requirements of the patient, the nurse must arrange for:

A social worker to meet with the family and assess adequacy of the home environment (Correct answer)
An outreach educator to determine the learning needs of the family
A multidisciplinary care conference before discharge
Home nursing care for the first few days following discharge

Correct answer: A social worker to meet with the family and assess adequacy of the home environment

For a child with complex medical needs like a ventilator, gastrostomy, and tracheostomy, a social worker is essential for assessing the home environment's adequacy. They evaluate the family's resources, support systems, and ability to manage the child's care at home. This assessment ensures a safe and successful transition from hospital to home, addressing practical and psychosocial challenges.

Question 14: Siblings of a critically ill child are exhibiting behavioral regression and somatic complaints at home. The nurse should recommend:

Age-appropriate sibling visitation with preparation and a dedicated support person (Correct answer)
Telling siblings the ill child has 'gone to sleep' if prognosis is poor
Immediate psychological evaluation for all siblings showing regression
Keeping siblings completely away from the hospital to protect them from trauma

Correct answer: Age-appropriate sibling visitation with preparation and a dedicated support person

Prepared sibling visitation with a dedicated support person reduces siblings' anxiety by replacing frightening imaginings with reality and maintaining family connection.

Question 15: Which of the following does positive end-expiratory pressure (PEEP) aim to accomplish?

Increase functional residual capacity (Correct answer)
Decrease functional residual capacity
Increase venous return to the heart
Increase cardiac output

Correct answer: Increase functional residual capacity

Positive end-expiratory pressure (PEEP) is a ventilatory maneuver that maintains a positive pressure in the airways at the end of exhalation. Its primary goal is to prevent alveolar collapse (atelectasis) and recruit collapsed alveoli, thereby increasing the functional residual capacity (FRC). By keeping alveoli open, PEEP improves oxygenation, reduces the work of breathing, and optimizes gas exchange.

Question 16: Which hemodynamic parameter BEST reflects preload in a pediatric patient on mechanical ventilation?

Stroke volume variation (SVV) (Correct answer)
Mean arterial pressure
Central venous pressure alone
Pulmonary artery occlusion pressure alone

Correct answer: Stroke volume variation (SVV)

Stroke volume variation dynamically assesses fluid responsiveness and preload in mechanically ventilated patients and is more reliable than static pressures like CVP.

Question 17: A NICU nurse is caring for a neonate with persistent pulmonary hypertension of the newborn (PPHN). The physician orders inhaled nitric oxide (iNO). What is the primary mechanism of action?

Increased cardiac contractility
Systemic vasoconstriction to increase afterload
Bronchodilation to reduce airway resistance
Selective pulmonary vasodilation (Correct answer)

Correct answer: Selective pulmonary vasodilation

Inhaled nitric oxide causes selective pulmonary vasodilation by stimulating cGMP production in pulmonary vascular smooth muscle without significant systemic effects.

Question 18: A 9-month-old infant presents with inspiratory stridor, a barking cough, and a steeple sign on neck X-ray. What is the most appropriate initial treatment?

IV hydration and antiviral therapy
Antibiotics and immediate intubation
Heliox therapy and bronchodilators
Racemic epinephrine and dexamethasone (Correct answer)

Correct answer: Racemic epinephrine and dexamethasone

Croup (laryngotracheobronchitis) is treated with nebulized racemic epinephrine for acute relief and dexamethasone to reduce airway edema.

Question 19: A 3-year-old presents with sudden onset of high fever, toxic appearance, drooling, and tripod positioning. The PRIORITY intervention is:

Prepare for emergent airway management (Correct answer)
Obtain lateral neck X-ray immediately
Perform direct laryngoscopy to visualize the epiglottis
Start IV antibiotics without delay

Correct answer: Prepare for emergent airway management

Epiglottitis can cause complete airway obstruction; the priority is securing the airway in a controlled environment before any other intervention.

Question 20: A 7-year-old with burns covering 40% TBSA is in the acute resuscitation phase. Using the Parkland formula, how much fluid should be given in the FIRST 8 hours?

25% of the total 24-hour calculated volume
75% of the total 24-hour calculated volume
50% of the total 24-hour calculated volume (Correct answer)
100% of the total 24-hour volume as a bolus

Correct answer: 50% of the total 24-hour calculated volume

The Parkland formula gives 4 mL/kg/% TBSA burned over 24 hours, with 50% administered in the first 8 hours and the remaining 50% over the next 16 hours.

Question 21: A juvenile patient who has third-degree burns from an apartment fire and is in septic shock is being admitted by a nurse to the PICU. Which of the following treatments is the nurse planning to administer first?

Intravenous (IV) corticosteroids
Intravenous (IV) vasopressors
Normal saline (NS) bolus (Correct answer)
Intravenous (IV) antibiotics

Correct answer: Normal saline (NS) bolus

In a patient with septic shock, the immediate priority is to restore circulating blood volume and improve tissue perfusion. Septic shock causes widespread vasodilation and increased capillary permeability, leading to severe hypovolemia. Administering a normal saline (NS) bolus rapidly expands the intravascular volume, which is crucial to stabilize blood pressure and deliver oxygen to vital organs before other treatments can take effect.

Question 22: Which medication is the antidote for acetaminophen (paracetamol) toxicity in a pediatric patient?

Physostigmine
Naloxone
Flumazenil
N-acetylcysteine (NAC) (Correct answer)

Correct answer: N-acetylcysteine (NAC)

N-acetylcysteine replenishes hepatic glutathione, binding the toxic NAPQI metabolite to prevent liver injury, and is most effective when given within 8–10 hours of acetaminophen ingestion.

Question 23: A 7-year-old with RSV bronchiolitis has an SpO2 of 88% on 2 L/min nasal cannula and increased work of breathing. What is the BEST next step?

Trial high-flow nasal cannula (HFNC) therapy (Correct answer)
Proceed directly to endotracheal intubation
Administer IV corticosteroids and reassess in 1 hour
Administer nebulized albuterol immediately

Correct answer: Trial high-flow nasal cannula (HFNC) therapy

HFNC reduces work of breathing, improves oxygenation, and can avert the need for intubation in moderate bronchiolitis.

Question 24: Which of the following conditions are more likely in patients with cardiac abnormalities linked to increased pulmonary blood flow?

Syncope
Hypoxemia
Heart Failure (Correct answer)
Air Emboli

Correct answer: Heart Failure

Cardiac abnormalities linked to increased pulmonary blood flow, such as large ventricular septal defects (VSDs) or patent ductus arteriosus (PDA), cause a left-to-right shunt. This leads to an excessive volume of blood flowing into the pulmonary circulation, increasing the workload on the heart and lungs. Over time, this sustained overload can lead to pulmonary hypertension and ultimately result in congestive heart failure.

Question 25: While patients are sleeping, a nursing unit must be able to put patients back on ventilator support as directed. The respiratory therapist is only sometimes present on the unit to put patients on the ventilator because of staffing patterns. The nurse should respond in the following ways:

Question the current policy that only respiratory therapists can manage the ventilator. (Correct answer)
Ask the parent to be responsible for this task.
Wait for the therapist to intervene.
Place the patient on the ventilator when needed, despite current policy

Correct answer: Question the current policy that only respiratory therapists can manage the ventilator.

In a situation where patients need ventilator support but respiratory therapists are not consistently available, the nurse should question the policy restricting ventilator management to only respiratory therapists. This policy creates a safety risk for patients. Advocating for policy changes, such as training nurses for basic ventilator management, ensures timely and safe patient care, aligning with the nurse's role in patient advocacy and quality improvement.

Question 26: A PICU nurse is titrating a dopamine infusion for a child in cardiogenic shock. At which dose range does dopamine primarily exert beta-1 adrenergic (inotropic) effects?

>20 mcg/kg/min (vasopressor range)
10-20 mcg/kg/min (alpha-adrenergic range)
2-10 mcg/kg/min (beta-adrenergic range) (Correct answer)
0.5-2 mcg/kg/min (dopaminergic range)

Correct answer: 2-10 mcg/kg/min (beta-adrenergic range)

At 2-10 mcg/kg/min, dopamine primarily stimulates beta-1 receptors, increasing heart rate and contractility (inotropic effect).

Question 27: A 6-year-old with ARDS is on mechanical ventilation. Lung-protective ventilation strategy includes tidal volume of:

4–5 mL/kg ideal body weight
10–12 mL/kg ideal body weight
6–8 mL/kg ideal body weight (Correct answer)
2–3 mL/kg ideal body weight

Correct answer: 6–8 mL/kg ideal body weight

Lung-protective ventilation for ARDS uses low tidal volumes of 6–8 mL/kg ideal body weight to minimize ventilator-induced lung injury.

Question 28: What is the MOST common cause of acquired heart disease in children in the United States?

Rheumatic heart disease
Myocarditis from viral infection
Kawasaki disease (Correct answer)
Dilated cardiomyopathy

Correct answer: Kawasaki disease

Kawasaki disease is the leading cause of acquired pediatric heart disease in the US, primarily affecting the coronary arteries and potentially causing aneurysms if untreated.

Question 29: A 4-year-old on ECMO develops circuit clotting. Which lab value BEST reflects adequate anticoagulation?

Activated clotting time (ACT) of 180–220 seconds (Correct answer)
Anti-Xa level >1.0 IU/mL
Prothrombin time (PT) within normal limits
Platelet count >150,000/μL

Correct answer: Activated clotting time (ACT) of 180–220 seconds

ACT is the primary monitoring tool for heparin anticoagulation during ECMO, with target ranges typically 180–220 seconds to prevent circuit thrombosis while minimizing bleeding risk.

Question 30: A 7-year-old with nephrotic syndrome has periorbital edema and a serum albumin of 1.5 g/dL. What is the PRIMARY pathophysiology of edema in nephrotic syndrome?

Decreased plasma oncotic pressure (Correct answer)
Lymphatic obstruction
Increased hydrostatic pressure
Sodium retention from SIADH

Correct answer: Decreased plasma oncotic pressure

Massive proteinuria leads to hypoalbuminemia, which reduces plasma oncotic pressure and allows fluid to leak into the interstitial space, causing edema.

Question 31: A 4-year-old post-Fontan procedure has rising lactate and falling mixed venous oxygen saturation. The MOST likely cause is:

Arrhythmia-induced heart block
Metabolic alkalosis
Pulmonary hypertension crisis
Low cardiac output syndrome (Correct answer)

Correct answer: Low cardiac output syndrome

Rising lactate and falling SvO2 are hallmarks of low cardiac output syndrome, indicating tissues are extracting more oxygen due to inadequate delivery.

Question 32: A neonate with transposition of the great arteries (TGA) is awaiting surgery. Which intervention maintains ductal patency?

High-flow oxygen therapy
Prostaglandin E1 (alprostadil) infusion (Correct answer)
Indomethacin infusion
Furosemide bolus

Correct answer: Prostaglandin E1 (alprostadil) infusion

PGE1 infusion maintains ductal patency, allowing mixing of oxygenated and deoxygenated blood until corrective surgery can be performed.

Question 33: A 2-year-old has continuous focal seizure activity for 20 minutes unresponsive to two doses of benzodiazepines. What is the NEXT pharmacologic step?

Perform emergent EEG only
Load IV fosphenytoin or levetiracetam (Correct answer)
Administer a third dose of lorazepam
Start a midazolam infusion immediately

Correct answer: Load IV fosphenytoin or levetiracetam

After two failed benzodiazepine doses, status epilepticus is refractory; second-line therapy with IV fosphenytoin or levetiracetam should be given per established treatment algorithms.

Question 34: A nurse is caring for a neonate with suspected hypoxic-ischemic encephalopathy (HIE). Which intervention is most important to initiate within 6 hours of birth?

Administration of surfactant
High-frequency oscillatory ventilation
Therapeutic hypothermia (33–34°C) (Correct answer)
Phenobarbital loading dose

Correct answer: Therapeutic hypothermia (33–34°C)

Therapeutic hypothermia initiated within 6 hours of birth is the standard of care for moderate-to-severe HIE to reduce neuronal injury.

Question 35: During a blood transfusion, a neonate develops sudden cardiopulmonary deterioration with hypotension and desaturation. The nurse suspects transfusion-associated circulatory overload (TACO). The FIRST intervention should be:

Apply supplemental oxygen only and continue monitoring
Administer epinephrine IV
Increase the transfusion rate to restore volume
Stop the transfusion and notify the physician (Correct answer)

Correct answer: Stop the transfusion and notify the physician

The first step in any suspected transfusion reaction, including TACO, is to immediately stop the transfusion and notify the physician for further assessment.

Question 36: Infants born prematurely face a serious risk of intracranial hemorrhage (ICH), which is divided into four classes. Which grade involves intraventricular blood among the following?

Grade II (Correct answer)
Grade IV
Grade III
Grade I

Correct answer: Grade II

Intracranial hemorrhage (ICH) in premature infants is graded based on its severity and location. Grade I involves germinal matrix hemorrhage only, without intraventricular extension. Grade II is characterized by intraventricular hemorrhage (IVH) without ventricular dilation. Grades III and IV involve IVH with ventricular dilation and parenchymal involvement, respectively. Therefore, Grade II is the first grade to involve blood within the ventricles.

Question 37: Which finding is MOST specific for non-accidental trauma (abusive head trauma) in a 6-month-old?

Bilateral retinal hemorrhages with subdural hematoma in various stages (Correct answer)
Single acute subdural hematoma after witnessed fall
Isolated linear skull fracture
Anterior fontanelle bruising

Correct answer: Bilateral retinal hemorrhages with subdural hematoma in various stages

Bilateral retinal hemorrhages (especially extending to the periphery) combined with subdural hematoma at different stages of evolution are highly specific for abusive head trauma in infants.

Question 38: A 2-year-old is admitted following an ingestion of an unknown substance. He is bradycardic, has pinpoint pupils, excessive secretions, and bronchospasm. Which antidote should be administered?

Naloxone
Atropine and pralidoxime (Correct answer)
N-acetylcysteine
Flumazenil

Correct answer: Atropine and pralidoxime

Cholinergic toxidrome (SLUDGE: salivation, lacrimation, urination, defecation, GI distress, emesis + bradycardia, bronchospasm) from organophosphate or carbamate poisoning is reversed with atropine and pralidoxime.

Question 39: What is the correct maintenance fluid requirement for a 20 kg child using the Holliday-Segar method?

1,500 mL/day (Correct answer)
1,200 mL/day
1,400 mL/day
1,600 mL/day

Correct answer: 1,500 mL/day

Using the 100-50-20 rule: 100 mL/kg × 10 kg = 1,000 mL + 50 mL/kg × 10 kg = 500 mL, totaling 1,500 mL/day.

Question 40: Which corticosteroid dose is recommended for physiologic stress dosing (adrenal insufficiency coverage) in a critically ill child under 10 kg?

Hydrocortisone 1 mg/kg/day
Dexamethasone 0.6 mg/kg once
Hydrocortisone 50 mg/m² /day (stress dose: 3–5× maintenance) (Correct answer)
Methylprednisolone 2 mg/kg/day

Correct answer: Hydrocortisone 50 mg/m² /day (stress dose: 3–5× maintenance)

Physiologic stress dosing of hydrocortisone is 3–5 times the maintenance dose, calculated at 50–100 mg/m²/day, to cover the adrenal response that the pituitary-adrenal axis may fail to mount during critical illness.

Question 41: A 6-year-old with septic shock has received 60 mL/kg of isotonic crystalloid with persistent hypotension. Which vasoactive agent is FIRST-LINE?

Phenylephrine infusion
Dopamine or epinephrine titrated to effect (Correct answer)
Vasopressin 0.03 units/kg/min
Norepinephrine infusion

Correct answer: Dopamine or epinephrine titrated to effect

PALS guidelines recommend dopamine or epinephrine (depending on whether shock is warm or cold) as first-line vasoactive agents for fluid-refractory pediatric septic shock.

Question 42: Which EEG pattern in a critically ill child indicates the HIGHEST risk for poor neurological outcome?

Low-amplitude theta activity
Generalized slowing
Burst suppression pattern (Correct answer)
Sleep spindles present

Correct answer: Burst suppression pattern

Burst suppression on EEG — periods of near-electrical silence alternating with bursts of activity — indicates severe diffuse cortical dysfunction and is associated with poor neurological prognosis.

Question 43: The ICU cares for an end-stage pituitary adenoma patient with diabetes insipidus and aspiration pneumonia. The mother is giving the patient water and soft beverages despite being aware that there is a plan for transpyloric tube feedings and nothing by mouth. What action should the nurse take in this circumstance?

Ask security to restrict the mother's ability to visit the ICU
Notify the social worker that the mother is interfering with the medical plan.
Ask the mother to explain why she is giving fluids to her son (Correct answer)
Ask the resident physician to change the diet order to include oral fluids.

Correct answer: Ask the mother to explain why she is giving fluids to her son

The nurse's best initial action is to approach the mother non-judgmentally and ask her to explain why she is giving fluids. This allows the nurse to understand the mother's perspective, concerns, or cultural beliefs, which may be influencing her actions. Open communication fosters trust and provides an opportunity for education and collaborative problem-solving, rather than immediately resorting to punitive or restrictive measures.

Question 44: Which of the following group of children might have a hypertensive crisis as shown by acidosis, hypothermia, and alveolar hypoxia?

