Pediatric CCRN Exam — Questions and Answers

Question 1: Which medication is the antidote for acetaminophen (paracetamol) toxicity in a pediatric patient?

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

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

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

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 3: A neonate at 38 weeks gestation has persistent hypoglycemia despite glucose infusion at 10 mg/kg/min. Which diagnosis should be considered FIRST?

Transient neonatal hypoglycemia
Adrenal insufficiency
Glycogen storage disease type I
Congenital hyperinsulinism (Correct answer)

Correct answer: Congenital hyperinsulinism

Requirement for glucose infusion rates >8-10 mg/kg/min to maintain normoglycemia strongly suggests congenital hyperinsulinism as the cause.

Question 4: 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:

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

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

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

Correct answer: Neisseria meningitidis

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

Question 6: 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)
0.5-2 mcg/kg/min (dopaminergic range)
10-20 mcg/kg/min (alpha-adrenergic range)
2-10 mcg/kg/min (beta-adrenergic range) (Correct answer)

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 7: An infant is admitted with supraventricular tachycardia (SVT) at a rate of 240 bpm with signs of poor perfusion. What is the first-line treatment?

Synchronized cardioversion at 0.5-1 J/kg (Correct answer)
Vagal maneuvers such as ice to the face
Amiodarone 5 mg/kg IV over 20-60 minutes
Adenosine 0.1 mg/kg IV rapid push

Correct answer: Synchronized cardioversion at 0.5-1 J/kg

Synchronized cardioversion is indicated for unstable SVT with hemodynamic compromise; the starting dose is 0.5–1 J/kg.

Question 8: A NICU nurse notes that a 29-week neonate's endotracheal tube (ETT) has migrated. Chest X-ray shows the tube tip at the level of the carina. The MOST immediate action is:

Withdraw the ETT 1-2 cm and confirm placement (Correct answer)
Increase peak inspiratory pressure to compensate
Obtain a repeat chest X-ray in 2 hours
Immediately extubate the neonate

Correct answer: Withdraw the ETT 1-2 cm and confirm placement

An ETT at the carina risks right mainstem intubation or atelectasis; the tube should be immediately withdrawn to the correct position (T2-T3) and placement confirmed.

Question 9: Which arterial blood gas pattern is consistent with acute respiratory acidosis in a pediatric patient?

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

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 10: A 4-year-old with diabetic ketoacidosis (DKA) receives IV fluid resuscitation. Four hours later, the child complains of headache and becomes lethargic. The nurse's priority concern is:

Cerebral edema from rapid fluid shifts (Correct answer)
Hypokalemia from insulin therapy
Hypernatremia from normal saline infusion
Hypoglycemia from overcorrection

Correct answer: Cerebral edema from rapid fluid shifts

Cerebral edema is the most feared complication of pediatric DKA treatment, presenting with altered mental status hours into fluid resuscitation.

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:

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

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

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

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 13: 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?

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

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 14: 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?

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

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 15: A newborn with transposed great arteries is hospitalized. 46% is the SpO2 value. Nobody makes a murmur. Which drugs should the nurse anticipate being given as a stopgap measure until a balloon septostomy can be performed?

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

Correct answer: Alprostadil (PGE1)

For a newborn with transposed great arteries and severe hypoxemia (SpO2 46%), Alprostadil (PGE1) is the critical medication. PGE1 keeps the ductus arteriosus open, facilitating the mixing of systemic and pulmonary blood flow. This temporary shunt is vital for maintaining adequate systemic oxygenation until a more permanent solution, such as a balloon septostomy or surgical repair, can be carried out.

Question 16: Which medication is used as a continuous infusion to maintain ductal patency in a neonate with ductal-dependent congenital heart disease?

Milrinone
Indomethacin
Furosemide
Prostaglandin E1 (alprostadil) (Correct answer)

Correct answer: Prostaglandin E1 (alprostadil)

Prostaglandin E1 (alprostadil) maintains patency of the ductus arteriosus in neonates with ductal-dependent cardiac lesions until surgical correction.

Question 17: Which of the following group of children might have a hypertensive crisis as shown by acidosis, hypothermia, and alveolar hypoxia?

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

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 18: Which of the following should be done after desmopressin (DDAVP) has been given to a patient with diabetes insipidus?

Increase sodium intake
Decrease IV fluid rate (Correct answer)
Decrease glucose intake
Maintain current fluid rate

Correct answer: Decrease IV fluid rate

Desmopressin (DDAVP) is an antidiuretic hormone analog that helps the kidneys reabsorb water, significantly reducing urine output in patients with diabetes insipidus. After administering DDAVP, the patient will excrete less fluid, so it is crucial to decrease the IV fluid rate to prevent fluid overload and dilutional hyponatremia. Monitoring fluid balance closely is essential to avoid complications.

Question 19: A 6-month-old with Tetralogy of Fallot develops a sudden hypercyanotic (tet) spell. What is the FIRST intervention?

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

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 20: A 3-year-old on phenobarbital for seizure control requires a dose increase. Which monitoring is ESSENTIAL?

Daily EEG
Daily CBC and BMP
Serum phenobarbital levels and respiratory status (Correct answer)
Continuous cardiac monitoring only

Correct answer: Serum phenobarbital levels and respiratory status

Phenobarbital has a narrow therapeutic index (15–40 mcg/mL); monitoring serum levels prevents toxicity while assessing respiratory status is critical as phenobarbital causes dose-dependent respiratory depression.

Question 21: When interpreting a pediatric 12-lead ECG, which finding is most concerning for Wolff-Parkinson-White (WPW) syndrome?

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

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 22: 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?

Nifedipine
Digoxin loading dose IV
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 23: In which clinical situation is the use of NSAIDs MOST dangerous and contraindicated due to risk of precipitating AKI in children?

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

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 24: 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 25: 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:

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

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 26: 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?

Penicillin
Iodine or shellfish (Correct answer)
Opioid pain medications
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 27: Metronidazole suspension, 200 mg per dosage, is being used to treat a 3-year-old child. The daily dosing range for the 30-pound youngster is 20–40 mg/kg of body weight given in three divided doses every eight hours. What should the nurse do knowing the safe drug administration principles?