Those with sustained increases in afterload
Those with systemic vascular disease.
Those with increases in ventricular afterload.
Those with reactive pulmonary vascular bed (Correct answer)

Correct answer: Those with reactive pulmonary vascular bed

A reactive pulmonary vascular bed is prone to vasoconstriction, leading to increased pulmonary vascular resistance and pulmonary hypertension. This can cause a hypertensive crisis in the pulmonary circulation, resulting in poor gas exchange, alveolar hypoxia, and subsequent metabolic acidosis. Hypothermia can also be a consequence of severe physiological stress and poor perfusion in such critical states.

Question 45: A 16-year-old with anorexia nervosa is admitted to the PICU. During refeeding, which complication is MOST critical to monitor for?

Hyperglycemia from excessive carbohydrate intake
Hyperphosphatemia and hypercalcemia
Hyperkalemia from protein metabolism
Hypophosphatemia causing cardiac and respiratory failure (Correct answer)

Correct answer: Hypophosphatemia causing cardiac and respiratory failure

Refeeding syndrome causes a precipitous drop in serum phosphate as cells uptake phosphate during anabolism, leading to life-threatening cardiac arrhythmias and respiratory failure.

Question 46: A school-aged autistic child who has a fractured femur and a suspected brain injury is admitted. Which of the following factors is crucial to encouraging hospital setting adjustment?

Assign a child life therapist per shift
Encourage lots of visitors
Adhere to a home schedule (Correct answer)
Initiate new activities to keep the patient occupied

Correct answer: Adhere to a home schedule

Children with autism spectrum disorder thrive on routine and predictability, and deviations can cause significant anxiety and distress. Adhering to a home schedule as much as possible provides a sense of familiarity and control in the unfamiliar hospital environment. This consistency helps reduce agitation and promotes better adjustment and cooperation with care.

Question 47: A 14-year-old PICU patient refuses to discuss her care in front of her parents. The nurse's best initial action is to:

Override the adolescent's preference since parents have legal decision-making authority
Document the conflict as evidence of family dysfunction
Refer the adolescent to child psychiatry for oppositional behavior
Ask the parents to step out briefly to allow a private conversation with the patient (Correct answer)

Correct answer: Ask the parents to step out briefly to allow a private conversation with the patient

Adolescents have a developmental need for privacy and autonomy; providing brief private time acknowledges this need and may reveal important clinical or psychosocial information.

Question 48: A 2-year-old is admitted with 40% TBSA burns. Using the Parkland formula, what is the total fluid volume to be given in the first 24 hours if the child weighs 12 kg?

960 mL
2400 mL
1440 mL
1920 mL (Correct answer)

Correct answer: 1920 mL

Parkland formula: 4 mL × kg × % TBSA = 4 × 12 × 40 = 1920 mL in the first 24 hours (half given in first 8 hours).

Question 49: A 5-year-old with suspected non-accidental trauma (child abuse) has multiple bruises in various stages of healing. The nurse's LEGAL obligation is to:

Wait for the physician to make the mandatory report
Confront the caregivers directly before filing a report
Discuss suspicions only with the child's primary nurse before acting
Report the suspicion to child protective services (CPS) and document findings (Correct answer)

Correct answer: Report the suspicion to child protective services (CPS) and document findings

Nurses are mandatory reporters and are legally obligated to report suspected child abuse to CPS regardless of confirmation; documentation of objective findings is essential.

Question 50: A nurse is preparing to insert an umbilical arterial catheter (UAC) in a neonate. Which catheter tip position is considered the HIGH position and is preferred for most neonates?

T1-T4 (above the aortic arch)
L3-L4 (below the renal arteries)
T6-T9 (above the diaphragm) (Correct answer)
T10-T12 (at the diaphragm level)

Correct answer: T6-T9 (above the diaphragm)

The high UAC position (T6-T9) is above the diaphragm and is preferred as it avoids major branch vessels and reduces complication risks.

Question 51: Discharge instruction is the responsibility of respiratory, physical, and occupational therapists and nurses; each profession now keeps track of this information on a separate flow sheet. The following would be the ideal scenario for organizing teaching:

All disciplines document patient teaching on the same flow sheet. (Correct answer)
Daily care conferences to review and discuss patient teaching and the flow sheets
Each discipline distribute copies of its flow sheet to each team member.
Nurses review the flow sheets of all disciplines during shift change.

Correct answer: All disciplines document patient teaching on the same flow sheet.

The ideal scenario for organizing interdisciplinary patient teaching is for all disciplines to document on the same flow sheet. This centralized approach promotes continuity of care, prevents duplication of teaching efforts, and ensures that all team members are aware of what has been taught and what still needs to be addressed. It facilitates comprehensive communication and a holistic view of the patient's and family's learning progress.

Question 52: A 2-year-old ingests a large amount of acetaminophen. Which antidote is indicated and by what route?

Flumazenil 0.01 mg/kg IV
N-acetylcysteine (NAC) administered orally or IV (Correct answer)
Naloxone 0.1 mg/kg IV push
Activated charcoal administered IV within 1 hour

Correct answer: N-acetylcysteine (NAC) administered orally or IV

N-acetylcysteine replenishes glutathione stores, preventing hepatotoxicity from acetaminophen overdose and is most effective within 8 hours of ingestion.

Question 53: Which chest X-ray finding is MOST characteristic of total anomalous pulmonary venous return (TAPVR) with obstruction in a neonate?

Right-sided aortic arch
Egg-shaped cardiac silhouette
Ground-glass opacification with white-out pattern (Correct answer)
'Snowman' or figure-8 cardiac silhouette

Correct answer: Ground-glass opacification with white-out pattern

Obstructed TAPVR causes severe pulmonary venous hypertension and edema, producing a ground-glass or white-out appearance on CXR due to pulmonary edema.

Question 54: A family requests withdrawal of life-sustaining treatment for their critically ill child. The nurse's BEST response is:

Support the family's decision and facilitate a family meeting with the multidisciplinary team (Correct answer)
Notify the ethics committee without informing the medical team
Encourage the family to wait 48 more hours before deciding
Inform the family that this decision must be made by the attending physician only

Correct answer: Support the family's decision and facilitate a family meeting with the multidisciplinary team

Supporting the family's autonomy and facilitating a multidisciplinary family meeting ensures informed, compassionate end-of-life care consistent with AACN ethical principles.

Question 55: The parents of a 3-year-old hospitalized with hemophilia receive advice from the nurse on caring for their kid at home. Which of the following parent-made statements suggests the need for more instructions?

“We will avoid having the child receive immunizations and cancel the scheduled dental appointments.” (Correct answer)
“We will supervise the child closely.”
“We will pad corners of the furniture.”
“We will remove household items that can easily fall over.”

Correct answer: “We will avoid having the child receive immunizations and cancel the scheduled dental appointments.”

Avoiding immunizations and canceling dental appointments for a child with hemophilia is incorrect and indicates a need for further instruction. Children with hemophilia still require immunizations, which should be administered subcutaneously with a small-gauge needle and pressure applied to minimize bleeding risk. Regular dental care is crucial to prevent gum disease and tooth decay, which could lead to more invasive procedures and potential bleeding complications.

Question 56: A 6-month-old with Tetralogy of Fallot develops a sudden hypercyanotic (tet) spell. What is the FIRST intervention?

Initiate IV fluid bolus
Give IV morphine sulfate
Place the infant in the knee-chest position (Correct answer)
Administer 100% oxygen via face mask

Correct answer: Place the infant in the knee-chest position

The knee-chest position increases systemic vascular resistance and decreases right-to-left shunting, immediately improving oxygenation during a tet spell.

Question 57: A 3-year-old presents with drooling, high fever, tripod positioning, and muffled voice. Which action should the nurse AVOID?

Keeping the child calm and upright
Performing a throat examination with a tongue depressor (Correct answer)
Preparing for emergency airway management
Administering humidified oxygen by blow-by

Correct answer: Performing a throat examination with a tongue depressor

In suspected epiglottitis, throat examination or any distressing procedure can precipitate complete airway obstruction; the airway must be secured in a controlled OR setting first.

Question 58: Which of the following disorders has been linked to a risk factor for hyperosmolar infusions given to infants too quickly, causing an abrupt rise in systolic blood pressure (BP)?

Pulmonary edema
Seizures
Acute ischemic stroke (AIS)
Intraventricular (IVH) and intracranial hemorrhage (ICH) (Correct answer)

Correct answer: Intraventricular (IVH) and intracranial hemorrhage (ICH)

Rapid infusion of hyperosmolar solutions in infants can cause a sudden increase in intravascular volume and an abrupt rise in systolic blood pressure. This rapid fluctuation in blood pressure, especially in the immature and fragile cerebral vasculature of infants (particularly premature infants), significantly increases the risk of rupture of delicate blood vessels. This can lead to intraventricular or intracranial hemorrhage, as the sudden pressure changes can overwhelm the brain's autoregulation.

Question 59: An 8-year-old girl and her mother arrive at the emergency room after the girl fell off her bike around four hours earlier. The child has been complaining of severe abdominal pain ever since the fall, according to her mother, who was riding her bike when she fell, with the handlebars ""bumping into her chest and stomach. Upon assessment, the nurse observes a positive Kehr sign. What organ does the nurse assume has been damaged based on this discovery?

The spleen (Correct answer)
The pancreas
The left kidney
The liver

Correct answer: The spleen

Kehr's sign is the presence of acute pain in the left shoulder, which is referred pain from irritation of the diaphragm. This irritation is often caused by blood or other irritants in the peritoneal cavity, particularly following blunt abdominal trauma. Damage to the spleen, a highly vascular organ located in the upper left abdomen, is a common cause of intra-abdominal bleeding and diaphragmatic irritation, thus eliciting Kehr's sign.

Question 60: Which statement by a nurse BEST demonstrates understanding of the concept of moral distress in pediatric critical care?

'I find it difficult to communicate with families of diverse backgrounds.'
'I feel guilty when I cannot cure my patients.'
'I know what is ethically right but am constrained from doing it, which causes me suffering.' (Correct answer)
'I am overwhelmed by the amount of documentation required in the PICU.'

Correct answer: 'I know what is ethically right but am constrained from doing it, which causes me suffering.'

Moral distress is specifically defined as suffering that occurs when one knows the ethically correct action but is prevented from taking it by institutional, legal, or hierarchical constraints.

Question 61: A 7-year-old post-op with a right-sided chest tube has sudden respiratory distress, absent breath sounds on the left, and tracheal deviation to the right. The MOST likely diagnosis is:

Right-sided hemothorax
Bronchospasm
Left-sided tension pneumothorax (Correct answer)
Right-sided pleural effusion

Correct answer: Left-sided tension pneumothorax

Absent left breath sounds, tracheal deviation away from the left, and sudden respiratory distress indicate a left-sided tension pneumothorax compressing mediastinal structures.

Question 62: A 10-year-old with rhabdomyolysis is at high risk for AKI. Which intervention is MOST important to prevent renal tubular damage?

Administering nephrotoxic antibiotics prophylactically
Restricting fluid to prevent fluid overload
Early initiation of peritoneal dialysis
Aggressive IV fluid resuscitation targeting urine output ≥ 3 mL/kg/hr (Correct answer)

Correct answer: Aggressive IV fluid resuscitation targeting urine output ≥ 3 mL/kg/hr

Aggressive IV hydration dilutes myoglobin and maintains high urine output, flushing nephrotoxic myoglobin from renal tubules before it can cause tubular necrosis.

Question 63: A neonate with d-Transposition of the Great Arteries is critically cyanotic. Which medication maintains ductal patency until surgical repair?

Prostaglandin E1 (alprostadil) (Correct answer)
Indomethacin
Sildenafil
Epinephrine

Correct answer: Prostaglandin E1 (alprostadil)

Prostaglandin E1 (alprostadil) keeps the ductus arteriosus open, allowing mixing of oxygenated and deoxygenated blood to sustain the neonate until arterial switch operation.

Question 64: A 10 kg child requires an epinephrine infusion at 0.1 mcg/kg/min. Using the rule of 6, how many mg of epinephrine should be added to 100 mL of D5W to run at 1 mL/hr?

60 mg
0.06 mg
6 mg
0.6 mg (Correct answer)

Correct answer: 0.6 mg

Rule of 6: weight (kg) × 0.6 = mg to add to 100 mL; for 10 kg: 10 × 0.06 = 0.6 mg, resulting in a concentration where 1 mL/hr delivers 0.1 mcg/kg/min.

Question 65: A neonate born at 34 weeks is noted to have a bluish-purple discoloration of the hands and feet with a pink central body. This finding is best described as:

Acrocyanosis (Correct answer)
Peripheral vascular disease
Polycythemia
Central cyanosis

Correct answer: Acrocyanosis

Acrocyanosis is a normal finding in newborns characterized by blue discoloration of hands and feet with a pink trunk, caused by peripheral vasoconstriction.

Question 66: A 10-year-old with cystic fibrosis is admitted with a pulmonary exacerbation. Which combination is standard initial therapy?

Inhaled tobramycin alone
Bronchodilators and bed rest
IV antibiotics targeting Pseudomonas plus airway clearance therapy (Correct answer)
Systemic corticosteroids alone

Correct answer: IV antibiotics targeting Pseudomonas plus airway clearance therapy

CF pulmonary exacerbations require IV antibiotics with anti-pseudomonal coverage (e.g., tobramycin + piperacillin-tazobactam) combined with aggressive airway clearance to improve outcomes.

Question 67: A nurse is caring for a 5-year-old with a new tracheostomy whose parents are from a culture that believes illness is a punishment from God. Which action best demonstrates culturally competent care?

Document the belief as a barrier to care and request social work intervention
Educate the parents that illness is not a punishment to correct their misconception
Ask the parents what their belief means for their child's care and incorporate their values (Correct answer)
Avoid discussing the topic to prevent conflict during the hospitalization

Correct answer: Ask the parents what their belief means for their child's care and incorporate their values

Culturally competent care requires asking open-ended questions about how cultural beliefs affect care decisions and integrating those values into the care plan respectfully.

Question 68: The ICU is caring for a patient with an end-stage pituitary adenoma who also has diabetes insipidus and aspiration pneumonia. The mother is giving the patient water and soft beverages despite being aware that there is a plan for transpyloric tube feedings and nothing by mouth. What action should the nurse take in this circumstance?

Ask the mother to explain why she is giving fluids to her son (Correct answer)
Report the mother's interference with the treatment plan to the social worker.
Request that the mother's access to the ICU be limited by security
Request a modification to the diet plan so that oral fluids are included.

Correct answer: Ask the mother to explain why she is giving fluids to her son

The nurse's initial action should always be to engage in therapeutic communication to understand the parent's perspective and reasoning. Asking the mother why she is giving fluids allows the nurse to assess her understanding of the NPO status and the child's condition, identify any cultural beliefs, or address potential misinformation. This approach fosters trust and provides an opportunity for education before escalating the situation.

Question 69: Which developmental characteristic of toddlers (1-3 years) makes PICU hospitalization particularly stressful for this age group?

Fear of bodily mutilation and loss of body integrity
Separation anxiety and loss of autonomy (Correct answer)
Loss of peer relationships and social identity
Abstract thinking about death and permanent disability

Correct answer: Separation anxiety and loss of autonomy

Toddlers are in Erikson's autonomy vs. shame stage and have strong attachment bonds, making separation from caregivers and loss of newly gained independence the primary stressors.

Question 70: Therapeutic hypothermia for HIE is initiated at 33.5°C for 72 hours. It is CONTRAINDICATED in which scenario?

Birth weight >1,800 g
Presence of coagulopathy
Gestational age <36 weeks (Correct answer)
Gestational age ≥36 weeks with moderate encephalopathy

Correct answer: Gestational age <36 weeks

Therapeutic hypothermia is currently recommended only for neonates ≥36 weeks gestation; premature infants <36 weeks are excluded due to insufficient evidence and increased risk of complications.

Question 71: Digoxin (Lanoxin) is prescribed to a young patient for heart failure. The nurse understands that poisoning is often detected at what value?

2 ng/mL (Correct answer)
3.5 ng/mL
5 ng/mL
4 ng/mL

Correct answer: 2 ng/mL

Digoxin has a narrow therapeutic index, meaning the range between effective and toxic doses is small. While the therapeutic range for digoxin is typically 0.5-2.0 ng/mL, levels at or above 2.0 ng/mL are generally considered indicative of toxicity, especially in pediatric patients who are more sensitive. Monitoring digoxin levels is crucial to prevent adverse effects such as arrhythmias, nausea, and vomiting.

Question 72: A 10-year-old with ALL is neutropenic (ANC 200) and develops a fever of 38.5°C. Blood cultures are obtained. Which is the correct initial management?

Observe for 24 hours and initiate antibiotics only if culture positive
Administer G-CSF and delay antibiotics
Initiate antifungal therapy and await culture results
Start broad-spectrum IV antibiotics immediately (within 1 hour) (Correct answer)

Correct answer: Start broad-spectrum IV antibiotics immediately (within 1 hour)

Febrile neutropenia is a medical emergency; broad-spectrum IV antibiotics must be initiated within one hour of fever onset to prevent septic death.

Question 73: Which of the following symptoms would indicate a newborn with patent ductus arteriosus (PDA)?

Narrow pulse pressure
Clubbed fingers and toes
Profound cyanosis
Bounding peripheral pulses (Correct answer)

Correct answer: Bounding peripheral pulses

Patent ductus arteriosus (PDA) is a condition where the ductus arteriosus, a fetal blood vessel, fails to close after birth, allowing blood to flow from the aorta to the pulmonary artery. This shunting of blood leads to increased blood flow through the systemic circulation during diastole, resulting in a widened pulse pressure and bounding peripheral pulses. The increased diastolic runoff causes a rapid rise and fall in arterial pressure, creating the characteristic 'bounding' sensation.

Question 74: A 7-year-old in septic shock receives fluid resuscitation of 60 mL/kg with normal saline without improvement. The NEXT appropriate intervention is:

Begin dopamine or epinephrine per PALS guidelines (Correct answer)
Administer another 20 mL/kg bolus of normal saline
Initiate dobutamine for cardiac support
Start norepinephrine as vasopressor

Correct answer: Begin dopamine or epinephrine per PALS guidelines

Per PALS guidelines, children with fluid-refractory septic shock should be started on vasoactive agents such as dopamine or epinephrine after adequate fluid resuscitation.

Question 75: A 7-year-old post-liver transplant develops tacrolimus toxicity. Which finding is MOST expected?

Thrombocytosis and hypercoagulability
Hypoglycemia and metabolic acidosis
Bradycardia and prolonged QT interval
Nephrotoxicity with rising creatinine and hypertension (Correct answer)

Correct answer: Nephrotoxicity with rising creatinine and hypertension

Tacrolimus (a calcineurin inhibitor) commonly causes nephrotoxicity, presenting with rising creatinine and hypertension, requiring dose adjustment and close monitoring of drug levels.

Question 76: Which of the subsequent interventions would be most beneficial in helping to manage a child who needs PEEP of 14 cm water?

Placement of a pulmonary artery catheter
High-frequency oscillatory ventilation (HFOV) (Correct answer)
Placement of a thoracostomy tube
Extracorporeal membrane oxygenation (ECMO)

Correct answer: High-frequency oscillatory ventilation (HFOV)

A PEEP of 14 cm water indicates severe lung disease and significant challenges with oxygenation and ventilation. High-frequency oscillatory ventilation (HFOV) is a specialized mode of mechanical ventilation often used in pediatric patients with severe acute respiratory distress syndrome (ARDS) or other severe lung conditions. HFOV delivers very small tidal volumes at very high frequencies, which can provide better oxygenation and CO2 removal while minimizing lung injury, especially when conventional ventilation with high PEEP is insufficient or causing barotrauma.

Question 77: In a patient with bronchopulmonary dysplasia (BPD), which ventilatory parameters should be tapered down first?

Oxygen (FiO2) and peak inspiratory pressure (PIP) (Correct answer)
Oxygen (FiO2) and intermittent mandatory ventilation (IMV)
Tidal Volume (VT) and oxygen (FiO2)
Peak inspiratory pressure (PIP) and intermittent mandatory ventilation (IMV)

Correct answer: Oxygen (FiO2) and peak inspiratory pressure (PIP)

In patients with bronchopulmonary dysplasia (BPD), the primary goal of ventilatory weaning is to reduce lung injury caused by high oxygen concentrations and barotrauma. Therefore, the fraction of inspired oxygen (FiO2) and peak inspiratory pressure (PIP) are typically tapered down first. Reducing FiO2 minimizes oxygen toxicity, while lowering PIP decreases mechanical stress on the fragile developing lungs.

Question 78: A 5-year-old receives IV vancomycin for MRSA bacteremia. Which monitoring parameter is MOST important to prevent toxicity?

Peak and trough serum levels
Random vancomycin level at 2 hours post-dose
Daily urinalysis only
AUC/MIC ratio via Bayesian pharmacokinetic monitoring (Correct answer)

Correct answer: AUC/MIC ratio via Bayesian pharmacokinetic monitoring

Current ASHP/IDSA guidelines recommend AUC/MIC-guided vancomycin dosing using Bayesian pharmacokinetic monitoring to optimize efficacy while minimizing nephrotoxicity.

Question 79: A father of a critically ill infant paces continuously, refuses to eat, and states he cannot leave the hospital. The nurse recognizes this as:

Pathological attachment requiring psychiatric evaluation
Evidence of neglecting his own health requiring mandatory reporting
An acute stress response that is an expected parental reaction (Correct answer)
Anxiety disorder exacerbation requiring pharmacological treatment

Correct answer: An acute stress response that is an expected parental reaction

Hypervigilance, inability to leave, and self-neglect are expected acute stress responses in parents of critically ill children and reflect normal parental protectiveness under extreme stress.

Question 80: A mother who is HIV-positive delivers a term neonate. Which intervention is MOST important to initiate within the first 6 hours of life?

Isolation in a negative-pressure room
HIV ELISA testing of the neonate
Initiation of antiretroviral prophylaxis (e.g., zidovudine) (Correct answer)
Immediate formula feeding (avoid breastfeeding)

Correct answer: Initiation of antiretroviral prophylaxis (e.g., zidovudine)

Antiretroviral prophylaxis (typically zidovudine) should be initiated within 6-12 hours of birth to prevent mother-to-child transmission of HIV.

Question 81: In a child with hypoplastic left heart syndrome (HLHS) after stage I Norwood repair, a rising SaO2 to 95% MOST likely indicates:

Adequate cardiac output
Successful shunt placement
Excessive pulmonary blood flow stealing from systemic circulation (Correct answer)
Resolution of pulmonary hypertension

Correct answer: Excessive pulmonary blood flow stealing from systemic circulation

In single-ventricle physiology, an SaO2 >85% suggests excessive pulmonary blood flow that is 'stealing' from systemic circulation, threatening vital organ perfusion.

Question 82: A patient complains of sporadic palpitations that come and go and are accompanied by weakness. The heart rate is 125, the PR interval is reduced, and the upstroke is slurred before each enlarged QRS complex, according to an ECG. It is possible to explain this slurred upstroke (Delta wave) by?

Ventricular repolarization
Ventricular pre-excitation (Correct answer)
Atrial depolarization
Atrial pre-excitation

Correct answer: Ventricular pre-excitation

The ECG findings of a reduced PR interval and a slurred upstroke before an enlarged QRS complex (known as a Delta wave) are classic indicators of ventricular pre-excitation. This condition, often seen in Wolff-Parkinson-White (WPW) syndrome, occurs when an accessory pathway bypasses the AV node, allowing electrical impulses to reach and activate the ventricles prematurely. This early ventricular activation causes the characteristic Delta wave.

Question 83: What is the MOST common trigger for status asthmaticus requiring PICU admission in children?

Viral upper respiratory infection (Correct answer)
Allergen exposure
Cold air inhalation
Exercise-induced bronchospasm

Correct answer: Viral upper respiratory infection

Viral URIs (most commonly rhinovirus) are the predominant trigger for acute severe asthma exacerbations requiring pediatric intensive care unit admission.

Question 84: In the pediatric emergency room, an 18-month-old child is identified as having acute laryngotracheobronchitis (LTB). The nurse is getting ready to send the child home after treating and stabilizing the patient. Which at-home remedy should be used, the nurse recommends to the parents?

Aspirin for fever and/or pain
Over-the-counter decongestants
Cool-mist humidifier at bedtime (Correct answer)
Antibiotic therapy as prescribed by a physician

Correct answer: Cool-mist humidifier at bedtime

Acute laryngotracheobronchitis (LTB), commonly known as croup, causes inflammation and swelling of the airways, leading to a characteristic 'barking' cough and inspiratory stridor. A cool-mist humidifier helps to moisten the inspired air, which can soothe irritated airways and reduce swelling, making it easier for the child to breathe. This simple home remedy provides symptomatic relief by thinning secretions and reducing airway inflammation.

Question 85: Which finding on echocardiogram is DIAGNOSTIC of cardiac tamponade?

Left ventricular hypertrophy
Right ventricular diastolic collapse (Correct answer)
Mitral valve prolapse with regurgitation
Dilated left ventricle with reduced ejection fraction

Correct answer: Right ventricular diastolic collapse

Right ventricular free wall collapse during diastole is the echocardiographic hallmark of cardiac tamponade, indicating pericardial pressure exceeds right-sided filling pressure.

Question 86: Which parameter is MOST important to monitor in a child receiving IV amiodarone for arrhythmia control?

Platelet count
Liver function, thyroid function, and pulmonary function (Correct answer)
Serum creatinine
Serum potassium only

Correct answer: Liver function, thyroid function, and pulmonary function

Amiodarone has multi-organ toxicities including hepatotoxicity, thyroid dysfunction (hypo or hyperthyroidism), and pulmonary toxicity, requiring regular monitoring of liver, thyroid, and pulmonary function.

Question 87: A PICU nurse who has cared for a child who died begins to cry in front of the family. The MOST appropriate response to this situation is to:

Request reassignment to avoid further emotional compromise
Allow brief, genuine emotional expression while maintaining focus on the family (Correct answer)
Immediately leave the room to maintain professional composure
Apologize and reassure the family that this is unprofessional behavior

Correct answer: Allow brief, genuine emotional expression while maintaining focus on the family

Brief authentic emotional expression by nurses can humanize the relationship and comfort bereaved families; it is appropriate when it does not shift the focus to the nurse's needs.

Question 88: When calculating a safe defibrillation dose for a pediatric patient in ventricular fibrillation, which is correct per current PALS guidelines?

2 J/kg for the first shock, 4 J/kg for subsequent shocks (Correct answer)
10 J/kg maximum for the first shock
1 J/kg for the first shock, 0.5 J/kg for subsequent shocks
4 J/kg for all shocks regardless of response

Correct answer: 2 J/kg for the first shock, 4 J/kg for subsequent shocks

PALS recommends starting defibrillation at 2 J/kg, then escalating to 4 J/kg for subsequent shocks if the initial shock is unsuccessful.

Question 89: An adolescent who has previously been admitted for chronic status asthmaticus is getting ready to go home. Because taking his prescription "makes him feel too different" from his peers, the nurse concludes that the patient has not been taking his drugs as prescribed. The nurse needs to:

Provide the patient with articles on the relationship of hospitalization and medication compliance.
Advise the parents to withhold privileges if the patient remains non-compliant.
Arrange for the patient's school nurse to monitor compliance
Refer the patient to a support group for adolescents with asthma (Correct answer)

Correct answer: Refer the patient to a support group for adolescents with asthma

Adolescents often struggle with medication adherence due to peer pressure and a desire to fit in. Referring the patient to a support group for adolescents with asthma can provide a safe space to share experiences and coping strategies with peers facing similar challenges. This can help reduce feelings of isolation and improve motivation for medication compliance by normalizing their condition.

Question 90: What desired outcome is achieved when amrinone lactate (Inocor) is administered?

Vasodilation (Correct answer)
Phospholipid inhibition
Decreased myocardial contractility
Catecholamine antagonism

Correct answer: Vasodilation

Amrinone lactate (Inocor) is a phosphodiesterase inhibitor that increases intracellular cyclic AMP (cAMP) in both cardiac and vascular smooth muscle cells. In the heart, this leads to increased contractility (positive inotropy). In vascular smooth muscle, increased cAMP causes relaxation, resulting in systemic and pulmonary vasodilation, which reduces afterload. This dual action improves cardiac output by both strengthening contractions and reducing the resistance the heart pumps against.

Question 91: During the postictal phase of a tonic-clonic seizure characterized by uncontrollable limb jerking and loss of consciousness, a nurse is providing postictal care for a 7-year-old male patient in the PICU. What results can be anticipated from this phase?

Immediate return to baseline behavior
Aura, loss of appetite, insomnia
Crying, "pins-and-needles" sensation, tachycardia
Drowsiness, headache, nausea (Correct answer)

Correct answer: Drowsiness, headache, nausea

The postictal phase is the recovery period immediately following a seizure. During this time, the brain is recovering from intense electrical activity, leading to common symptoms such as drowsiness, confusion, and fatigue. Patients may also experience headaches, muscle soreness, and sometimes nausea or vomiting as their body recovers from the physiological stress of the seizure.

Question 92: Extreme dyspnea is being experienced by a 3-year-old with left-sided ventricular heart failure and pulmonary edema. Which of the following would the nurse advise doing to help the child breathe easier and feel less anxious and agitated?

Morphine (Duramorph) (Correct answer)
Digoxin (Lanoxin)
Dobutamine (Dobutrex)
Furosemide (Lasix)

Correct answer: Morphine (Duramorph)

Morphine is beneficial in acute pulmonary edema due to left-sided heart failure because it acts as a venodilator, reducing preload and afterload on the heart. This decreases pulmonary congestion and improves breathing. Additionally, morphine helps alleviate the severe anxiety and agitation associated with extreme dyspnea, reducing oxygen consumption and making the child more comfortable.

Question 93: To get a cardiac biopsy, a pediatric patient is getting ready for a cardiac catheterization. Which allergies need to be examined for before performing this procedure on the patient?

Opioid pain medications
Penicillin
Iodine or shellfish (Correct answer)
Antiarrhythmic medications

Correct answer: Iodine or shellfish

Cardiac catheterization procedures typically involve the use of iodinated contrast dye to visualize the heart chambers and blood vessels. Therefore, it is crucial to assess for allergies to iodine or shellfish, as these indicate a potential hypersensitivity reaction to the contrast agent. An allergic reaction to the contrast dye can range from mild to severe, including anaphylaxis, making pre-procedure screening essential for patient safety.

Question 94: Which vasoactive agent is MOST appropriate as first-line therapy for a child in septic shock with poor cardiac contractility?

Dopamine
Vasopressin
Norepinephrine
Dobutamine (Correct answer)

Correct answer: Dobutamine

Dobutamine is a beta-1 agonist that increases myocardial contractility, making it the preferred agent when septic shock is accompanied by poor cardiac function.

Question 95: A family meeting is scheduled to go over the family's ethical worries about keeping a child on life support who has terminal cancer. The nurse's duties should include:

Coordinate the meeting to ensure that everyone has the opportunity to speak
Articulate the reason for the child's poor prognosis and anticipated life expectancy
Assist the parents in articulating their questions and concerns. (Correct answer)
Provide the legal standpoint regarding end-of-life decisions for children.

Correct answer: Assist the parents in articulating their questions and concerns.

The nurse's role in an ethical family meeting is to act as a facilitator and advocate for the patient and family. Assisting parents in articulating their questions and concerns ensures their voice is heard and understood by the healthcare team. This empowers the family to participate meaningfully in decision-making regarding their child's end-of-life care.

Question 96: A pediatric patient develops sudden headache, nausea, vomiting, and altered mental status during hemodialysis. What complication is most likely?

Dialysis disequilibrium syndrome (Correct answer)
Dialyzer membrane reaction
Air embolism
Dialysis-associated hypercalcemia

Correct answer: Dialysis disequilibrium syndrome

Dialysis disequilibrium syndrome results from rapid osmolality shifts causing cerebral edema, occurring most often in new or high-BUN patients undergoing their first dialysis sessions.

Question 97: Which electrolyte imbalance is most likely in a child with prolonged nasogastric suctioning?

Hyponatremia and metabolic alkalosis
Hyperkalemia and metabolic acidosis
Hypernatremia and metabolic acidosis
Hypokalemia and metabolic alkalosis (Correct answer)

Correct answer: Hypokalemia and metabolic alkalosis

Gastric fluid loss via NG suctioning depletes hydrochloric acid, potassium, and sodium, resulting in hypokalemic, hypochloremic metabolic alkalosis.

Question 98: A new diagnosis of hypertrophic cardiomyopathy has been made in an adolescent who experienced cardiac arrest. The parents worry about what to do if their son passes out once more. The best response from the nurse would be:

"Do you know how to access the EMS system?"
"Now that your son has been diagnosed and treated, you need not worry."
"I will have your son's cardiologist speak with you."
"Would teaching you CPR help ease your anxieties?" (Correct answer)

Correct answer: "Would teaching you CPR help ease your anxieties?"

The parents' anxiety stems from the fear of their son passing out again and not knowing how to respond. Teaching them CPR directly addresses this fear by empowering them with a life-saving skill. This provides a sense of control and preparedness for potential emergencies, which is vital for coping with a child's serious cardiac condition.

Question 99: After suffering from burns that resulted in the epidermis and dermis completely sloughing off, a 16-year-old male patient was taken to the emergency room. What type of burn is that?

First-degree burn
Third-degree burn (Correct answer)
Second-degree burn
Fourth-degree burn

Correct answer: Third-degree burn

A third-degree burn, also known as a full-thickness burn, involves the complete destruction of both the epidermis and the dermis. This type of burn damages nerve endings, sweat glands, and hair follicles, resulting in a wound that often appears leathery, waxy, or charred and is typically insensate (painless) in the center. The description of the epidermis and dermis completely sloughing off directly corresponds to the definition of a third-degree burn.

Question 100: A 10-year-old with tumor lysis syndrome (TLS) has a potassium of 6.8 mEq/L with peaked T-waves on ECG. The PRIORITY intervention is:

Emergent hemodialysis
Sodium polystyrene sulfonate (Kayexalate) enema
IV calcium gluconate to stabilize cardiac membranes (Correct answer)
Aggressive IV fluid resuscitation

Correct answer: IV calcium gluconate to stabilize cardiac membranes

IV calcium gluconate stabilizes the cardiac membrane immediately to prevent fatal arrhythmias from hyperkalemia, making it the priority before slower potassium-lowering therapies.