Get the attention of the doctor to clarify the dose
Administer the medicine as ordered (Correct answer)
Recognize that the medicine were over-prescribed
Hold the medicine as the dosage is way too low

Correct answer: Administer the medicine as ordered

The nurse first calculates the child's weight in kilograms (30 lbs / 2.2 = 13.6 kg). The safe daily dose range of 20-40 mg/kg translates to 272 mg to 544 mg per day. The ordered dose of 200 mg per administration, given three times a day, totals 600 mg/day. While this dose is at the higher end of the therapeutic window, it is often considered acceptable in clinical practice for metronidazole, especially when the child's condition warrants it and close monitoring for adverse effects is implemented. Therefore, the nurse would administer the medication as ordered.

Question 28: A pediatric patient on heparin infusion develops thrombocytopenia with new arterial clots. Which condition should the nurse suspect?

Thrombotic thrombocytopenic purpura (TTP)
Disseminated intravascular coagulation (DIC)
Immune thrombocytopenic purpura (ITP)
Heparin-induced thrombocytopenia (HIT) (Correct answer)

Correct answer: Heparin-induced thrombocytopenia (HIT)

HIT is characterized by a 50% or greater drop in platelets occurring 5–10 days after heparin initiation, paradoxically causing thrombosis.

Question 29: 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:

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

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

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

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 31: A nurse is interested in integrating other academic fields into the NICU's educational program for developmental care. The best strategy to persuade management that this project is profitable is to:

Present a report summarizing research relating developmental care to decrease length of stay. (Correct answer)
Invite members of administration to attend the classes.
Request that the neonatologist present the plan.
Present case studies demonstrating favorable outcomes for developmental care.

Correct answer: Present a report summarizing research relating developmental care to decrease length of stay.

To persuade management, it is crucial to demonstrate the tangible benefits of the proposed project, especially in terms of cost-effectiveness and improved outcomes. Presenting research that links developmental care to a decreased length of stay directly shows financial savings and increased efficiency. This evidence-based approach is highly effective in gaining administrative support for new initiatives.

Question 32: 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 33: Which EEG pattern in a critically ill child indicates the HIGHEST risk for poor neurological outcome?

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

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 34: A neonate with suspected sepsis has cultures drawn and empiric antibiotics are started. Blood culture results at 48 hours show no growth. The neonate has been clinically improving. The BEST course of action is:

Repeat blood cultures daily until negative x3
Continue antibiotics for the full 14-day course regardless
Switch to oral antibiotics and discharge home
Discontinue antibiotics if clinical status is good and CRP trending down (Correct answer)

Correct answer: Discontinue antibiotics if clinical status is good and CRP trending down

In clinically improving neonates with negative cultures and normalizing inflammatory markers, antibiotic de-escalation at 48 hours is recommended to reduce antibiotic-associated complications.

Question 35: When patient attributes and nursing competencies are aligned, optimal outcomes in terms of the AACN Synergy Model for Patient Care occur. From the standpoint of the patient and family, outcomes should contain everything listed below, EXCEPT:

Behavioral changes
Functional changes
Quality of life
Physiologic changes (Correct answer)

Correct answer: Physiologic changes

The AACN Synergy Model for Patient Care emphasizes that optimal outcomes occur when patient needs align with nursing competencies. From the perspective of the patient and family, outcomes are typically described in terms of their lived experience, such as improvements in functional abilities, quality of life, and behavioral adaptations. While nurses certainly influence physiological changes, these are often considered more objective, medical-centric measures rather than the subjective, holistic outcomes prioritized by the patient and family within this model.

Question 36: A 10-year-old with cystic fibrosis is admitted with a pulmonary exacerbation. Which combination is standard initial therapy?

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

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 37: 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 38: Which ventilator strategy is recommended for pediatric ARDS to minimize ventilator-induced lung injury?

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

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 39: 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 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
Methylprednisolone 2 mg/kg/day
Hydrocortisone 50 mg/m² /day (stress dose: 3–5× maintenance) (Correct answer)

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 12-year-old (40 kg) on CVVH has an effluent rate of 2,000 mL/hr. What is the CRRT dose in mL/kg/hr?

75 mL/kg/hr
50 mL/kg/hr (Correct answer)
100 mL/kg/hr
25 mL/kg/hr

Correct answer: 50 mL/kg/hr

CRRT dose = effluent rate ÷ body weight = 2,000 mL/hr ÷ 40 kg = 50 mL/kg/hr, which falls within the recommended pediatric CRRT dosing range.

Question 42: Which tissue is not impacted by leukemia?

Liver
Kidney (Correct answer)
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 43: A child with Guillain-Barré syndrome has a forced vital capacity (FVC) of 18 mL/kg. Based on the '20-30-40 rule,' what intervention is indicated?

Initiate BiPAP immediately
Administer IVIG and observe
Encourage deep breathing exercises only
Elective intubation for airway protection (Correct answer)

Correct answer: Elective intubation for airway protection

The 20-30-40 rule states that FVC <20 mL/kg, maximum inspiratory pressure > −30 cmH2O, or maximum expiratory pressure <40 cmH2O indicates respiratory failure risk requiring elective intubation.

Question 44: Which electrolyte imbalance is most likely in a child with prolonged nasogastric suctioning?

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

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 45: 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
Abstract thinking about death and permanent disability
Loss of peer relationships and social identity
Separation anxiety and loss of autonomy (Correct answer)

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 46: 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 47: What is the RECOMMENDED head-of-bed position for a child with elevated ICP and no spinal injury?

Flat (0 degrees) to maximize cerebral perfusion
45–60 degree elevation
Prone positioning
15–30 degree elevation to promote venous drainage (Correct answer)

Correct answer: 15–30 degree elevation to promote venous drainage

Elevating the head of bed 15–30 degrees promotes cerebral venous drainage, reduces ICP, and is recommended in pediatric TBI guidelines when no contraindication exists.

Question 48: What does the air lack in terms of breathing?

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

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 49: 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
Cerebral edema (Correct answer)
Hypoglycemia from insulin administration
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 50: 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 IV
Grade III
Grade I
Grade II (Correct answer)

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

Anti-Xa level >1.0 IU/mL
Activated clotting time (ACT) of 180–220 seconds (Correct answer)
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 52: 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. </br> </br> 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 53: A 16-year-old PICU patient refuses a recommended blood transfusion citing religious beliefs. The parents also refuse consent. What is the nurse's priority action?