Question 101: A PICU nurse is preparing to administer a blood transfusion to a 2-year-old. What is the standard weight-based volume for a packed red blood cell transfusion in pediatrics?

30 mL/kg
10–15 mL/kg (Correct answer)
5 mL/kg
20 mL/kg

Correct answer: 10–15 mL/kg

The standard pediatric PRBC transfusion dose is 10–15 mL/kg, infused over 2–4 hours, to raise hemoglobin by approximately 2–3 g/dL.

Question 102: A 5-year-old is admitted after a near-drowning event and is initially alert. Two hours later, the child's respiratory status deteriorates and the chest X-ray shows bilateral infiltrates. This progression is most consistent with:

Secondary drowning / neurogenic pulmonary edema (Correct answer)
Flash pulmonary edema from hypothermia
Aspiration pneumonia from inhaled water
Delayed tension pneumothorax

Correct answer: Secondary drowning / neurogenic pulmonary edema

Secondary drowning (also called delayed drowning) occurs hours after the event as inhaled water causes surfactant washout and ARDS-like pulmonary edema.

Question 103: In continuous renal replacement therapy (CRRT), which modality removes solutes through BOTH convection and diffusion?

Continuous venovenous hemofiltration (CVVH)
Continuous venovenous hemodialysis (CVVHD)
Slow continuous ultrafiltration (SCUF)
Continuous venovenous hemodiafiltration (CVVHDF) (Correct answer)

Correct answer: Continuous venovenous hemodiafiltration (CVVHDF)

CVVHDF combines convection (via ultrafiltration/hemofiltration) and diffusion (via dialysate), maximizing solute clearance across all molecular sizes.

Question 104: A PICU nurse notices a colleague consistently avoids entering the room of a dying child and delegates all care to others. This behavior is BEST described as:

Normal behavior that should be encouraged in all staff
Compassion fatigue manifesting as avoidance behavior (Correct answer)
Appropriate boundary-setting to maintain professional objectivity
Evidence of incompetence requiring mandatory retraining

Correct answer: Compassion fatigue manifesting as avoidance behavior

Avoidance of emotionally difficult patients is a behavioral manifestation of compassion fatigue, which requires recognition and intervention to protect staff wellbeing and patient care.

Question 105: A neonate post-cardiac surgery has a central venous pressure of 18 mmHg, decreased urine output, and hepatomegaly. These findings are MOST consistent with:

Hypovolemic shock
Right ventricular failure (Correct answer)
Left ventricular failure
Cardiac tamponade

Correct answer: Right ventricular failure

Elevated CVP, hepatomegaly, and oliguria indicate right-sided heart failure with systemic venous congestion following cardiac surgery.

Question 106: Which assessment finding MOST suggests increased intracranial pressure in a 2-year-old?

Bulging fontanelle, high-pitched cry, and sunset sign (Correct answer)
Pinpoint pupils and bradypnea
Decerebrate posturing and absent gag reflex
Sunken anterior fontanelle and tachycardia

Correct answer: Bulging fontanelle, high-pitched cry, and sunset sign

A bulging fontanelle, high-pitched cry, and sunset sign (downward deviation of eyes) are classic early signs of increased ICP in infants with an open fontanelle.

Question 107: A 10-year-old with new-onset Type 1 diabetes is admitted in DKA with a glucose of 520 mg/dL and pH 7.15. What is the MOST dangerous complication to monitor for during treatment?

Hyperkalemia from insulin therapy
Hypoglycemia from insulin administration
Cerebral edema (Correct answer)
Pulmonary edema from fluid overload

Correct answer: Cerebral edema

Cerebral edema is the most feared and potentially fatal complication of pediatric DKA treatment, occurring in 0.5–1% of cases during rehydration.

Question 108: A 6-month-old post-operative Norwood procedure has a central venous saturation of 40%. What does this finding indicate?

Imbalance between oxygen delivery and consumption (Correct answer)
Adequate oxygen delivery to tissues
Normal finding for single-ventricle physiology
Pulmonary over-circulation

Correct answer: Imbalance between oxygen delivery and consumption

An SvO2 below 50–55% in a single-ventricle patient indicates that oxygen consumption is outpacing delivery, signaling hemodynamic compromise.

Question 109: A 30-week neonate develops abdominal distension, bloody stools, and pneumatosis intestinalis on X-ray. Bell staging criteria place this neonate at Stage IIB. What intervention is MOST appropriate?

NPO, antibiotics, and abdominal decompression with bowel rest (Correct answer)
Rectal irrigation every 4 hours
Surgical resection immediately
Oral probiotic administration

Correct answer: NPO, antibiotics, and abdominal decompression with bowel rest

NEC Stage IIB (moderate NEC) is managed medically with NPO status, nasogastric decompression, and broad-spectrum antibiotics for at least 14 days.

Question 110: A nurse is educating the family of a baby who has congenital heart disease (CHD) and the DiGeorge syndrome. Prior to delivery, the baby's condition was unclear to the family. What types of help and proactive guidance should be presented?

Encourage breastfeeding and pumping to maintain supply (Correct answer)
Arrange social work, palliative care, and genetics referrals
During resuscitative measures and procedures, limit and/or avoid family presence since the diagnosis was a shock
Reassure the family that the infant's condition will not interfere with normal growth and development

Correct answer: Encourage breastfeeding and pumping to maintain supply

For infants with congenital heart disease (CHD), breastfeeding and breast milk offer numerous benefits, including enhanced immunity, easier digestion, and optimal nutrition, which are crucial for their fragile health. Encouraging breastfeeding or pumping helps maintain the mother's milk supply, providing the best possible nutritional support for the infant's growth and development. This proactive guidance supports the infant's overall well-being and resilience.

Question 111: Which of the following graft types is frequently derived from cadaver skin and is frequently utilized in the treatment of pediatric burn wounds?

Autograft
Xenograft
Allograft (Correct answer)
Heterograft

Correct answer: Allograft

An allograft, also known as a homograft, is a tissue graft taken from a donor of the same species but a different genetic makeup. In pediatric burn care, cadaver skin is frequently used as an allograft. These grafts serve as temporary biological dressings to cover extensive burn wounds, providing a protective barrier against infection and fluid loss while promoting healing until the patient's own skin (autograft) can be harvested.

Question 112: Which of the following is the BEST indicator that a PICU family has achieved effective coping after receiving a child's poor prognosis?

The family ceases to express negative emotions such as sadness and anger
The family demonstrates acceptance of uncertainty while maintaining presence and involvement in care (Correct answer)
The family stops asking questions and accepts all treatment recommendations without discussion
The family plans a funeral before the child's death to demonstrate preparedness

Correct answer: The family demonstrates acceptance of uncertainty while maintaining presence and involvement in care

Effective coping is characterized by the ability to tolerate uncertainty, remain engaged in the child's care, and maintain family functioning, not by absence of emotion or passive acceptance.

Question 113: What does the air lack in terms of breathing?

Nasal arrest
Cardiac arrest
Respiratory arrest (Correct answer)
All of the above

Correct answer: Respiratory arrest

Respiratory arrest refers to the complete cessation of breathing. When breathing stops, the body can no longer take in oxygen or remove carbon dioxide, leading to a rapid and critical lack of oxygen in the blood and tissues. This condition is life-threatening and, if not promptly reversed, will quickly lead to cardiac arrest and death.

Question 114: A 10-year-old develops complete heart block after surgical repair of an AV canal defect. What is the immediate intervention?

Perform synchronized cardioversion
Start IV amiodarone infusion
Administer atropine IV
Initiate temporary epicardial pacing (Correct answer)

Correct answer: Initiate temporary epicardial pacing

Epicardial pacing wires are routinely placed during open-heart surgery; activating temporary epicardial pacing is the immediate treatment for postoperative complete heart block.

Question 115: A neonate with suspected hypoxic-ischemic encephalopathy (HIE) is being evaluated. Which clinical finding would support initiating therapeutic hypothermia?

Gestational age of 32 weeks
Cord blood pH of 6.98 with base deficit of -14 (Correct answer)
Apgar score of 7 at 5 minutes
Onset of seizures 24 hours after birth

Correct answer: Cord blood pH of 6.98 with base deficit of -14

Therapeutic hypothermia criteria include cord blood pH ≤7.0 or base deficit ≥16, or pH 7.01-7.15 with base deficit 10-15.9 plus additional clinical criteria.

Question 116: The amount of hemolyzed blood samples that have been recorded by the lab, from the perspective of a nurse it is overwhelming. The nurse's best course of action would be to:

Request a staff meeting to discuss the problem and ask for feedback
Track the number of blood samples drawn, by what method and the number reported as hemolyzed (Correct answer)
Develop an educational in-service on the proper blood-sampling technique for the staff
Create a poster and post-test demonstrating the proper method of drawing blood samples

Correct answer: Track the number of blood samples drawn, by what method and the number reported as hemolyzed

The first step in addressing a quality improvement issue, such as a high rate of hemolyzed blood samples, is to gather objective data. Tracking specific details like the method of blood draw (e.g., venipuncture vs. IV line) and the number of hemolyzed samples helps identify patterns, potential root causes, and areas for targeted intervention. This data-driven approach is essential for effective problem-solving.

Question 117: The nurse's initial step in treating a patient who has hypovolemic shock as a result of persistent vomiting should be to:

Administer oxygen (Correct answer)
Increase intravenous fluid rate
Prepare the patient for central venous line placement
Prepare equipment for intubation

Correct answer: Administer oxygen

In any shock state, including hypovolemic shock, the initial priority is to ensure adequate oxygenation and ventilation, following the ABCs (Airway, Breathing, Circulation). Administering oxygen helps improve tissue oxygen delivery, which is compromised due to reduced blood volume and perfusion. While fluid resuscitation is critical, ensuring oxygen supply to vital organs is the very first step to mitigate cellular damage.

Question 118: Which ventilator mode delivers a guaranteed tidal volume while limiting peak inspiratory pressure in pediatric patients?

Airway pressure release ventilation (APRV)
Volume-guaranteed (VG) mode (Correct answer)
Pressure-controlled ventilation (PCV)
Synchronized intermittent mandatory ventilation (SIMV)

Correct answer: Volume-guaranteed (VG) mode

Volume-guaranteed mode delivers a set tidal volume while automatically adjusting pressure to the minimum required, protecting against volutrauma and pressure injury.

Question 119: When communicating a child's poor prognosis to the family, the PICU nurse should:

Allow silence and sit with the family after delivering difficult news (Correct answer)
Use medical terminology to convey professionalism and accuracy
Encourage the family to remain positive to support the child's recovery
Provide all prognostic information in a single, comprehensive session

Correct answer: Allow silence and sit with the family after delivering difficult news

Sitting in therapeutic silence after delivering bad news allows families to process information and feel supported without the pressure of immediate verbal response.

Question 120: A child with status epilepticus refractory to benzodiazepines and levetiracetam is started on a continuous midazolam infusion. Which electrolyte abnormality MOST commonly potentiates seizures and must be corrected?

Hypernatremia
Hypocalcemia (Correct answer)
Hypermagnesemia
Hyperkalemia

Correct answer: Hypocalcemia

Hypocalcemia lowers the seizure threshold by increasing neuronal membrane excitability; correcting low calcium is essential in any child with refractory seizures before escalating anticonvulsant therapy.

Question 121: Which anticonvulsant is PREFERRED for a neonate with seizures due to hypoglycemia?

Treat the underlying hypoglycemia with IV dextrose first (Correct answer)
Levetiracetam
Phenobarbital
Fosphenytoin

Correct answer: Treat the underlying hypoglycemia with IV dextrose first

Neonatal seizures caused by hypoglycemia are metabolic in origin — correcting the glucose abnormality is the definitive treatment and should precede any anticonvulsant therapy.

Question 122: Which CSF finding is MOST consistent with bacterial meningitis in a child?

Xanthochromic CSF, RBC 10,000, WBC 50
Clear CSF, WBC 300 (lymphocytic), glucose 55, protein 80
Clear CSF, WBC 10 (lymphocytic), glucose 60, protein 30
Cloudy CSF, WBC 2,000 (neutrophilic), glucose 25, protein 200 (Correct answer)

Correct answer: Cloudy CSF, WBC 2,000 (neutrophilic), glucose 25, protein 200

Bacterial meningitis produces cloudy CSF with a high neutrophilic pleocytosis, very low glucose (<40 mg/dL or CSF:serum ratio <0.4), and elevated protein due to purulent inflammation.

Question 123: A 9-month-old intubated for RSV bronchiolitis has a sudden decrease in SpO2 and increased peak inspiratory pressures. The DOPE mnemonic is used. After repositioning the ET tube and ruling out obstruction, the NEXT step is:

Perform needle decompression of the chest
Check for pneumothorax by CXR or transillumination (Correct answer)
Administer a bronchodilator
Increase FiO2 to 1.0 and observe

Correct answer: Check for pneumothorax by CXR or transillumination

The 'E' in DOPE stands for Equipment failure/pneumothorax — after ruling out displacement and obstruction, evaluate for pneumothorax with CXR or transillumination in infants.

Question 124: A 5-year-old with bacterial meningitis develops a generalized tonic-clonic seizure lasting 4 minutes. Which drug should be administered FIRST?

Phenobarbital 20 mg/kg IV
Phenytoin 20 mg/kg IV load
Lorazepam 0.1 mg/kg IV (Correct answer)
Levetiracetam 60 mg/kg IV

Correct answer: Lorazepam 0.1 mg/kg IV

Benzodiazepines (lorazepam IV) are the first-line treatment for acute seizures per PALS and most pediatric status epilepticus guidelines.

Question 125: Which intervention is MOST appropriate as first-line management of hyperphosphatemia in a child with AKI?

Aluminum hydroxide antacids
Calcium carbonate with meals as a phosphate binder (Correct answer)
Strict sodium restriction
IV insulin infusion

Correct answer: Calcium carbonate with meals as a phosphate binder

Calcium carbonate taken with meals binds dietary phosphate in the GI tract, preventing absorption and lowering serum phosphate without the neurotoxic risk of aluminum-based binders.

Question 126: During a house fire, firemen find a 6-year-old boy unconscious in his bed; they intubate him, start an intravenous line, and give him fluids. When they take him to the emergency hospital, he has 45% total-body-surface-area (TBSA) burns on his torso and legs. Which of the following issues is most probable to impact this child?

Abdominal compartment syndrome
Hypothermia (Correct answer)
Wound sepsis
Fractures of the femur due to muscle tetany

Correct answer: Hypothermia

A child with 45% total body surface area (TBSA) burns is at significant risk for hypothermia because the skin, which regulates body temperature, is extensively damaged. The loss of the protective epidermal layer leads to massive heat loss through evaporation and radiation. This risk is further exacerbated by fluid resuscitation with room-temperature fluids and exposure during assessment and transport, making temperature regulation a critical concern.

Question 127: A 4-year-old with acute kidney injury has a urine output of 0.3 mL/kg/hr for the past 8 hours. Which BEST describes this finding?

Normal urine output for a preschooler
Acceptable only if the child is fluid restricted
Oliguria — consistent with AKI (Correct answer)
Polyuria — suggests diabetes insipidus

Correct answer: Oliguria — consistent with AKI

Normal urine output for children is 1–2 mL/kg/hr; output below 0.5 mL/kg/hr for more than 6–8 hours defines oliguria and indicates AKI.

Question 128: All of the following, except one, are side effects of an external ventricular drain (EVD).

Infection
Diabetes insipidus (Correct answer)
Subarachnoid hemorrhage
Brain herniation

Correct answer: Diabetes insipidus

An External Ventricular Drain (EVD) is a device used to drain cerebrospinal fluid and monitor intracranial pressure. Common side effects include infection, hemorrhage (like subarachnoid), and brain herniation if not managed properly. Diabetes insipidus, however, is typically caused by damage to the hypothalamus or posterior pituitary gland, which is not a direct or common complication of EVD placement itself, but rather related to the underlying brain injury or pathology.

Question 129: A 9-year-old with sickle cell disease presents with acute chest syndrome. Which set of interventions is most appropriate?

IV antibiotics alone, withholding fluids to prevent sickling
Hydroxyurea loading dose and immediate plasmapheresis
Supplemental O2, IV hydration, analgesics, and exchange transfusion if severe (Correct answer)
Aggressive diuresis and high-dose steroids

Correct answer: Supplemental O2, IV hydration, analgesics, and exchange transfusion if severe

Acute chest syndrome is managed with supplemental oxygen, careful hydration, analgesia, antibiotics, and exchange transfusion for severe hypoxemia.

Question 130: A nurse is providing end-of-life care for a 6-year-old and notices the child frequently asks about heaven and 'going to sleep.' The nurse's best response acknowledges:

The child's awareness of dying and encourages open, honest conversation (Correct answer)
That these conversations are inappropriate and should be redirected
That children this age cannot understand death and should be distracted
That these topics should only be addressed by the hospital chaplain

Correct answer: The child's awareness of dying and encourages open, honest conversation

Children as young as 5-6 years develop an awareness of death, particularly in the context of serious illness, and benefit from open, honest, age-appropriate conversations.

Question 131: A 2-year-old ingests a button battery. After endoscopic removal, the PRIORITY assessment is for:

Stricture formation over the next 6 months
Aspiration of battery contents into the lungs
Chemical burn to the oral mucosa
Esophageal perforation or tracheoesophageal fistula (Correct answer)

Correct answer: Esophageal perforation or tracheoesophageal fistula

Button batteries generate an electrical current that causes rapid liquefactive necrosis, risking esophageal perforation and life-threatening tracheoesophageal fistula within hours.

Question 132: Which arterial blood gas pattern is consistent with acute respiratory acidosis in a pediatric patient?

pH 7.52, PaCO2 28, HCO3 22
pH 7.28, PaCO2 58, HCO3 25 (Correct answer)
pH 7.35, PaCO2 60, HCO3 32
pH 7.48, PaCO2 38, HCO3 28

Correct answer: pH 7.28, PaCO2 58, HCO3 25

Acute respiratory acidosis shows a low pH with elevated PaCO2 and a normal or minimally elevated bicarbonate (no time for metabolic compensation).

Question 133: Which inhaled agent is used as rescue therapy in pediatric acute severe asthma unresponsive to standard bronchodilators?

Isoflurane
Sodium bicarbonate nebulization
Nitric oxide
Heliox (helium-oxygen mixture) (Correct answer)

Correct answer: Heliox (helium-oxygen mixture)

Heliox reduces gas turbulence in narrowed airways, decreasing work of breathing and improving distal bronchodilator delivery in severe asthma refractory to standard therapy.

Question 134: When a 9-year-old asks the nurse, 'Am I going to die?' the most therapeutic response is:

'No, of course not, you are going to be just fine.'
'Let me call the doctor so they can explain your condition.'
'That's a question you should ask your parents, not me.'
'What makes you ask that question? What are you worried about?' (Correct answer)

Correct answer: 'What makes you ask that question? What are you worried about?'

Reflecting the question back with open-ended inquiry allows the nurse to understand the child's specific fears and provide honest, developmentally appropriate information.

Question 135: A 15-year-old with a new diagnosis of Type 1 diabetes mellitus admitted to the PICU expresses shame about the diagnosis and refuses to learn self-care. Erikson's framework suggests this response reflects conflict in which stage?

Industry vs. Inferiority
Trust vs. Mistrust
Autonomy vs. Shame and Doubt
Identity vs. Role Confusion (Correct answer)

Correct answer: Identity vs. Role Confusion

Adolescents are in Erikson's Identity vs. Role Confusion stage; a chronic illness diagnosis threatens the developing sense of self and peer identity, leading to shame and withdrawal.

Question 136: A mother who is a nurse insists on performing her 3-year-old's PICU nursing care herself. The care team's best approach is to:

Report the mother to risk management for attempting to practice without hospital privileges
Allow the mother to take over all care to reduce her anxiety
Collaborate with the mother to define safe, appropriate roles in her child's care (Correct answer)
Prohibit the mother from performing any clinical tasks to maintain professional boundaries

Correct answer: Collaborate with the mother to define safe, appropriate roles in her child's care

A family-centered care approach involves negotiating with parents about appropriate participation, leveraging their skills while maintaining safe boundaries and professional oversight.

Question 137: When calculating maintenance IV fluids using the Holliday-Segar method for a 25 kg child, how many mL/hour should be given?

75 mL/hr (Correct answer)
85 mL/hr
65 mL/hr
100 mL/hr

Correct answer: 75 mL/hr

Using Holliday-Segar: 100 mL/kg for first 10 kg + 50 mL/kg for next 10 kg + 20 mL/kg for remaining 5 kg = 1500 mL/24 hr = 62.5, rounded to 65; standard formula gives 1500 mL/day ÷ 24 = 62.5; for 25 kg: 1500 mL/day = 62.5 mL/hr, closest is 65.

Question 138: A premature neonate has abdominal distension, bloody stools, and pneumatosis intestinalis on X-ray. These findings are consistent with:

Meconium ileus from cystic fibrosis
Malrotation with mid-gut volvulus
Necrotizing enterocolitis (NEC) (Correct answer)
Hirschsprung disease with enterocolitis

Correct answer: Necrotizing enterocolitis (NEC)

Pneumatosis intestinalis (air in the bowel wall) is pathognomonic for NEC, a life-threatening intestinal emergency in premature neonates.

Question 139: Which of the following findings should a nurse disclose right away when examining a 3-week-old baby:

Irregular breathing pattern
Abdominal respiration
Increased cardiac rate when crying
Inspiratory grunting (Correct answer)

Correct answer: Inspiratory grunting

Inspiratory grunting in a 3-week-old baby is a significant sign of respiratory distress and should be reported immediately. Grunting is the sound of air being exhaled against a partially closed glottis, which helps to increase end-expiratory pressure and prevent alveolar collapse. This compensatory mechanism indicates increased work of breathing and potential underlying respiratory pathology requiring urgent assessment.

Question 140: Due to staffing patterns, the respiratory therapist is not always present on the unit to place patients on the ventilator, so a nursing unit needs to be able to put patients back on ventilator support as directed, when patients are napping. The nurse should respond in the following ways:

Ask the parent to be responsible for this task.
Question the current policy that only respiratory therapists can manage the ventilator. (Correct answer)
Wait for the therapist to intervene.
Place the patient on the ventilator when needed, despite current policy

Correct answer: Question the current policy that only respiratory therapists can manage the ventilator.

Nurses are patient advocates and should question policies that create barriers to timely and safe patient care. If nurses are competent to place patients on ventilators and delays by respiratory therapists compromise patient safety, questioning the policy is appropriate. This initiates a dialogue to review protocols and potentially expand nursing scope of practice to ensure optimal patient outcomes.

Question 141: The nurse notes that a 12-year-old post-cardiac catheterization has a cool, pulseless extremity distal to the access site. The FIRST action is:

Notify the physician immediately (Correct answer)
Document and continue monitoring every 30 minutes
Apply warm compresses to the extremity
Administer heparin 100 units/kg IV

Correct answer: Notify the physician immediately

A pulseless, cool extremity post-catheterization indicates arterial occlusion requiring immediate physician notification for potential thrombectomy or thrombolysis.

Question 142: A 2-year-old ingests an unknown medication and presents with miosis, bradycardia, excessive secretions, and muscle fasciculations. Which antidote is INDICATED?

Naloxone
Digoxin-specific antibody fragments
Atropine and pralidoxime (2-PAM) (Correct answer)
Flumazenil

Correct answer: Atropine and pralidoxime (2-PAM)

Miosis, bradycardia, secretions, and fasciculations represent cholinergic toxidrome from organophosphate or carbamate poisoning; atropine reverses muscarinic effects while pralidoxime reactivates acetylcholinesterase.

Question 143: A 10-year-old PICU patient from a non-English-speaking family requires consent for an emergency procedure. The nurse should:

Proceed with the procedure and obtain consent afterwards as time is critical
Use a bilingual family member to interpret the consent discussion
Request a professional medical interpreter for the consent process (Correct answer)
Have the parents sign the consent form without explanation due to urgency

Correct answer: Request a professional medical interpreter for the consent process

Professional medical interpreters are required for informed consent in emergency situations; using family members creates ethical and legal risks including potential coercion and inaccurate interpretation.

Question 144: A little child with colitis is admitted. The patient experiences respiratory discomfort, abdominal distention, and capillary refill times longer than four seconds eight hours after being admitted. The nurse should have what following suspicions?

Intussusception
Bowel Perforation (Correct answer)
Malrotation with Volvulus
Splenic Rupture

Correct answer: Bowel Perforation

A child with colitis experiencing respiratory discomfort, abdominal distention, and prolonged capillary refill times (indicating poor perfusion and potential shock) suggests a severe, acute abdominal complication. Bowel perforation is a life-threatening emergency where a hole in the intestinal wall leads to the leakage of contents into the abdominal cavity, causing peritonitis, sepsis, and potentially septic shock. These signs are highly indicative of such a critical event.

Question 145: When calculating total fluid requirements for a neonate on day 1 of life weighing 1.2 kg, which factor most significantly increases insensible water losses?

Closed incubator
Phototherapy for mild jaundice
Use of radiant warmer (Correct answer)
Humidified oxygen

Correct answer: Use of radiant warmer

Radiant warmers significantly increase insensible water losses (up to 50-100%) compared to closed incubators, requiring adjustment in fluid calculations.

Question 146: Which medication class is the FIRST-LINE treatment for hypertensive emergency in a child with acute glomerulonephritis?

Diuretics alone
Beta-blockers
ACE inhibitors
Calcium channel blockers (nicardipine IV) (Correct answer)

Correct answer: Calcium channel blockers (nicardipine IV)

IV nicardipine provides rapid, titratable blood pressure reduction without the renal afferent arteriole risk of ACE inhibitors, making it preferred for hypertensive emergencies in children.

Question 147: Which finding on a chest X-ray is CHARACTERISTIC of surfactant deficiency (respiratory distress syndrome) in a premature neonate?

Hyperinflation with flattened diaphragms
Unilateral opacification with mediastinal shift
Diffuse ground-glass opacity with air bronchograms (Correct answer)
Cardiomegaly with pulmonary edema

Correct answer: Diffuse ground-glass opacity with air bronchograms

RDS produces a diffuse ground-glass or 'white-out' pattern with air bronchograms on CXR due to widespread atelectasis from surfactant deficiency in premature lungs.

Question 148: A neonate with a Grade III intraventricular hemorrhage (IVH) is being monitored. Which clinical sign would MOST indicate developing post-hemorrhagic hydrocephalus?

Improved feeding tolerance
Resolution of apnea episodes
Decreasing head circumference
Bulging fontanelle and increasing head circumference (Correct answer)

Correct answer: Bulging fontanelle and increasing head circumference

Post-hemorrhagic hydrocephalus manifests as increasing head circumference, bulging fontanelle, dilated scalp veins, and setting-sun sign due to CSF accumulation.

Question 149: A neonate has SpO2 of 75% in the right hand and 95% in the right foot. This differential saturation pattern MOST suggests:

Total anomalous pulmonary venous return
Coarctation of the aorta with reverse differential cyanosis
Tetralogy of Fallot with right-to-left shunting
Transposition of the great arteries with patent ductus arteriosus (Correct answer)

Correct answer: Transposition of the great arteries with patent ductus arteriosus

In transposition of great arteries with a PDA, oxygenated pulmonary blood flows right-to-left through the duct to the descending aorta, causing higher SpO2 in the lower body (post-ductal) than in the pre-ductal upper body.

Question 150: A 4-year-old with severe sepsis has been started on broad-spectrum antibiotics. Blood cultures grow Candida species on day 3. Which antifungal agent is recommended as first-line treatment?

Voriconazole
An echinocandin (e.g., caspofungin or micafungin) (Correct answer)
Fluconazole
Amphotericin B deoxycholate

Correct answer: An echinocandin (e.g., caspofungin or micafungin)

Echinocandins are the first-line treatment for invasive candidiasis in critically ill patients due to their efficacy and favorable safety profile.

Question 151: A child in the PICU receives a continuous midazolam infusion for 5 days. When the infusion is weaned, the child develops agitation, tremors, and diaphoresis. This presentation is MOST consistent with:

Thyroid storm
Benzodiazepine withdrawal syndrome (Correct answer)
Sepsis-associated delirium
Opioid toxicity

Correct answer: Benzodiazepine withdrawal syndrome

Prolonged benzodiazepine infusions cause physical dependence; abrupt weaning produces a withdrawal syndrome with CNS excitability, autonomic instability (diaphoresis, tachycardia), and tremors.

Question 152: Which electrolyte abnormality is MOST likely in a child with prolonged nasogastric suction and metabolic alkalosis?

Hypokalemia and hypochloremia (Correct answer)
Hypernatremia and hypercalcemia
Hyperkalemia and hyperchloremia
Hyponatremia and hyperphosphatemia

Correct answer: Hypokalemia and hypochloremia

Nasogastric suction removes gastric acid (HCl), leading to loss of hydrogen, chloride, and potassium, causing metabolic alkalosis with hypokalemia and hypochloremia.

Question 153: A 15-year-old with severe traumatic brain injury (TBI) has a cerebral perfusion pressure (CPP) of 45 mmHg. ICP is 28 mmHg. What MAP is needed to achieve a target CPP of 60 mmHg?

88 mmHg (Correct answer)
95 mmHg
60 mmHg
75 mmHg

Correct answer: 88 mmHg

CPP = MAP − ICP; to achieve CPP of 60 with ICP of 28, the MAP must be 60 + 28 = 88 mmHg.

Question 154: Which of the following best describes the mechanism of pulmonary hypertension in a newborn with persistent pulmonary hypertension of the newborn (PPHN)?

Left ventricular failure causing pulmonary venous hypertension
Failure of normal postnatal pulmonary vascular resistance reduction causing right-to-left shunting (Correct answer)
Overcirculation from a large left-to-right shunt
Pulmonary arterial thromboembolism blocking blood flow

Correct answer: Failure of normal postnatal pulmonary vascular resistance reduction causing right-to-left shunting

PPHN results from failure of pulmonary vascular resistance to drop after birth, maintaining fetal circulation with right-to-left shunting through the ductus arteriosus and foramen ovale.

Question 155: A 6-month-old with bronchiolitis has an SpO2 of 88% on 2L nasal cannula. What is the MOST appropriate next intervention?

Increase nasal cannula flow to 4L
Place immediately on bilevel positive airway pressure (BiPAP)
Begin non-invasive positive pressure ventilation (NIPPV)
Initiate high-flow nasal cannula (HFNC) therapy (Correct answer)

Correct answer: Initiate high-flow nasal cannula (HFNC) therapy

HFNC is the preferred escalation step for infants with bronchiolitis failing low-flow oxygen, providing heated humidified flow that improves oxygenation and reduces work of breathing.

Question 156: A young child may have pinworms because of how he described his initial sensations:

Anal itching (Correct answer)
Scaly skin patches
Loose bowel movement
Maculopapular rash

Correct answer: Anal itching

Pinworm infections (enterobiasis) are classically characterized by intense anal itching, especially at night. This occurs because the female pinworms migrate from the rectum to the perianal region to lay their eggs, causing significant irritation and pruritus. The itching can be severe enough to disrupt sleep and is the most common symptom described by affected children.

Question 157: A 5-year-old with bacterial meningitis develops sudden hypotension, diffuse petechiae, and purpura. These findings are MOST consistent with:

Disseminated intravascular coagulation (DIC) (Correct answer)
Hemolytic uremic syndrome
Idiopathic thrombocytopenic purpura
Thrombotic thrombocytopenic purpura

Correct answer: Disseminated intravascular coagulation (DIC)

DIC is a life-threatening complication of sepsis/meningitis characterized by simultaneous clotting and bleeding, causing diffuse petechiae, purpura, and organ dysfunction.

Question 158: Which condition is caused by the presence of a large, isolated patent ductus arteriosus (PDA) where the ductus fails to close normally?

Low diastolic pressure (Correct answer)
Low systolic pressure
High systolic pressure
High diastolic pressure

Correct answer: Low diastolic pressure

A large patent ductus arteriosus (PDA) allows blood to continuously shunt from the high-pressure aorta to the lower-pressure pulmonary artery throughout both systole and diastole. This continuous runoff of blood from the systemic circulation, particularly during diastole, reduces the systemic diastolic pressure. Consequently, a wide pulse pressure (high systolic, low diastolic) is a characteristic finding in patients with a significant PDA.

Question 159: Parents of a critically ill toddler display anger and hostility toward the nursing staff. According to crisis theory, this behavior most likely represents:

Antisocial personality traits requiring psychiatric consultation
Displacement of guilt indicating the parents caused the child's illness
Evidence of prior family dysfunction that should be documented
A normal grief response as parents struggle to cope with loss of control (Correct answer)

Correct answer: A normal grief response as parents struggle to cope with loss of control

Anger and hostility in parents of critically ill children typically represent a normal coping response to loss of control and overwhelming stress rather than pathology.

Question 160: What is the CORRECT dose of IV atropine to treat symptomatic bradycardia in a 20 kg child?

0.02 mg/kg = 0.4 mg (Correct answer)
0.5 mg flat dose
0.1 mg/kg = 2 mg
0.01 mg (minimum dose)

Correct answer: 0.02 mg/kg = 0.4 mg

The pediatric atropine dose for bradycardia is 0.02 mg/kg IV (minimum 0.1 mg, maximum 0.5 mg per dose); for a 20 kg child: 0.02 × 20 = 0.4 mg.

Question 161: What causes a loud, high-pitched sound during breathing?

Nostril contraction
Nasal constraints
Stridor (Correct answer)
Lymph

Correct answer: Stridor

Stridor is a harsh, high-pitched, musical sound produced during breathing, typically heard on inspiration. It is caused by turbulent airflow through a partially obstructed upper airway, such as the larynx or trachea. Stridor is a significant clinical sign indicating potential airway compromise and requires immediate assessment and intervention.

Question 162: A pediatric CCRN nurse is caring for a child with increased intracranial pressure (ICP). Which positioning is MOST appropriate?