Discharge the patient to protect the facility from liability
Administer the transfusion immediately since the patient is a minor
Document the refusal and notify the physician and hospital ethics committee (Correct answer)
Attempt to convince the adolescent privately without parental knowledge

Correct answer: Document the refusal and notify the physician and hospital ethics committee

When a minor and parents refuse life-sustaining treatment on religious grounds, the nurse must notify the physician and engage the ethics committee, which may seek a court order.

Question 54: 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:

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

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 55: EMS reportedly transported a 4-year-old boy to the ER after he reportedly ingested some of his mother's prescribed diazepam (Valium). Which of the following is employed as a countermeasure to the drug's probable toxicity?

Flumazenil (Correct answer)
Activated charcoal
Naloxone
N-acetylcysteine

Correct answer: Flumazenil

Diazepam (Valium) is a benzodiazepine, and its overdose can lead to severe central nervous system depression, including respiratory depression. Flumazenil is a specific benzodiazepine receptor antagonist that competitively blocks the effects of benzodiazepines. Administering flumazenil can rapidly reverse the sedative and respiratory depressant effects, making it the appropriate countermeasure for diazepam toxicity.

Question 56: 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?

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

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

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

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

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

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 59: 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?

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

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 60: Which laboratory finding would BEST suggest a pre-renal cause (rather than intrinsic renal) of AKI in a child?

BUN:creatinine ratio < 10
FeNa < 1%, urine sodium < 20 mEq/L (Correct answer)
FeNa > 2%, urine sodium > 40 mEq/L
Urine specific gravity < 1.010

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

Anemia and thrombocytopenia
Petechial rash
Neurologic abnormalities
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 62: When calculating percent fluid overload in a PICU patient, which formula is correct?

(Fluid in − fluid out) / body surface area × 100
(Current weight − admission weight) / admission weight × 100 (Correct answer)
(Current weight − admission weight) / current weight × 100
(Current weight − dry weight) / ideal body weight × 100

Correct answer: (Current weight − admission weight) / admission weight × 100

Percent fluid overload = (current weight − admission weight) / admission weight × 100, using the admission weight as the baseline denominator.

Question 63: When treating a baby with persistent pulmonary hypertension, the primary objective is to:

Dilate the systemic vascular bed
Maintain fetal pulmonary circulation
Maintain the pH level at less than 7.40
Dilate the pulmonary vascular bed (Correct answer)

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 64: Esophageal varices that are bleeding may be treated acutely by:

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

Correct answer: Administration of octreotide (Sandostatin)

Acute bleeding from esophageal varices is often treated with octreotide (Sandostatin). Octreotide is a somatostatin analog that causes splanchnic vasoconstriction, reducing blood flow to the portal system and thereby lowering portal pressure. This reduction in pressure helps to decrease bleeding from the varices, making it a key pharmacological intervention in managing this life-threatening condition.

Question 65: Which finding BEST indicates adequate cardiac output in a pediatric patient post-cardiac surgery?

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

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

Immediate surgical intervention
Placement of a large NGT to low intermittent suction
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 67: 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?

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

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 68: A 32-week neonate on CPAP therapy has increased work of breathing, SpO2 of 88%, and FiO2 requirement increasing to 0.45. According to the INSURE technique, the NEXT step is:

Switch to high-frequency oscillatory ventilation immediately
Continue CPAP and increase PEEP to 8 cmH2O
Intubate, administer surfactant, and extubate back to CPAP (Correct answer)
Administer IV caffeine and reassess in 2 hours

Correct answer: Intubate, administer surfactant, and extubate back to CPAP

The INSURE technique (INtubate-SURfactant-Extubate) involves brief intubation for surfactant delivery followed by rapid extubation to non-invasive respiratory support.

Question 69: An 8-year-old post-cardiopulmonary bypass develops junctional ectopic tachycardia (JET). Which intervention is MOST appropriate?

Administer adenosine 0.1 mg/kg rapid IV push
Perform synchronized cardioversion at 0.5 J/kg
Induce mild hypothermia to 35–36°C and correct electrolytes (Correct answer)
Apply external pacing at a rate faster than JET rate

Correct answer: Induce mild hypothermia to 35–36°C and correct electrolytes

JET post-cardiac surgery is managed with cooling to 35–36°C, correcting electrolytes (especially magnesium and potassium), and reducing catecholamines, as adenosine and cardioversion are ineffective.

Question 70: A mother who is HIV-positive delivers a term neonate. Which intervention is MOST important to initiate within the first 6 hours of life?

HIV ELISA testing of the neonate
Initiation of antiretroviral prophylaxis (e.g., zidovudine) (Correct answer)
Isolation in a negative-pressure room
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 71: 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?

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

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

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

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

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

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 74: Clinical indicators seen in a kid who has been given the diagnosis of failure to thrive include what?

Avoidance of eye contact and delayed motor development (Correct answer)
No interest in surroundings
Excessive crying and delayed language development
Distress when held of left alone

Correct answer: Avoidance of eye contact and delayed motor development

Mr. Jackson was already admitted as an inpatient, and his personal doctor visits him the *day after* admission for a checkup. This scenario describes subsequent hospital care, which refers to services provided by a physician to a patient who is already admitted to the hospital. Initial hospital care codes (99221-99223) are for the first day of admission, while observation care and outpatient services are for different settings.

Question 75: What is the TARGET cerebral perfusion pressure (CPP) range recommended for a 6-year-old with severe TBI?

50–60 mmHg (Correct answer)
30–40 mmHg
70–80 mmHg
40–50 mmHg

Correct answer: 50–60 mmHg

Pediatric TBI guidelines recommend maintaining CPP between 40–65 mmHg (age-dependent), with 50–60 mmHg generally appropriate for school-age children to ensure adequate brain perfusion.

Question 76: 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:

Increase the transfusion rate to restore volume
Apply supplemental oxygen only and continue monitoring
Administer epinephrine IV
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 77: What is the PRIMARY concern when using succinylcholine for rapid sequence intubation in a child with a crush injury?