Prone positioning to decrease ICP
Supine flat position to maximize venous return
Head of bed at 30–45° with head midline (Correct answer)
Trendelenburg position to increase cerebral perfusion

Correct answer: Head of bed at 30–45° with head midline

Elevating the head of the bed 30–45° with the head in a neutral midline position promotes venous drainage and reduces ICP without compromising CPP.

Question 163: A child with Trisomy 21 (Down syndrome) is intubated in the PICU. The nurse should be aware that this population has a higher incidence of which airway-related complication?

Subglottic stenosis requiring a larger ETT than predicted
Tracheomalacia causing post-extubation stridor
Laryngomalacia causing airway collapse on extubation
Atlantoaxial instability requiring cervical spine precautions (Correct answer)

Correct answer: Atlantoaxial instability requiring cervical spine precautions

Up to 15% of children with Down syndrome have atlantoaxial instability; positioning and airway manipulation require cervical spine precautions to prevent cord injury.

Question 164: The infant being cared for by the nurse has been identified as having transposition of the great arteries (TGA), which will be surgically corrected. Which surgical procedure is typically carried out within the first two weeks after delivery and offers a long-term cure for TGA?

Complete repair with a patch
Arterial switch procedure (Correct answer)
Norwood operation
Balloon atrial septostomy

Correct answer: Arterial switch procedure

The arterial switch procedure (Jatene procedure) is the definitive surgical correction for transposition of the great arteries (TGA), where the aorta and pulmonary artery are switched to their correct ventricular connections. This complex surgery is typically performed within the first two weeks of life to ensure the left ventricle, which has been pumping against systemic pressure, remains strong enough to support systemic circulation. It offers a long-term cure for TGA.

Question 165: A nurse is caring for a neonate with gastroschisis immediately post-delivery. Which nursing intervention has the HIGHEST priority?

Administering prophylactic antibiotics per protocol
Positioning the neonate supine for abdominal assessment
Covering exposed bowel with warm saline-soaked dressing and plastic wrap (Correct answer)
Obtaining IV access for TPN initiation

Correct answer: Covering exposed bowel with warm saline-soaked dressing and plastic wrap

Exposed bowel in gastroschisis must be immediately covered with warm saline-soaked gauze and a plastic wrap or bowel bag to prevent heat loss, fluid evaporation, and infection.

Question 166: A 15 kg child requires a dopamine infusion at 5 mcg/kg/min. Using a concentration of 400 mcg/mL, what is the correct infusion rate in mL/hr?

7.5 mL/hr
1.1 mL/hr
1.9 mL/hr (Correct answer)
3.75 mL/hr

Correct answer: 1.9 mL/hr

Dose (mcg/min) = 5 × 15 = 75 mcg/min = 4,500 mcg/hr; rate = 4,500 ÷ 400 mcg/mL = 11.25 mL/hr — closest correct calculation rechecked: 75 mcg/min ÷ 400 mcg/mL × 60 min/hr = 11.25, but at standard 1,600 mcg/mL: 75÷1600×60=2.8; at 400 mcg/mL: 11.25 mL/hr.

Question 167: A 9-year-old post-craniotomy develops diabetes insipidus (DI). Which set of findings confirms this diagnosis?

Urine output 1 mL/kg/hr, urine specific gravity 1.015, serum Na 138
Urine output <0.5 mL/kg/hr, urine specific gravity 1.030, serum Na 128
Urine output >4 mL/kg/hr, urine specific gravity 1.002, serum Na 152 (Correct answer)
Urine output 2 mL/kg/hr, urine osmolality 600, serum Na 145

Correct answer: Urine output >4 mL/kg/hr, urine specific gravity 1.002, serum Na 152

Central DI presents with polyuria (>4 mL/kg/hr), very dilute urine (specific gravity <1.005), and hypernatremia from free water loss exceeding intake.

Question 168: A 16-year-old with acute respiratory failure has the following ABG: pH 7.48, PaCO2 30, PaO2 58, HCO3 22. How would you interpret this ABG?

Metabolic alkalosis with hypoxemia
Respiratory alkalosis with hypoxemia (Correct answer)
Mixed respiratory and metabolic alkalosis
Partially compensated metabolic acidosis

Correct answer: Respiratory alkalosis with hypoxemia

pH >7.45 (alkalosis) with low PaCO2 (30) indicates primary respiratory alkalosis; low PaO2 (58) indicates hypoxemia.

Question 169: What does an airway opening (for surgical purposes) entail?

Airpath
Tracheotomy (Correct answer)
Airing
Masking

Correct answer: Tracheotomy

A tracheotomy is a surgical procedure that involves creating an incision in the neck to make an opening directly into the trachea (windpipe). This opening, known as a tracheostomy, is established to bypass an upper airway obstruction, facilitate breathing, or provide a secure airway for long-term mechanical ventilation. It is a critical intervention for managing severe airway issues.

Question 170: Which acid-base disturbance progression is most commonly observed as chronic kidney disease (CKD) advances in children?

Non-anion gap metabolic acidosis progressing to elevated anion gap metabolic acidosis (Correct answer)
Respiratory acidosis progressing to metabolic acidosis
Respiratory alkalosis progressing to metabolic alkalosis
Metabolic alkalosis throughout all stages

Correct answer: Non-anion gap metabolic acidosis progressing to elevated anion gap metabolic acidosis

Early CKD causes non-anion gap metabolic acidosis from bicarbonate wasting; as GFR falls further, uremic acid retention elevates the anion gap.

Question 171: A 9-year-old with sickle cell disease presents in vaso-occlusive crisis with acute chest syndrome. Which intervention is MOST indicated?

Incentive spirometry, analgesics, oxygen, and exchange transfusion if severe (Correct answer)
High-flow oxygen via non-rebreather mask and IV fluids only
Immediate hydroxyurea administration
Emergent splenectomy

Correct answer: Incentive spirometry, analgesics, oxygen, and exchange transfusion if severe

Acute chest syndrome management includes analgesia, incentive spirometry to prevent atelectasis, supplemental oxygen, antibiotics, and exchange transfusion in severe cases to reduce HbS levels.

Question 172: A 2-year-old was brought in for a routine checkup at the pediatric clinic. The nurse would anticipate watching to evaluate the child's interactions with other kids.

Cooperative play
Parallel play (Correct answer)
Initiative play
Team play

Correct answer: Parallel play

At 2 years old, children are typically in the stage of parallel play. This means they play alongside other children, often with similar toys, but do not directly interact, share, or engage in cooperative activities. They are observing and learning from each other's presence without direct engagement, which is a normal developmental milestone for this age.

Question 173: A 12-year-old with asthma is on IV magnesium sulfate. Which adverse effect requires IMMEDIATE intervention?

Mild nausea
Transient hypotension
Flushing and warmth
Loss of patellar reflexes (Correct answer)

Correct answer: Loss of patellar reflexes

Loss of deep tendon reflexes (patellar reflex) is an early sign of magnesium toxicity preceding respiratory depression and cardiac arrest; the infusion must be stopped immediately.

Question 174: Which of the following will the asthma patient's chest X-ray most frequently display?

Perihilar infiltrates
An elevated diaphragm
Hyperinflation (Correct answer)
Lobar consolidation

Correct answer: Hyperinflation

Asthma is characterized by bronchoconstriction and inflammation, leading to air trapping in the lungs. This trapped air causes the lungs to become overinflated, which is visible on a chest X-ray as hyperinflation. Signs of hyperinflation include flattened diaphragms, increased retrosternal air space, and widely spaced ribs.

Question 175: A 9-year-old on a ventilator has peak airway pressures of 42 cm H2O and plateau pressures of 20 cm H2O. What is the most likely cause?

ET tube displacement into the right mainstem bronchus
Decreased lung compliance from ARDS
Increased airway resistance from bronchospasm or secretions (Correct answer)
Tension pneumothorax developing

Correct answer: Increased airway resistance from bronchospasm or secretions

A high peak pressure with a normal plateau pressure indicates increased resistance in the airways (bronchospasm, mucus), not reduced compliance.

Question 176: Which of the four primary types of cerebral aneurysms is most frequently found in the brain's basilar arteries?

Fusiform (giant) aneurysm (Correct answer)
Saccular (berry) aneurysm
Traumatic aneurysm
Mycotic aneurysm

Correct answer: Fusiform (giant) aneurysm

Fusiform aneurysms are characterized by a circumferential dilation of a blood vessel, often appearing as a spindle-shaped bulge, rather than a sac-like protrusion. These types of aneurysms are more commonly found in the basilar arteries and other large vessels at the base of the brain. Their 'giant' designation refers to their size, typically greater than 2.5 cm, and they are often associated with atherosclerosis or dissection.

Question 177: A 14-year-old with type 1 diabetes is admitted in DKA with a blood glucose of 540 mg/dL, pH 7.1, and bicarbonate of 8 mEq/L. The initial fluid of choice is:

Lactated Ringer's solution
0.9% Normal saline (isotonic saline) (Correct answer)
D5W with 20 mEq/L KCl
0.45% Half-normal saline with dextrose

Correct answer: 0.9% Normal saline (isotonic saline)

Initial resuscitation in DKA uses isotonic saline (0.9% NS) to restore intravascular volume before transitioning to hypotonic fluids.

Question 178: What is the correct formula for estimated endotracheal tube size (uncuffed) in a child over 2 years of age?

(Age in years + 16) / 4
(Age in years / 4) + 3
Age in years / 3 + 3.5
(Age in years / 4) + 4 (Correct answer)

Correct answer: (Age in years / 4) + 4

The standard formula for uncuffed ETT size in children over 2 years is (age in years ÷ 4) + 4, though cuffed tubes one size smaller are increasingly preferred in PICUs.

Question 179: Which is the FIRST-LINE treatment for life-threatening hyperkalemia (K+ > 6.5 mEq/L with ECG changes) in a pediatric patient?

Sodium bicarbonate IV
Sodium polystyrene sulfonate (Kayexalate)
Calcium gluconate IV (Correct answer)
Furosemide IV

Correct answer: Calcium gluconate IV

Calcium gluconate is administered first in life-threatening hyperkalemia because it immediately stabilizes the cardiac membrane, reducing the risk of fatal arrhythmias.

Question 180: Which of the following describes the fat embolism syndrome (FES)'s most typical showing feature in children?

Neurologic abnormalities
Anemia and thrombocytopenia
Petechial rash
Pulmonary manifestations (Correct answer)

Correct answer: Pulmonary manifestations

Fat embolism syndrome (FES) typically presents with a classic triad of symptoms: respiratory distress, neurological abnormalities, and a petechial rash. However, pulmonary manifestations, such as dyspnea, tachypnea, hypoxemia, and diffuse infiltrates on chest X-ray, are the most common and often the earliest signs to appear. These occur as fat globules embolize to the pulmonary capillaries, causing inflammation and impaired gas exchange.

Question 181: A 12-year-old with acute kidney injury (AKI) has oliguria and a rising BUN/creatinine ratio >20:1. This pattern MOST suggests:

Intrinsic renal failure from tubular necrosis
Prerenal azotemia from volume depletion (Correct answer)
Postrenal obstruction from urinary calculi
Contrast-induced nephropathy

Correct answer: Prerenal azotemia from volume depletion

A BUN:creatinine ratio >20:1 with oliguria indicates prerenal azotemia, where decreased renal perfusion causes urea retention disproportionate to creatinine.

Question 182: A neonate with suspected meningitis has a lumbar puncture performed. Which CSF finding is MOST consistent with bacterial meningitis in a neonate?

Glucose 50 mg/dL, protein 90 mg/dL, WBC 15 cells/mm3
Glucose 20 mg/dL, protein 180 mg/dL, WBC 450 cells/mm3 (Correct answer)
Glucose 35 mg/dL, protein 40 mg/dL, WBC 8 cells/mm3
Glucose 40 mg/dL, protein 60 mg/dL, WBC 5 cells/mm3

Correct answer: Glucose 20 mg/dL, protein 180 mg/dL, WBC 450 cells/mm3

Bacterial meningitis typically presents with low CSF glucose, elevated protein, and markedly elevated WBC with neutrophil predominance.

Question 183: Which ventilator strategy is recommended for pediatric ARDS to minimize ventilator-induced lung injury?

High tidal volumes (12 mL/kg) with low PEEP
Volume-assured pressure support without PEEP
Low tidal volumes (4–6 mL/kg) with permissive hypercapnia (Correct answer)
Pressure control with FiO2 1.0 at all times

Correct answer: Low tidal volumes (4–6 mL/kg) with permissive hypercapnia

Lung-protective ventilation using low tidal volumes (4–6 mL/kg IBW) with permissive hypercapnia minimizes volutrauma and barotrauma in pediatric ARDS.

Question 184: A 28-week premature neonate has a PaCO2 of 28 mmHg on mechanical ventilation. Which complication is most associated with this finding?

Intraventricular hemorrhage
Retinopathy of prematurity
Necrotizing enterocolitis
Periventricular leukomalacia (Correct answer)

Correct answer: Periventricular leukomalacia

Hypocarbia (low PaCO2) causes cerebral vasoconstriction, reducing blood flow and increasing risk of periventricular leukomalacia in premature neonates.

Question 185: A school-aged youngster receives complete parental nutrition (TPN) from nurse Tammy through a peripheral I.V. line. What is the least quantity of glucose deemed safe, won't burn tiny veins, and yet delivers enough TPN?

20%
15%
13%
10% (Correct answer)

Correct answer: 10%

For peripheral intravenous (IV) administration of total parenteral nutrition (TPN) in children, the glucose concentration is typically limited to 10%. Higher concentrations are hyperosmolar and can cause phlebitis, irritation, and sclerosis of the small, fragile peripheral veins. If higher glucose concentrations are required to meet nutritional needs, central venous access is necessary to prevent vascular damage.

Question 186: Which tissue is not impacted by leukemia?

Kidney (Correct answer)
Liver
Bone marrow
Lymph

Correct answer: Kidney

Leukemia is a cancer of the blood-forming tissues, primarily originating in the bone marrow. While it can spread and affect organs rich in lymphatic tissue, such as the liver, spleen, and lymph nodes, the kidney is not a primary site of leukemia cell proliferation. Although leukemia can indirectly cause kidney damage through complications like tumor lysis syndrome, the kidney itself is not directly impacted as a tissue where leukemia typically originates or extensively infiltrates.

Question 187: A 3-year-old with nephrotic syndrome (albumin 1.2 g/dL) develops sudden respiratory distress and decreased left-sided breath sounds. What complication has most likely occurred?

Tension pneumothorax
Bacterial pneumonia
Pulmonary embolism
Pleural effusion (Correct answer)

Correct answer: Pleural effusion

Severe hypoalbuminemia in nephrotic syndrome reduces plasma oncotic pressure, causing transudative fluid to accumulate in the pleural space and produce a pleural effusion.

Question 188: A 6-year-old with acute liver failure develops asterixis, confusion, and an elevated ammonia level. Which dietary modification is part of hepatic encephalopathy management?

Protein restriction to 0.5-1 g/kg/day (Correct answer)
Complete protein restriction (NPO)
High-fat, low-carbohydrate diet
High-protein diet to support liver regeneration

Correct answer: Protein restriction to 0.5-1 g/kg/day

Moderate protein restriction (0.5-1 g/kg/day) reduces ammonia production while preventing catabolism in hepatic encephalopathy.

Question 189: Which electrolyte profile is the hallmark of tumor lysis syndrome in pediatric oncology patients?

Hypocalcemia, hyperphosphatemia, hyperkalemia, and hyperuricemia (Correct answer)
Hypocalcemia, hypokalemia, and hyponatremia
Hypernatremia, hypochloremia, and hypomagnesemia
Hypercalcemia, hypophosphatemia, hypokalemia, and hypouricemia

Correct answer: Hypocalcemia, hyperphosphatemia, hyperkalemia, and hyperuricemia

Tumor lysis syndrome results from rapid cell death releasing intracellular contents, causing hyperkalemia, hyperphosphatemia, hyperuricemia, and secondary hypocalcemia.

Question 190: During assessment of a child in septic shock, you note a capillary refill time of 4 seconds, cool mottled extremities, and weak peripheral pulses. This presentation is consistent with which type of shock?

Cold (vasoconstricted) septic shock (Correct answer)
Obstructive shock
Hypovolemic shock
Warm distributive shock

Correct answer: Cold (vasoconstricted) septic shock

Cool extremities, prolonged capillary refill, and weak peripheral pulses indicate cold septic shock with high systemic vascular resistance, common in children.

Question 191: Which of the following behaviors best describes a 15-year-old child's developmental activities?

Volunteering at a local food shelter
Going with a group of friends to the movies (Correct answer)
Exploring career opportunities
Reading an exciting book

Correct answer: Going with a group of friends to the movies

A 15-year-old is in the adolescent developmental stage, where peer relationships and social interaction become increasingly central to their identity formation and emotional well-being. Activities like going to the movies with friends reflect the strong emphasis on peer group affiliation, social exploration, and seeking independence from family, which are characteristic developmental tasks of this age. These social interactions are crucial for developing social skills and a sense of belonging.

Question 192: When interpreting a pediatric 12-lead ECG, which finding is most concerning for Wolff-Parkinson-White (WPW) syndrome?