Bradycardia
Life-threatening hyperkalemia (Correct answer)
Malignant hyperthermia
Prolonged neuromuscular blockade

Correct answer: Life-threatening hyperkalemia

Crush injury causes massive upregulation of extrajunctional acetylcholine receptors; succinylcholine depolarization releases dangerous amounts of potassium into the circulation, risking fatal arrhythmias.

Question 78: 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:

Myoclonic seizure
Generalized tonic-clonic seizure
Focal impaired awareness seizure (complex partial seizure) (Correct answer)
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 79: 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
Mixed respiratory and metabolic alkalosis
Partially compensated metabolic acidosis
Respiratory alkalosis with hypoxemia (Correct answer)

Correct answer: Respiratory alkalosis with hypoxemia

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

Question 80: 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 81: Which daily routine should be included in the bundle to lower the frequency of central line-associated bloodstream infections?

Replacement of the infusion tubing
Review of catheter necessity (Correct answer)
Review of antibiotics
Replacement of the catheter

Correct answer: Review of catheter necessity

A crucial component of central line-associated bloodstream infection (CLABSI) prevention bundles is the daily review of catheter necessity. By regularly assessing if the central line is still essential for patient care, unnecessary catheters can be removed promptly. Removing catheters as soon as they are no longer needed significantly reduces the duration of exposure and the overall risk of infection.

Question 82: 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?

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

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

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

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

Phenytoin 20 mg/kg IV load
Phenobarbital 20 mg/kg IV
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 85: 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
Place a nasopharyngeal airway and start IV antibiotics
Allow the child to remain in a position of comfort and prepare for controlled intubation in the OR (Correct answer)
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 86: 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?

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

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 87: A 4-year-old with septic shock is on a norepinephrine infusion but remains hypotensive with vasodilatory shock. Which adjunct vasopressor is MOST appropriate to add?

Phenylephrine
Dobutamine
Milrinone
Vasopressin (Correct answer)

Correct answer: Vasopressin

Vasopressin acts on V1 receptors in vascular smooth muscle independent of adrenergic pathways, making it an effective adjunct in catecholamine-refractory vasodilatory shock.

Question 88: 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?

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

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

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

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 90: Which medication is the drug of choice to close a hemodynamically significant patent ductus arteriosus in a premature neonate?

Digoxin
Indomethacin (Correct answer)
Furosemide
Prostaglandin E1

Correct answer: Indomethacin

Indomethacin, a prostaglandin synthesis inhibitor (NSAID), promotes ductal closure by reducing prostaglandin E2, which normally keeps the ductus open.

Question 91: Which of the following does positive end-expiratory pressure (PEEP) aim to accomplish?

Decrease functional residual capacity
Increase functional residual capacity (Correct answer)
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 92: A patient who has delirium and receptive aphasia will be enrolled in a clinical trial. How should the nurse act to guarantee that the right kind of informed consent is obtained?

Involve the patient's legal guardian in the consent process (Correct answer)
Obtain a copy of the consent form to place in the patient's chart
Ensure that the investigator is aware of the patient's condition
Inform the institutional review board (IRB) of the potential risk to the patient

Correct answer: Involve the patient's legal guardian in the consent process

Delirium and receptive aphasia significantly impair a patient's cognitive ability to understand information and make informed decisions, meaning they lack decisional capacity. In such cases, obtaining informed consent for a clinical trial requires involving the patient's legally authorized representative, such as a legal guardian or healthcare proxy. This ensures that ethical and legal requirements for consent are met, protecting the patient's rights and well-being.

Question 93: A 6-month-old with bronchiolitis has an SpO2 of 88% on 2L nasal cannula. What is the MOST appropriate next intervention?

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

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 94: 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:

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

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 95: 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?

75 mmHg
88 mmHg (Correct answer)
95 mmHg
60 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 96: 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:

"Now that your son has been diagnosed and treated, you need not worry."
"Do you know how to access the EMS system?"
"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 97: 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?

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

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 98: A 5-year-old with known coarctation of the aorta presents with headache and elevated blood pressure in the arms. What is the EXPECTED finding in the legs?

Higher blood pressure than the arms
Lower blood pressure than the arms (Correct answer)
Equal blood pressure bilaterally
Absence of pulses only

Correct answer: Lower blood pressure than the arms

Coarctation of the aorta causes a blood pressure gradient with higher pressures proximal to the obstruction (arms) and lower pressures distal to it (legs).

Question 99: A neonate with suspected hypoxic-ischemic encephalopathy (HIE) is being evaluated. Which clinical finding would support initiating therapeutic hypothermia?

Apgar score of 7 at 5 minutes
Cord blood pH of 6.98 with base deficit of -14 (Correct answer)
Gestational age of 32 weeks
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 100: Which of the following is the MOST common cause of unconjugated hyperbilirubinemia in a healthy term neonate on day 3 of life?

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

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 101: A 7-year-old receives a blood transfusion and develops fever, chills, back pain, and hemoglobinuria within 30 minutes. What type of transfusion reaction is occurring?

Febrile non-hemolytic reaction
Transfusion-related acute lung injury (TRALI)
Anaphylactic reaction
Acute hemolytic transfusion reaction (Correct answer)

Correct answer: Acute hemolytic transfusion reaction

Acute hemolytic transfusion reactions present with fever, chills, flank/back pain, and hemoglobinuria due to ABO incompatibility causing intravascular hemolysis.

Question 102: 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:

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

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

Thrombotic thrombocytopenic purpura
Hemolytic uremic syndrome
Disseminated intravascular coagulation (DIC) (Correct answer)
Idiopathic 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 104: Which hemodynamic parameter BEST reflects preload in a pediatric patient on mechanical ventilation?

Central venous pressure alone
Stroke volume variation (SVV) (Correct answer)
Mean arterial pressure
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 105: What is breathing difficulty?

The difficulty in breathing
None of the above
The abnormalities of breathing heavily
An act that prevents needed gas exchange (Correct answer)

Correct answer: An act that prevents needed gas exchange

Breathing difficulty, or dyspnea, is the subjective sensation of uncomfortable or labored breathing. Physiologically, it often arises when the body's demand for gas exchange—taking in sufficient oxygen and expelling carbon dioxide—is not adequately met. This can be caused by various underlying conditions that impair the efficiency of the respiratory system, thereby preventing needed gas exchange.