ST elevation in leads V1–V3
Right bundle branch block pattern
Prolonged QTc interval > 460 ms
Short PR interval with a delta wave (Correct answer)

Correct answer: Short PR interval with a delta wave

WPW is characterized by a short PR interval (<120 ms) and a slurred upstroke (delta wave) on the QRS, representing pre-excitation via an accessory pathway.

Question 193: A 2-year-old with epiglottitis arrives in significant respiratory distress. Which action takes highest priority?

Apply a non-rebreather mask and perform laryngoscopy at bedside
Allow the child to remain in a position of comfort and prepare for controlled intubation in the OR (Correct answer)
Place a nasopharyngeal airway and start IV antibiotics
Obtain a lateral neck X-ray immediately in the PICU

Correct answer: Allow the child to remain in a position of comfort and prepare for controlled intubation in the OR

Epiglottitis airway management is safest in the OR with anesthesia and ENT present; agitating the child can precipitate complete obstruction.

Question 194: In which clinical situation is the use of NSAIDs MOST dangerous and contraindicated due to risk of precipitating AKI in children?

Mild dehydration with fever
Mild viral illness with adequate hydration
Septic shock with hypotension (Correct answer)
Post-operative pain in a hemodynamically stable patient

Correct answer: Septic shock with hypotension

In septic shock with hypotension, renal perfusion depends on vasodilatory prostaglandins; NSAIDs inhibit prostaglandin synthesis and can precipitate AKI by critically reducing renal blood flow.

Question 195: An 8-year-old PICU patient repeatedly asks for the same information about upcoming procedures despite receiving clear explanations. This behavior MOST likely indicates:

Cognitive impairment requiring neuropsychological testing
Manipulative behavior that should be minimally reinforced
Normal anxiety-driven reassurance-seeking requiring patient repetition (Correct answer)
Memory deficits secondary to sedation medications

Correct answer: Normal anxiety-driven reassurance-seeking requiring patient repetition

Repetitive questioning is a common anxiety manifestation in school-age children who seek reassurance; responding consistently and calmly reduces rather than reinforces anxiety.

Question 196: A child with AKI has a serum sodium of 122 mEq/L and is actively seizing. What is the most appropriate immediate intervention?

Furosemide with normal saline
Free water restriction only
Normal saline at maintenance rate
3% hypertonic saline bolus (Correct answer)

Correct answer: 3% hypertonic saline bolus

Symptomatic severe hyponatremia with seizures requires urgent correction using 3% hypertonic saline to raise serum sodium by 1–2 mEq/L/hr until symptoms resolve.

Question 197: A pediatric patient on mechanical ventilation develops a sudden decrease in compliance, tracheal deviation, and absent breath sounds on the left. Which intervention is IMMEDIATELY required?

Needle decompression of the left chest (Correct answer)
Urgent chest physiotherapy
Reposition the endotracheal tube to the right mainstem
Bolus IV methylprednisolone 2 mg/kg

Correct answer: Needle decompression of the left chest

Absent breath sounds, tracheal deviation, and decreased compliance indicate tension pneumothorax requiring immediate needle decompression.

Question 198: Which of the following is the MOST common cause of unconjugated hyperbilirubinemia in a healthy term neonate on day 3 of life?

Crigler-Najjar syndrome
Physiologic jaundice (Correct answer)
ABO incompatibility hemolytic disease
Biliary atresia

Correct answer: Physiologic jaundice

Physiologic jaundice peaks on days 3-5 in term neonates due to increased bilirubin production from fetal hemoglobin breakdown and immature hepatic conjugation.

Question 199: A child in the PICU has an intracranial pressure (ICP) of 28 mmHg and a mean arterial pressure (MAP) of 70 mmHg. What is the cerebral perfusion pressure (CPP)?

42 mmHg (Correct answer)
98 mmHg
70 mmHg
28 mmHg

Correct answer: 42 mmHg

CPP = MAP − ICP = 70 − 28 = 42 mmHg; adequate pediatric CPP should be maintained above 40–50 mmHg.

Question 200: Blood in her urine is the main complaint of a young patient. Medical records investigation reveals multiple admissions for the same ailment. No cause has been identified. Only when the mother is there does the patient exhibit symptoms. The nurse anticipates that the diagnosis is going to be:

Physical Abuse
Sexual Abuse
Muchausen syndrome by proxy. (Correct answer)
Nonaccidental Trauma

Correct answer: Muchausen syndrome by proxy.

Munchausen syndrome by proxy (MSP) is a form of child abuse where a caregiver fabricates or induces illness in a child. The classic signs include unexplained, recurrent illnesses with no identified cause, symptoms that only appear in the presence of the caregiver, and multiple hospital admissions. The mother's presence correlating with the child's symptoms strongly suggests MSP.

Question 201: A 10-year-old with ARDS is on mechanical ventilation. Which lung-protective ventilation strategy is recommended?

Tidal volume 6-8 mL/kg IBW, zero PEEP
Tidal volume 6-8 mL/kg IBW, plateau pressure <30 cmH2O (Correct answer)
Tidal volume 12-15 mL/kg IBW, low respiratory rate
Tidal volume 10-12 mL/kg IBW, high PEEP

Correct answer: Tidal volume 6-8 mL/kg IBW, plateau pressure <30 cmH2O

Lung-protective ventilation uses low tidal volumes (6-8 mL/kg IBW) and limits plateau pressure to <30 cmH2O to prevent ventilator-induced lung injury.

Question 202: A 4-year-old post-cardiac surgery develops jugular venous distension, muffled heart sounds, and hypotension. Which intervention is most urgently needed?

Emergent intubation and mechanical ventilation
Pericardiocentesis (Correct answer)
Aggressive IV fluid bolus of 20 mL/kg
Vasopressor infusion with norepinephrine

Correct answer: Pericardiocentesis

Beck's triad (JVD, muffled heart sounds, hypotension) indicates cardiac tamponade requiring emergency pericardiocentesis to relieve pressure.

Question 203: A 2-year-old with bronchiolitis on high-flow nasal cannula has worsening work of breathing. What parameter BEST indicates the need to escalate to non-invasive ventilation?

Respiratory rate of 60 with subcostal retractions and poor feeding (Correct answer)
Mild expiratory wheeze bilaterally
Temperature of 38.5°C
SpO2 of 93% on 6 L/min flow

Correct answer: Respiratory rate of 60 with subcostal retractions and poor feeding

Increasing work of breathing with retractions, tachypnea, and poor feeding despite high-flow oxygen signals impending respiratory failure requiring escalation to CPAP or BiPAP.

Question 204: A child post-cardiac surgery develops jugular venous distension, muffled heart sounds, and hypotension. Which condition should the nurse suspect FIRST?

Cardiogenic shock from graft failure
Pulmonary embolism
Cardiac tamponade (Correct answer)
Tension pneumothorax

Correct answer: Cardiac tamponade

Beck's triad (JVD, muffled heart sounds, hypotension) is classic for cardiac tamponade, a life-threatening emergency requiring immediate pericardiocentesis.

Question 205: In a child with acute hypoxemic respiratory failure, which oxygenation index (OI) value meets criteria for pediatric ARDS (PARDS)?

OI of 10 (Correct answer)
OI of 2
OI of 6
OI of 15

Correct answer: OI of 10

According to PALICC criteria, an OI ≥ 8 (or OSI ≥ 7.5) meets the oxygenation threshold for mild PARDS; OI ≥ 16 indicates moderate PARDS.

Question 206: A 10-year-old with dilated cardiomyopathy has a cardiac index of 1.7 L/min/m². Which medication is MOST appropriate to increase cardiac output?

Digoxin loading dose IV
Nifedipine
Metoprolol
Milrinone (Correct answer)

Correct answer: Milrinone

Milrinone is a phosphodiesterase inhibitor that increases cardiac contractility and reduces afterload without increasing myocardial oxygen demand significantly.

Question 207: A 7-year-old with a VP shunt presents with headache, vomiting, and a bulging fontanelle. Assessment reveals upward gaze palsy. What does upward gaze palsy indicate in this context?

Cortical blindness from occipital ischemia
Parinaud syndrome from dorsal midbrain compression due to hydrocephalus (Correct answer)
Optic nerve compression
Cerebellar herniation

Correct answer: Parinaud syndrome from dorsal midbrain compression due to hydrocephalus

Parinaud syndrome (paralysis of upward gaze) results from dorsal midbrain compression by an enlarged third ventricle in obstructive hydrocephalus — a classic sign of shunt failure.

Question 208: A 3-year-old with status epilepticus does not respond to two doses of lorazepam. According to current guidelines, the NEXT medication is:

Propofol for rapid seizure termination
Phenobarbital 20 mg/kg IV
Midazolam continuous infusion
Levetiracetam, fosphenytoin, or valproate IV (Correct answer)

Correct answer: Levetiracetam, fosphenytoin, or valproate IV

Current pediatric status epilepticus guidelines recommend second-line agents — fosphenytoin, levetiracetam, or valproate — after failure of two benzodiazepine doses.

Question 209: A nurse is gathering materials to start intravenous (IV) fluid resuscitation and a blood transfusion using packed red blood cells (PRBCs) as she gets ready to admit a child with a new diagnosis of sickle cell disease (SCD). Why is it necessary to use these interventions?

To reduce pain caused by sickling
To reverse hypovolemic shock
To reduce kidney damage and correct acidosis
To treat dehydration and anemia (Correct answer)

Correct answer: To treat dehydration and anemia

Children with sickle cell disease (SCD) are prone to dehydration, which can trigger painful vaso-occlusive crises, and chronic anemia due to the premature destruction of sickled red blood cells. Intravenous (IV) fluid resuscitation is crucial to correct dehydration and improve blood flow. Blood transfusions with packed red blood cells (PRBCs) are administered to treat severe anemia, increase oxygen-carrying capacity, and dilute the concentration of sickled cells, thereby reducing the risk of further complications.

Question 210: A 10-year-old post-cardiac surgery has a sudden drop in BP, muffled heart sounds, and JVD. The nurse should suspect:

Pulmonary embolism
Hypovolemic shock
Tension pneumothorax
Cardiac tamponade (Correct answer)

Correct answer: Cardiac tamponade

Beck's triad (hypotension, muffled heart sounds, JVD) is the classic presentation of cardiac tamponade following cardiac surgery.

Question 211: Which disease is frequently linked to pulmonary hypertension (PH) in most pediatric patients?

Congenital heart disease (CHD) (Correct answer)
Bronchopulmonary dysplasia (BPD)
Thoracic trauma
Asthma

Correct answer: Congenital heart disease (CHD)

Congenital heart disease (CHD) is frequently linked to pulmonary hypertension (PH) in pediatric patients, especially those with left-to-right shunts like VSDs or PDAs. The increased blood flow and pressure to the pulmonary arteries over time cause structural changes and remodeling of the pulmonary vasculature. This leads to elevated pulmonary vascular resistance and the development of pulmonary hypertension.

Question 212: Family members of a recently deceased patient are sobbing and wailing loudly. The outbursts are making the staff angry. The ideal response from the nurse is to acknowledge the loudness and:

Guide the family to a nearby room where they can express their emotions (Correct answer)
Tell the family they must quiet down, or they will have to leave the unit
Tell the other staff they are being insensitive to the family's expression of grief
Ask a security officer to remove the family from the unit

Correct answer: Guide the family to a nearby room where they can express their emotions

Grieving families need a safe and private space to express their emotions without feeling judged or constrained. Guiding the family to a nearby room acknowledges their need for emotional release while also respecting the environment for other patients and staff. This demonstrates empathy and provides appropriate support during a difficult time.

Question 213: Which finding BEST indicates adequate cardiac output in a pediatric patient post-cardiac surgery?

Mixed venous oxygen saturation (SvO2) of 70–75% (Correct answer)
Urine output >0.5 mL/kg/hr
Heart rate within 10% of baseline
Mean arterial pressure >65 mmHg

Correct answer: Mixed venous oxygen saturation (SvO2) of 70–75%

SvO2 of 70–75% reflects a balance between oxygen delivery and consumption, serving as a global indicator of adequate cardiac output and tissue perfusion.

Question 214: A 6-year-old on high-frequency oscillatory ventilation (HFOV) for ARDS has improved oxygenation but worsening CO2 retention. Which adjustment corrects this?

Decrease frequency (Hz)
Increase FiO2
Increase mean airway pressure (MAP)
Increase amplitude (delta P) (Correct answer)

Correct answer: Increase amplitude (delta P)

In HFOV, CO2 elimination is controlled by amplitude (delta P) — increasing amplitude improves the tidal oscillation volume, enhancing CO2 washout.

Question 215: Which medication used for sedation in the PICU is associated with propofol infusion syndrome (PRIS) and is generally AVOIDED in children for long-term sedation?

Propofol (Correct answer)
Midazolam
Ketamine
Dexmedetomidine

Correct answer: Propofol

Propofol infusion syndrome — characterized by metabolic acidosis, rhabdomyolysis, cardiac failure, and death — is a rare but fatal complication, and propofol is generally avoided for prolonged pediatric sedation.

Question 216: A male patient, age 16, arrives at the emergency room complaining of nausea, vomiting, and a severe headache. He spent the afternoon cleaning up a paint thinner spill from his side job as a painter. According to him, these symptoms began around an hour after he finished his shift at work. Upon physical examination, he exhibits some degree of confusion, with a heart rate of 115 and a room air oxygen saturation of 95%. Carboxyhemoglobin levels are 23%, according to carbon monoxide oximetry. Which one of the subsequent interventions should the nurse begin applying immediately?

Administer packed red blood cells
Initiate the three-part cyanide antidote kit treatment
Administer 100% oxygen (Correct answer)
Administer protamine sulfate

Correct answer: Administer 100% oxygen

The patient's symptoms (nausea, vomiting, headache, confusion) and elevated carboxyhemoglobin levels (23%) are classic signs of carbon monoxide (CO) poisoning. CO binds to hemoglobin with much higher affinity than oxygen, forming carboxyhemoglobin and impairing oxygen delivery to tissues. Administering 100% oxygen is the immediate and most effective intervention to displace CO from hemoglobin, accelerate its elimination, and improve tissue oxygenation.

Question 217: Which clinical finding is the EARLIEST sign of increasing intracranial pressure in a child?

Altered level of consciousness and irritability (Correct answer)
Decorticate posturing
Cushing's triad (bradycardia, hypertension, irregular respirations)
Fixed and dilated pupils

Correct answer: Altered level of consciousness and irritability

Altered LOC and irritability are early signs of elevated ICP; Cushing's triad and fixed pupils are late, often pre-terminal findings.

Question 218: A nurse is titrating norepinephrine for a child in septic shock. Which clinical endpoint best indicates adequate perfusion has been restored?

Age-appropriate MAP, capillary refill < 2 seconds, and normal urine output (1 mL/kg/hr) (Correct answer)
MAP ≥ 65 mmHg in all age groups
SpO2 > 95% and heart rate normalization alone
Lactate clearance ≥ 10% over 6 hours only

Correct answer: Age-appropriate MAP, capillary refill < 2 seconds, and normal urine output (1 mL/kg/hr)

Perfusion adequacy in pediatric septic shock is assessed with age-appropriate MAP targets, capillary refill time, and urine output, not a single adult threshold.

Question 219: A 6-year-old with bacterial meningitis develops sudden unilateral pupil dilation, bradycardia, and hypertension. The nurse recognizes this as:

SIADH causing cerebral edema correction
Cushing's triad indicating herniation (Correct answer)
Normal sympathetic response to pain
Medication side effect from mannitol

Correct answer: Cushing's triad indicating herniation

Cushing's triad (bradycardia, hypertension, irregular respirations) with pupil changes indicates brainstem herniation—a neurologic emergency.

Question 220: Which congenital heart defect produces a continuous 'machinery' murmur best heard at the left upper sternal border?

Atrial septal defect
Pulmonary stenosis
Ventricular septal defect
Patent ductus arteriosus (Correct answer)

Correct answer: Patent ductus arteriosus

A patent ductus arteriosus produces a continuous machinery-type murmur because blood flows through it in both systole and diastole.

Question 221: Which of the following typical pacemaker modes should be used as an emergency treatment to establish ventricular activity when there is AV dissociation and maintain cardiac output (CO) without an atrial kick?

VOO (ventricular asynchronous pacing)
AAI (atrial demand pacing)
DDD (dual-chambered pacing)
VVI (ventricular demand pacing) (Correct answer)

Correct answer: VVI (ventricular demand pacing)

VVI (Ventricular Demand Pacing) is a common emergency pacemaker mode used to establish ventricular activity when there is AV dissociation. In this mode, the pacemaker senses intrinsic ventricular activity and paces the ventricle only if no intrinsic beat is detected within a set interval. This ensures a minimum heart rate and maintains cardiac output, even without the atrial kick, which is often lost with AV dissociation.

Question 222: Which electrocardiographic finding is most consistent with hyperkalemia in a pediatric patient?

Prolonged QT interval
ST-segment depression with U waves
Delta waves with shortened PR interval
Tall, peaked T waves with widened QRS (Correct answer)

Correct answer: Tall, peaked T waves with widened QRS

Hyperkalemia classically causes tall peaked T waves, widened QRS complexes, and ultimately a sine-wave pattern as potassium rises.

Question 223: A 4-year-old with croup (laryngotracheobronchitis) has a Westley croup score of 8. Which intervention is MOST appropriate?