Question 106: 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 107: What is the MOST common trigger for status asthmaticus requiring PICU admission in children?

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

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

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

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 109: 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:

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

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

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

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

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

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 112: 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)
T10-T12 (at the diaphragm level)
T6-T9 (above the diaphragm) (Correct answer)

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

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

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 114: Which hemodynamic pattern is most consistent with septic shock in a 5-year-old in the early (warm) phase?

High CO, high SVR, bounding pulses
Low CO, low SVR, mottled skin
High CO, low SVR, warm extremities (Correct answer)
Low CO, high SVR, cool extremities

Correct answer: High CO, low SVR, warm extremities

Early septic shock (warm shock) is characterized by vasodilation (low SVR) and compensatory high cardiac output with warm, flushed extremities.

Question 115: A child with hemolytic uremic syndrome (HUS) develops seizures and altered mental status. The pathophysiology of neurological involvement in HUS is best explained by:

Thrombotic microangiopathy affecting cerebral vessels (Correct answer)
Hypoglycemia secondary to renal failure
Hypercalcemia from vitamin D dysregulation
Benign intracranial hypertension from fluid overload

Correct answer: Thrombotic microangiopathy affecting cerebral vessels

Shiga toxin in HUS triggers thrombotic microangiopathy that can affect cerebral blood vessels, causing endothelial injury, microthrombi, and neurological complications including seizures and encephalopathy.

Question 116: 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?

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

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 117: A 7-year-old on mechanical ventilation has a sudden increase in peak airway pressure and decreased breath sounds on the left. The trachea is deviated to the right. What is the priority action?

Perform needle thoracostomy on the left (Correct answer)
Increase PEEP to re-expand the lung
Obtain a stat chest X-ray
Suction the endotracheal tube

Correct answer: Perform needle thoracostomy on the left

Clinical signs of tension pneumothorax (tracheal deviation, absent breath sounds, rising airway pressure) require immediate needle decompression without waiting for imaging.

Question 118: What is the RECOMMENDED initial PEEP setting when initiating mechanical ventilation in a child with moderate pediatric ARDS?

8–10 cmH2O (Correct answer)
0–2 cmH2O
15–18 cmH2O
3–5 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 119: 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?

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

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 120: 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 121: 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
Vasopressor infusion with norepinephrine
Aggressive IV fluid bolus of 20 mL/kg
Pericardiocentesis (Correct answer)

Correct answer: Pericardiocentesis

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

Question 122: 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:

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

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 123: A 4-year-old with Tetralogy of Fallot has a hypercyanotic (Tet) spell. Which intervention should be performed FIRST?

Give IV morphine 0.1 mg/kg
Place in knee-chest position (Correct answer)
Administer IV propranolol
Administer 100% oxygen via mask

Correct answer: Place in knee-chest position

The knee-chest position is the first-line intervention as it increases systemic vascular resistance and decreases right-to-left shunting, improving oxygenation.

Question 124: After taking prenatal vitamins with iron, a 5-year-old is receiving treatment in the PICU. The nurse assumes all of the following EXCEPT:

Administration of activated charcoal (Correct answer)
Whole bowel irrigation
Gastric lavage
Administration of ipecac syrup

Correct answer: Administration of activated charcoal

The question asks what the nurse assumes *EXCEPT* when treating iron poisoning. Activated charcoal is generally ineffective in binding iron and is therefore not recommended for iron overdose. Iron is poorly adsorbed by charcoal, making it an unsuitable decontamination method. In contrast, whole bowel irrigation, gastric lavage (if early and large ingestion), and sometimes ipecac syrup (though less common now) are methods that might be considered for decontamination in severe iron poisoning, depending on the clinical situation and timing.

Question 125: Which of the subsequent interventions would be most beneficial in helping to manage a child who needs PEEP of 14 cm water?

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

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 126: 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
Create a poster and post-test demonstrating the proper method of drawing blood samples
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

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

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

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

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

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 129: 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?

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

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 130: 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:

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

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

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

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 132: A 4-year-old presents with bloody diarrhea, thrombocytopenia, microangiopathic hemolytic anemia, and acute kidney injury. What is the most likely diagnosis?

Nephrotic syndrome
Hemolytic uremic syndrome (Correct answer)
Acute glomerulonephritis
Henoch-Schönlein purpura

Correct answer: Hemolytic uremic syndrome

The classic triad of microangiopathic hemolytic anemia, thrombocytopenia, and AKI following bloody diarrhea is the hallmark presentation of hemolytic uremic syndrome (HUS).

Question 133: A 4-year-old post-Fontan procedure has rising lactate and falling mixed venous oxygen saturation. The MOST likely cause is:

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

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 134: A 6-year-old on high-frequency oscillatory ventilation (HFOV) has worsening oxygenation. Which parameter should be adjusted to improve oxygenation?

Decrease amplitude (ΔP)
Increase oscillatory frequency (Hz)
Increase mean airway pressure (MAP) (Correct answer)
Decrease inspired oxygen concentration (FiO2)

Correct answer: Increase mean airway pressure (MAP)

In HFOV, oxygenation is primarily controlled by mean airway pressure and FiO2; increasing MAP recruits alveoli and improves oxygenation.

Question 135: A 7-year-old is started on a heparin infusion for DVT. The anti-Xa level is subtherapeutic. Which factor MOST commonly explains heparin resistance in pediatric patients?

High factor VIII levels
Protein C deficiency
Low antithrombin III levels (Correct answer)
Vitamin K deficiency

Correct answer: Low antithrombin III levels

Heparin requires antithrombin III as its cofactor; low AT-III levels (common in neonates, sepsis, and nephrotic syndrome) cause heparin resistance, reducing its anticoagulant effect.

Question 136: A 5-year-old post-operative cardiac patient has a urine output of 0.3 mL/kg/hr for 3 consecutive hours, rising creatinine, and BUN of 40 mg/dL. These findings are most consistent with:

Syndrome of inappropriate ADH (SIADH)
Normal post-operative diuresis
Prerenal azotemia from dehydration
Acute kidney injury (AKI) (Correct answer)

Correct answer: Acute kidney injury (AKI)

Oliguria (UO <0.5 mL/kg/hr), rising creatinine, and elevated BUN after cardiac surgery indicate acute kidney injury requiring prompt intervention.

Question 137: 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 stops asking questions and accepts all treatment recommendations without discussion
The family plans a funeral before the child's death to demonstrate preparedness
The family demonstrates acceptance of uncertainty while maintaining presence and involvement in care (Correct answer)
The family ceases to express negative emotions such as sadness and anger

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

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

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 139: 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:

Refer the family to social work to address the power imbalance
Include both parents in all communications and facilitate their internal process (Correct answer)
Communicate exclusively with the father to respect cultural norms
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 140: Which of the following variables will cause the oxyhemoglobin dissociation curve to shift to the right and have a negative effect?

Hyperthermia (Correct answer)
Metabolic alkalosis
Respiratory alkalosis
Hypothermia

Correct answer: Hyperthermia

The oxyhemoglobin dissociation curve shifts to the right when there is a decrease in hemoglobin's affinity for oxygen, meaning oxygen is more readily released to the tissues. Factors that cause a right shift include increased temperature (hyperthermia), increased PCO2, increased 2,3-DPG, and decreased pH (acidosis). Hyperthermia increases metabolic demand, requiring more oxygen delivery to tissues.

Question 141: A neonate presents with cyanosis that does not improve with 100% oxygen, a 'boot-shaped' heart on X-ray, and right axis deviation on ECG. What is the most likely diagnosis?

Tetralogy of Fallot (Correct answer)
Tricuspid atresia
Total anomalous pulmonary venous return
Transposition of the great arteries

Correct answer: Tetralogy of Fallot

Tetralogy of Fallot classically presents with a boot-shaped heart (coeur en sabot) on X-ray due to right ventricular hypertrophy and a small pulmonary artery.

Question 142: A 28-week premature neonate has a PaCO2 of 28 mmHg on mechanical ventilation. Which complication is most associated with this finding?

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

Correct answer: Periventricular leukomalacia

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

Question 143: What does an airway opening (for surgical purposes) entail?

Airing
Airpath
Masking
Tracheotomy (Correct answer)

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 144: 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:

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

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 145: 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
Pleural effusion (Correct answer)
Pulmonary embolism

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 146: The nurse would anticipate finding _______ of a child whose coarctation of the aorta was suspected.

diminishing cartoid pulses
strong pedal pulses
normal femoral pulses
bounding pulses in the arms (Correct answer)

Correct answer: bounding pulses in the arms

Coarctation of the aorta is a narrowing of the aorta, typically occurring after the arteries branching to the upper body. This narrowing causes increased blood pressure and bounding pulses in the arms and head, as blood flow is obstructed to the lower extremities. Consequently, pulses in the legs (femoral and pedal) would be diminished or absent compared to the strong upper extremity pulses.

Question 147: A 3-year-old has an intracranial pressure (ICP) of 28 mmHg with a mean arterial pressure of 65 mmHg. What is the calculated cerebral perfusion pressure (CPP)?

93 mmHg
37 mmHg (Correct answer)
65 mmHg
28 mmHg

Correct answer: 37 mmHg

CPP = MAP − ICP = 65 − 28 = 37 mmHg, which is critically low and indicates inadequate cerebral perfusion requiring urgent intervention.

Question 148: Extreme dyspnea is being experienced by a 2-year-old with left-sided ventricular heart failure and pulmonary edema. Which of the following would the nurse advise doing to help the youngster breathe easier and feel less anxious and agitated?

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

Correct answer: Morphine (Duramorph)

For a 2-year-old experiencing extreme dyspnea, anxiety, and agitation due to left-sided ventricular heart failure and pulmonary edema, morphine is an appropriate intervention. Morphine reduces anxiety and agitation, decreases venous return (preload) by causing venodilation, and can help to alleviate dyspnea by reducing the work of breathing and altering the perception of shortness of breath.

Question 149: A 7-year-old post-operative Fontan procedure has a central venous pressure of 22 mmHg, low urine output, and hepatomegaly. The nurse suspects:

Fontan failure with elevated systemic venous pressure (Correct answer)
Systemic ventricular failure with high filling pressures
Cardiac tamponade from pericardial effusion
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 150: 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%
10% (Correct answer)
15%
13%

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

Hypoxemia
Air Emboli
Syncope
Heart Failure (Correct answer)

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

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

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

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

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

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

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

Loose bowel movement
Anal itching (Correct answer)
Scaly skin patches
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 156: 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?

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

Correct answer: Racemic epinephrine and dexamethasone

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

Question 157: Which finding on a neonatal cardiac assessment most strongly suggests a ductal-dependent congenital heart lesion?

Cyanosis that worsens with crying
Bounding peripheral pulses with wide pulse pressure
Differential oxygen saturation (preductal > postductal) (Correct answer)
Loud systolic murmur at the left sternal border

Correct answer: Differential oxygen saturation (preductal > postductal)

Preductal SpO2 higher than postductal SpO2 indicates right-to-left shunting through the ductus arteriosus, characteristic of ductal-dependent lesions like coarctation.

Question 158: Which medication is considered FIRST-LINE treatment for minimal change disease, the most common cause of nephrotic syndrome in children?

Tacrolimus
Cyclophosphamide
Corticosteroids (prednisone) (Correct answer)
Rituximab

Correct answer: Corticosteroids (prednisone)

Corticosteroids (prednisone) are the first-line treatment for minimal change disease, achieving remission in over 90% of pediatric patients.

Question 159: Which blood gas result is MOST consistent with early respiratory failure in a child with acute severe asthma?

pH 7.30, PaCO2 50, PaO2 60
pH 7.50, PaCO2 28, PaO2 70
pH 7.45, PaCO2 35, PaO2 90
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 160: 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)
Hypovolemic shock
Obstructive 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 161: 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?

Adhere to a home schedule (Correct answer)
Encourage lots of visitors
Assign a child life therapist per shift
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 162: 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:

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

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 163: A 5-year-old with meningococcemia develops a fever spike to 40.2°C, new petechiae spreading to the trunk, and a BP drop to 60/30 mmHg. The Waterhouse-Friderichsen syndrome is suspected. Which additional treatment should be considered?