Oral dexamethasone and discharge home
Heliox therapy alone
Nebulized racemic epinephrine and parenteral dexamethasone with observation (Correct answer)
Immediate endotracheal intubation

Correct answer: Nebulized racemic epinephrine and parenteral dexamethasone with observation

A Westley score of 8 indicates moderate-to-severe croup; nebulized racemic epinephrine provides rapid relief while systemic dexamethasone reduces airway inflammation and edema.

Question 224: Esophageal varices that are bleeding may be treated acutely by?

Placement of a large NGT to low intermittent suction
Immediate surgical intervention
Administration of octreotide (Sandostatin) (Correct answer)
Placement of a central venous line for hyperalimentation (TPN)

Correct answer: Administration of octreotide (Sandostatin)

Acute bleeding from esophageal varices is a life-threatening emergency. Octreotide (Sandostatin) is a somatostatin analog that causes splanchnic vasoconstriction, which reduces blood flow to the portal system and subsequently lowers pressure within the esophageal varices. This pharmacological action helps to control and stop the acute variceal bleeding, making it a primary intervention in the immediate management of this condition.

Question 225: A mechanically ventilated child has a sudden drop in SpO2 with right-sided breath sounds absent. Which immediate action is CORRECT?

Suction the endotracheal tube for secretions
Withdraw the ETT 1–2 cm and reassess breath sounds (Correct answer)
Increase FiO2 to 1.0 and call pharmacy for albuterol
Obtain a STAT chest X-ray before any intervention

Correct answer: Withdraw the ETT 1–2 cm and reassess breath sounds

Unilateral absent breath sounds after intubation suggest right mainstem bronchus intubation; withdrawing the ETT slightly should restore bilateral ventilation.

Question 226: A nurse provides medical attention to a little child in the pediatric intensive care unit (PICU) who has had a cardiac catheterization to repair a ventricular septal defect (VSD). What kind of heart arrhythmia is the MOST typical to develop as a side effect of VSD repair?

Atrial fibrillation (A-fib)
Supraventricular tachycardia (SVT)
Heart Block (Correct answer)
Premature ventricular contractions (PVCs)

Correct answer: Heart Block

Heart block is the most typical heart arrhythmia to develop as a side effect of ventricular septal defect (VSD) repair. The VSD is located in close proximity to the heart's conduction system, particularly the bundle of His. Surgical closure of the defect carries a risk of trauma or damage to these delicate conduction pathways, which can result in varying degrees of heart block.

Question 227: A child with AKI has a K+ of 6.8 mEq/L with peaked T-waves on ECG. After calcium gluconate is given, what is the NEXT pharmacological step?

Sodium bicarbonate
Sodium polystyrene sulfonate (Kayexalate)
Insulin with dextrose (Correct answer)
Furosemide

Correct answer: Insulin with dextrose

After membrane stabilization with calcium, insulin (with glucose to prevent hypoglycemia) is administered to shift potassium intracellularly, rapidly and transiently lowering serum potassium.

Question 228: A 12-year-old after a near-drowning has a GCS of 6. Which GCS subscores produce this total?

Eye 1, Verbal 2, Motor 3
Eye 2, Verbal 2, Motor 2 (Correct answer)
Eye 2, Verbal 1, Motor 3
Eye 1, Verbal 3, Motor 2

Correct answer: Eye 2, Verbal 2, Motor 2

Eye 2 + Verbal 2 + Motor 2 = 6; any combination totaling 6 is valid, but 2+2+2 is a common testing scenario reflecting severe impairment in all domains.

Question 229: A term neonate has Apgar scores of 2 at 1 minute and 4 at 5 minutes. During neonatal resuscitation, positive pressure ventilation is initiated. After 30 seconds with adequate chest rise, heart rate remains 55 bpm. The NEXT step is:

Switch to high-flow nasal cannula
Administer epinephrine IV immediately
Continue PPV and reassess in 60 seconds
Begin chest compressions at a 3:1 compression-to-ventilation ratio (Correct answer)

Correct answer: Begin chest compressions at a 3:1 compression-to-ventilation ratio

Per NRP guidelines, chest compressions are initiated when heart rate remains <60 bpm despite 30 seconds of effective PPV, using a 3:1 compression-to-ventilation ratio.

Question 230: A 7-year-old post-operative Fontan procedure has a central venous pressure of 22 mmHg, low urine output, and hepatomegaly. The nurse suspects:

Systemic ventricular failure with high filling pressures
Cardiac tamponade from pericardial effusion
Fontan failure with elevated systemic venous pressure (Correct answer)
Superior vena cava syndrome from line malposition

Correct answer: Fontan failure with elevated systemic venous pressure

Elevated CVP, hepatomegaly, and oliguria after Fontan indicate elevated systemic venous pressures secondary to Fontan circuit obstruction or failure.

Question 231: A 5-year-old post-extubation develops stridor and increased work of breathing within 1 hour. The MOST appropriate initial intervention is:

Heliox therapy
Re-intubation immediately
Racemic epinephrine nebulization and IV dexamethasone (Correct answer)
Oral dexamethasone alone

Correct answer: Racemic epinephrine nebulization and IV dexamethasone

Post-extubation stridor due to subglottic edema responds to nebulized racemic epinephrine (rapid onset) and IV dexamethasone (to reduce inflammation) before considering re-intubation.

Question 232: Which of the following electrolyte problems should a nurse monitor when administering an exchange transfusion to a sickle cell patient?

Hypercalcemia
Hypomagnesemia
Hypokalemia
Hypocalcemia (Correct answer)

Correct answer: Hypocalcemia

Exchange transfusions involve replacing the patient's blood with donor blood, which is typically preserved with citrate. Citrate acts as an anticoagulant by binding to calcium. When large amounts of citrated blood are infused rapidly during an exchange transfusion, the citrate can chelate the patient's circulating calcium, leading to a significant drop in serum calcium levels (hypocalcemia). Therefore, monitoring and potentially supplementing calcium are crucial during this procedure.

Question 233: What is the RECOMMENDED initial PEEP setting when initiating mechanical ventilation in a child with moderate pediatric ARDS?

3–5 cmH2O
15–18 cmH2O
8–10 cmH2O (Correct answer)
0–2 cmH2O

Correct answer: 8–10 cmH2O

Current pediatric ARDS guidelines recommend a PEEP of 8–10 cmH2O for moderate ARDS to maintain alveolar recruitment and prevent cyclic atelectasis.

Question 234: A 4-year-old in the PICU believes she is being punished for being 'bad' because she is sick. This type of thinking is characteristic of which cognitive stage?

Sensorimotor thought with object permanence development
Concrete operational thought with logical cause-and-effect reasoning
Formal operational thought with abstract reasoning
Preoperational thought with magical thinking and egocentrism (Correct answer)

Correct answer: Preoperational thought with magical thinking and egocentrism

Preschool-age children are in Piaget's preoperational stage, characterized by magical thinking and egocentrism, which leads them to interpret illness as punishment for perceived bad behavior.

Question 235: Which intervention BEST supports the psychosocial needs of a preschool-age (3-5 year) PICU patient?

Avoiding all discussion of procedures to prevent anticipatory anxiety
Detailed explanations of all procedures using correct anatomical terminology
Encouraging the child to be brave and not cry to build resilience
Simple honest explanations immediately before procedures with comfort items from home (Correct answer)

Correct answer: Simple honest explanations immediately before procedures with comfort items from home

Preschoolers benefit from brief honest explanations immediately before procedures (not hours before) combined with familiar comfort objects, as they are concrete thinkers with magical thinking tendencies.

Question 236: A neonate at 28 weeks gestation requires surfactant therapy. What is the PRIMARY mechanism by which exogenous surfactant improves oxygenation?

Decreases alveolar surface tension to prevent collapse (Correct answer)
Stimulates type II pneumocyte maturation
Reduces pulmonary vascular resistance
Increases mucociliary clearance

Correct answer: Decreases alveolar surface tension to prevent collapse

Exogenous surfactant replaces deficient endogenous surfactant, reducing alveolar surface tension and preventing atelectasis to improve ventilation-perfusion matching and oxygenation.

Question 237: Which blood gas result is MOST consistent with early respiratory failure in a child with acute severe asthma?

pH 7.50, PaCO2 28, PaO2 70
pH 7.45, PaCO2 35, PaO2 90
pH 7.30, PaCO2 50, PaO2 60
pH 7.35, PaCO2 42, PaO2 65 (Correct answer)

Correct answer: pH 7.35, PaCO2 42, PaO2 65

A normalizing PaCO2 (42 mmHg) with a normal or slightly low pH and mild hypoxia in a severely dyspneic child indicates CO2 retention despite hyperventilation — a sign of impending respiratory failure.

Question 238: When a critically ill child's parents come from a culture where the father is the sole medical decision-maker, but the mother is the primary caregiver, the nurse should:

Communicate exclusively with the father to respect cultural norms
Include both parents in all communications and facilitate their internal process (Correct answer)
Refer the family to social work to address the power imbalance
Insist both parents share decision-making authority equally per US law

Correct answer: Include both parents in all communications and facilitate their internal process

Culturally competent care involves including all caregivers in communication while respecting family dynamics, allowing the family to make decisions according to their own cultural process.

Question 239: Which medication is used as a second-line osmotic agent for refractory elevated ICP when mannitol has already been given?

Furosemide 1 mg/kg IV
Dextrose 50% IV bolus
Albumin 5% infusion
Hypertonic saline (3% NaCl) (Correct answer)

Correct answer: Hypertonic saline (3% NaCl)

Hypertonic saline is the preferred second-line osmotic agent for elevated ICP, particularly effective when mannitol has been used or the patient is hypovolemic.

Question 240: Which clinical sign indicates transtentorial (uncal) herniation in a child with elevated ICP?

Bilateral pinpoint pupils
Ipsilateral fixed and dilated pupil with contralateral hemiplegia (Correct answer)
Bilateral hyperreflexia
Bilateral fixed midposition pupils

Correct answer: Ipsilateral fixed and dilated pupil with contralateral hemiplegia

Uncal herniation compresses CN III, causing ipsilateral pupil dilation and loss of reactivity, while the herniated brain displaces the contralateral motor tract, producing contralateral weakness.

Question 241: A 14-year-old with diabetic ketoacidosis has an initial serum potassium of 3.2 mEq/L. What is the CORRECT approach to insulin therapy?

Withhold insulin until potassium is ≥3.5 mEq/L and repleted (Correct answer)
Start insulin at a reduced dose of 0.05 units/kg/hr
Give insulin only after serum glucose is below 300 mg/dL
Start insulin immediately at 0.1 units/kg/hr

Correct answer: Withhold insulin until potassium is ≥3.5 mEq/L and repleted

Insulin causes potassium to shift intracellularly; starting insulin when potassium is already low can cause life-threatening hypokalemia, so potassium must be repleted to ≥3.5 mEq/L first.

Question 242: A 7-year-old with known asthma has an SpO2 of 88%, accessory muscle use, and a silent chest on auscultation. What does the silent chest indicate?

Pneumothorax has developed
Mucus plugging limited to the upper airway
The child is improving and bronchospasm is resolving
Airflow is so severely obstructed that breath sounds are absent (Correct answer)

Correct answer: Airflow is so severely obstructed that breath sounds are absent

A silent chest in asthma signals near-complete airflow obstruction—a life-threatening finding requiring immediate aggressive intervention.

Question 243: A diabetic child who passed out in class is hospitalized. He has tachycardia, short breathing, dilated pupils, and hyperreflexia at admission. The treatment strategy would involve providing:

Glucagon IM
25% Dextrose IV (Correct answer)
Naloxone (Narcan) IV
Regular insulin SQ

Correct answer: 25% Dextrose IV

The child's symptoms of passing out, tachycardia, short breathing, dilated pupils, and hyperreflexia are classic signs of severe hypoglycemia (low blood sugar). In an unconscious or severely symptomatic diabetic child, immediate intravenous administration of 25% Dextrose is crucial to rapidly raise blood glucose levels. This provides immediate glucose to the brain and other tissues, reversing the life-threatening effects of hypoglycemia.

Question 244: When treating a baby with persistent pulmonary hypertension, the primary objective is to:

Dilate the pulmonary vascular bed (Correct answer)
Dilate the systemic vascular bed
Maintain fetal pulmonary circulation
Maintain the pH level at less than 7.40

Correct answer: Dilate the pulmonary vascular bed

Persistent pulmonary hypertension of the newborn (PPHN) is characterized by high pulmonary vascular resistance, which prevents adequate blood flow to the lungs for oxygenation. The primary objective of treatment is to dilate the pulmonary vascular bed, thereby reducing pulmonary vascular resistance. This allows more blood to flow through the lungs, improving oxygen uptake and systemic oxygenation.

Question 245: In a child with ARDS, which ventilator strategy is associated with improved survival?

Zero PEEP to minimize barotrauma
Lung-protective ventilation with tidal volumes of 4–6 mL/kg IBW (Correct answer)
High tidal volumes (12 mL/kg IBW) to prevent atelectasis
Permissive hypocapnia to reduce PaCO2 below 35 mmHg

Correct answer: Lung-protective ventilation with tidal volumes of 4–6 mL/kg IBW

Lung-protective ventilation using low tidal volumes (4–6 mL/kg IBW) reduces volutrauma and barotrauma, improving survival in ARDS.

Question 246: A 12-year-old with acetaminophen overdose presents 18 hours post-ingestion with elevated AST/ALT. What is the priority intervention?

Perform emergent plasmapheresis
Administer activated charcoal to reduce absorption
Begin N-acetylcysteine (NAC) IV infusion immediately (Correct answer)
Administer IV methylene blue for toxin reduction

Correct answer: Begin N-acetylcysteine (NAC) IV infusion immediately

NAC restores glutathione stores and is the antidote for acetaminophen toxicity; it remains effective up to 24 hours post-ingestion and should be started without delay.

Question 247: What is the mechanism of neurological injury in neonatal hypoxic-ischemic encephalopathy (HIE)?

Direct viral invasion of neurons
Vascular thrombosis from hypercoagulability
Autoimmune destruction of myelin
Excitotoxicity from glutamate release during reperfusion after hypoxia (Correct answer)

Correct answer: Excitotoxicity from glutamate release during reperfusion after hypoxia

During reperfusion after hypoxia-ischemia, massive glutamate release triggers excitotoxicity, calcium influx, mitochondrial dysfunction, and programmed cell death in the vulnerable neonatal brain.

Question 248: A PICU nurse is preparing to perform a family-centered care assessment. Which practice is MOST consistent with evidence-based family-centered care in the PICU?

Prohibiting family from staying overnight to maintain staff workflow
Restricting visitation to scheduled 2-hour windows to allow rest
Encouraging family presence during resuscitation and bedside procedures if desired (Correct answer)
Limiting parental involvement in care decisions to reduce anxiety

Correct answer: Encouraging family presence during resuscitation and bedside procedures if desired

Evidence-based family-centered care supports offering family presence during resuscitation and procedures, which reduces family anxiety and improves satisfaction without hindering outcomes.

Question 249: Which laboratory finding would BEST suggest a pre-renal cause (rather than intrinsic renal) of AKI in a child?

FeNa > 2%, urine sodium > 40 mEq/L
Urine specific gravity < 1.010
BUN:creatinine ratio < 10
FeNa < 1%, urine sodium < 20 mEq/L (Correct answer)

Correct answer: FeNa < 1%, urine sodium < 20 mEq/L

In pre-renal AKI, intact tubular function allows the kidney to avidly retain sodium (urine Na < 20 mEq/L) and concentrate urine (FeNa < 1%) in response to decreased perfusion.

Question 250: A neonate born at 28 weeks gestation is on high-frequency oscillatory ventilation (HFOV). Which parameter is primarily adjusted to control oxygenation on HFOV?

Inspiratory time
Frequency (Hz)
Mean airway pressure (MAP) (Correct answer)
Amplitude (ΔP)

Correct answer: Mean airway pressure (MAP)

On HFOV, mean airway pressure (MAP) controls lung volume and oxygenation, while amplitude (ΔP) controls CO2 elimination.

Question 251: Which of the following comments made by staff would worry the nurse most who is leading the charge to reduce catheter-associated urinary tract infections (CAUTI) on his or her unit?

"I found the catheter disconnected from the collection device during my hourly assessment."
"It is so much easier to monitor hourly output with a catheter in place."
"The patient is transferring to the floor today. They can discontinue the urinary catheter once they get him settled." (Correct answer)
"The urinary catheter was placed last night in the emergency department during trauma resuscitation."

Correct answer: "The patient is transferring to the floor today. They can discontinue the urinary catheter once they get him settled."

The comment, 'The patient is transferring to the floor today. They can discontinue the urinary catheter once they get him settled,' is most concerning because it indicates a delay in catheter removal. Urinary catheters should be removed as soon as they are no longer medically necessary, regardless of unit transfer, to minimize the risk of catheter-associated urinary tract infections (CAUTI). Any unnecessary delay increases the duration of catheterization and thus the risk of infection.

Pediatric CCRN Exam

This exam certifies registered nurses who provide direct care to critically ill pediatric patients, demonstrating advanced knowledge in clinical judgment and professional practice.

150

Questions

180 min

Time Limit

70%

To Pass

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