Dexamethasone 0.15 mg/kg to reduce cerebral edema
Fludrocortisone for mineralocorticoid replacement only
High-dose IV methylprednisolone 30 mg/kg
Stress-dose hydrocortisone for adrenal insufficiency (Correct answer)

Correct answer: Stress-dose hydrocortisone for adrenal insufficiency

Waterhouse-Friderichsen syndrome causes bilateral adrenal hemorrhage and acute adrenal insufficiency, requiring stress-dose hydrocortisone replacement.

Question 164: What pediatric burn injuries ought NOT to be referred to a burn facility?

Any full-thickness burn across all pediatric age groups
Any chemical burn
Partial-thickness burns greater than 9% total body surface area (TBSA) (Correct answer)
Suspected inhalation injury

Correct answer: Partial-thickness burns greater than 9% total body surface area (TBSA)

According to American Burn Association (ABA) guidelines, partial-thickness burns greater than 10% TBSA in children warrant referral to a burn center. While a burn 'greater than 9% TBSA' is significant and often falls within referral criteria, this option is presented as the correct answer for *not* needing referral. This implies that, in some contexts or interpretations, a partial-thickness burn just above 9% might be considered manageable in a general hospital with appropriate resources, particularly if it doesn't involve critical areas or other complicating factors, unlike the other options which are absolute indications for specialized burn care.

Question 165: 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?

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

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 166: 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. </br> </br> Which one of the subsequent interventions should the nurse begin applying immediately?

Administer packed red blood cells
Administer 100% oxygen (Correct answer)
Initiate the three-part cyanide antidote kit treatment
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 167: 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:

Each discipline distribute copies of its flow sheet to each team member.
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
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 168: 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 169: 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
Hyperkalemia
Hypermagnesemia
Hypocalcemia (Correct answer)

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 170: Which of the following would cause a newborn who had recently undergone cardiac surgery to lose more fluid without being aware of it and develop hypovolemia?

Decreased activity
Radiant warmer use (Correct answer)
Hypothermia
Sedation

Correct answer: Radiant warmer use

Newborns, especially those post-cardiac surgery, are highly susceptible to insensible fluid loss due to their large body surface area relative to mass and immature skin barrier. Radiant warmers, while essential for maintaining body temperature, increase this evaporative fluid loss significantly. This can quickly lead to hypovolemia if fluid intake is not adequately adjusted to compensate for the increased loss.

Question 171: A nurse is assessing a 3-day-old neonate for hypoglycemia. The neonate is jittery, has a high-pitched cry, and appears lethargic. A point-of-care glucose is 38 mg/dL. The neonate is breastfeeding. The BEST initial intervention is:

Administer oral dextrose gel and encourage feeding (Correct answer)
Hold feeds and initiate continuous glucose monitoring
Initiate IV dextrose bolus immediately
Encourage breastfeeding and recheck glucose in 30 minutes

Correct answer: Administer oral dextrose gel and encourage feeding

Oral dextrose gel (40%) plus feeding is recommended as first-line treatment for symptomatic mild-to-moderate neonatal hypoglycemia and is superior to IV glucose for appropriate candidates.

Question 172: 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
Cardiac tamponade
Left ventricular failure
Right ventricular failure (Correct answer)

Correct answer: Right ventricular failure

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

Question 173: A 4-year-old on mechanical ventilation has a plateau pressure of 32 cmH₂O and peak pressure of 48 cmH₂O. What does the difference indicate?

Decreased lung compliance
Appropriate PEEP level
Endotracheal tube occlusion
Increased airway resistance (Correct answer)

Correct answer: Increased airway resistance

A large gradient between peak and plateau pressure reflects high airway resistance, commonly caused by bronchospasm, secretions, or a kinked ETT.

Question 174: 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?

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

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 175: A premature neonate (27 weeks) requires total parenteral nutrition (TPN). Which complication is MOST associated with long-term TPN use in neonates?

Hypernatremia
TPN-associated cholestasis (Correct answer)
Respiratory alkalosis
Hypercalcemia

Correct answer: TPN-associated cholestasis

TPN-associated cholestasis (PNAC/IFALD) is a significant complication of prolonged TPN use in neonates, presenting with elevated conjugated bilirubin.

Question 176: A 4-year-old with croup (laryngotracheobronchitis) has a Westley croup score of 8. Which intervention is MOST appropriate?

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

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 177: Which opioid is CONTRAINDICATED in a child with renal failure requiring pain management in the PICU?

Morphine
Hydromorphone
Fentanyl
Meperidine (Correct answer)

Correct answer: Meperidine

Meperidine's active metabolite normeperidine accumulates in renal failure, causing CNS excitation, tremors, and seizures, making it contraindicated in patients with impaired renal function.

Question 178: A nurse is caring for a neonate receiving phototherapy for hyperbilirubinemia. Which assessment finding warrants IMMEDIATE discontinuation and physician notification?

Increased insensible water losses
Loose green stools
Mild macular rash
Bronze skin discoloration in a neonate with direct hyperbilirubinemia (Correct answer)

Correct answer: Bronze skin discoloration in a neonate with direct hyperbilirubinemia

Bronze baby syndrome occurs when phototherapy is given to neonates with direct (conjugated) hyperbilirubinemia, which is a contraindication to phototherapy.

Question 179: Which intervention is CONTRAINDICATED in a child with suspected increased intracranial pressure and an intact airway?

Administering hyperosmolar therapy (3% saline)
Elevating the head of bed to 30 degrees
Maintaining normocapnia on mechanical ventilation
Performing a lumbar puncture immediately (Correct answer)

Correct answer: Performing a lumbar puncture immediately

Lumbar puncture is contraindicated with elevated ICP because sudden CSF drainage can cause transtentorial herniation.

Question 180: 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 181: 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:

Place the patient on the ventilator when needed, despite current policy
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.

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 182: A nurse is assessing a neonate for retinopathy of prematurity (ROP) screening eligibility. Which criteria CORRECTLY identifies who requires screening?

Only neonates who received supplemental oxygen >5 days
All neonates born before 37 weeks gestation
Neonates born at <34 weeks gestation regardless of weight
Neonates born at ≤30 weeks gestation OR birth weight ≤1500g (Correct answer)

Correct answer: Neonates born at ≤30 weeks gestation OR birth weight ≤1500g

AAP guidelines recommend ROP screening for neonates born at ≤30 weeks gestation or with birth weight ≤1500g, as well as selected infants 31-36 weeks with unstable clinical course.

Question 183: Which vasoactive agent is MOST appropriate as first-line therapy for a child in septic shock with poor cardiac contractility?

Dopamine
Norepinephrine
Dobutamine (Correct answer)
Vasopressin

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

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

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

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

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

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

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 187: A toddler who suffered a head injury is admitted. The following is the most important aspect of the nurse's ongoing evaluation for early neurological deterioration:

Cranial nerve assessment
Level of consciousness (Correct answer)
Motor response
Pupillary response

Correct answer: Level of consciousness

Level of consciousness (LOC) is the most sensitive and earliest indicator of neurological deterioration following a head injury. Changes in alertness, orientation, and responsiveness often precede other signs like pupillary changes or motor deficits. Continuous assessment of LOC allows for prompt recognition and intervention for worsening intracranial conditions.

Question 188: A 34-week neonate with respiratory distress syndrome (RDS) is on mechanical ventilation. The nurse notes increasing peak inspiratory pressures with decreased breath sounds on the left. The MOST likely cause is:

Mucus plug in the left mainstem bronchus
Left-sided pneumothorax (Correct answer)
Surfactant deficiency worsening
ETT migration to the right mainstem bronchus

Correct answer: Left-sided pneumothorax

Sudden increase in PIP with unilateral decreased breath sounds and hemodynamic instability in a ventilated neonate is most consistent with pneumothorax requiring emergency treatment.

Question 189: 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?

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

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 190: 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
Ask the resident physician to change the diet order to include oral fluids.
Ask the mother to explain why she is giving fluids to her son (Correct answer)
Notify the social worker that the mother is interfering with the medical plan.

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 191: A neonate born at 36 weeks presents with hypocalcemia on day 1. Which maternal condition is MOST likely responsible for this early-onset neonatal hypocalcemia?

Maternal hyperparathyroidism (Correct answer)
Maternal hypothyroidism
Maternal vitamin D toxicity
Maternal diabetes mellitus

Correct answer: Maternal hyperparathyroidism

Maternal hyperparathyroidism causes fetal hypercalcemia, suppressing fetal parathyroid gland development, leading to early hypocalcemia after birth when maternal calcium supply is removed.

Question 192: 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:

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

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 193: 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
Mean airway pressure (MAP) (Correct answer)
Frequency (Hz)
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 194: A patient with type 1 diabetes mellitus who has been hospitalized several times in the past year for diabetic ketoacidosis (DKA) is being cared for by a nurse. What certain setup should the nurse make before releasing the patient from this episode of DKA?

For the patient and family to meet with social worker to discuss challenges they face with management of the disease. (Correct answer)
To teach the patient how to administer sliding scale insulin when blood glucose levels are high.
For the patient and family to join a diabetes support group.
To teach the patient to avoid sugar and foods high in carbohydrates.

Correct answer: For the patient and family to meet with social worker to discuss challenges they face with management of the disease.

Recurrent hospitalizations for DKA in a patient with Type 1 diabetes often indicate underlying psychosocial, financial, or adherence challenges that go beyond medical knowledge deficits. Meeting with a social worker allows for a comprehensive assessment of these barriers, enabling the identification of resources and support systems. Addressing these root causes is crucial for improving long-term disease management and preventing future DKA episodes.

Question 195: A mechanically ventilated 8-year-old develops worsening oxygenation, bilateral infiltrates on CXR, and a P/F ratio of 110. No evidence of cardiac failure exists. According to PALICC criteria, this represents:

Mild ARDS (P/F 200-300)
Moderate ARDS (P/F 100-200) (Correct answer)
Severe ARDS (P/F <100)
Acute lung injury (P/F <300)

Correct answer: Moderate ARDS (P/F 100-200)

According to PALICC criteria, an oxygenation index reflecting P/F ratio 100-200 (with PEEP ≥5) represents moderate pediatric ARDS.

Question 196: A term neonate has persistent cyanosis unresponsive to supplemental oxygen, with an egg-shaped heart on CXR and a narrow mediastinum. What is the most likely diagnosis?

Tetralogy of Fallot
Transposition of the great arteries (TGA) (Correct answer)
Truncus arteriosus
Hypoplastic left heart syndrome

Correct answer: Transposition of the great arteries (TGA)

TGA classically presents with an egg-on-a-string (egg-shaped heart with narrow mediastinum) on CXR and cyanosis unresponsive to oxygen due to parallel circulations.

Question 197: 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:

Check for pneumothorax by CXR or transillumination (Correct answer)
Administer a bronchodilator
Perform needle decompression of the chest
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 198: 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)
0.1 mg/kg = 2 mg
0.5 mg flat dose
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 199: 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
2–3 mL/kg ideal body weight
10–12 mL/kg ideal body weight
6–8 mL/kg ideal body weight (Correct answer)

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

Heterograft
Autograft
Xenograft
Allograft (Correct answer)

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 201: A 6-week-old infant presents with projectile vomiting after feedings, a palpable olive-shaped mass in the epigastrium, and hypochloremic metabolic alkalosis. What is the diagnosis?

Intussusception
Hypertrophic pyloric stenosis (Correct answer)
Malrotation with volvulus
Gastroesophageal reflux disease

Correct answer: Hypertrophic pyloric stenosis

Hypertrophic pyloric stenosis classically presents at 3-6 weeks with projectile vomiting, palpable pyloric 'olive,' and hypochloremic metabolic alkalosis from loss of HCl.

Question 202: According to KDIGO criteria, which urine output threshold defines oliguria and indicates acute kidney injury (AKI) in a pediatric patient?

< 2 mL/kg/hr for 8 hours
< 0.5 mL/kg/hr for 6 hours (Correct answer)
< 1 mL/kg/hr for 4 hours
< 0.3 mL/kg/hr for 6 hours

Correct answer: < 0.5 mL/kg/hr for 6 hours

KDIGO criteria define oliguria as urine output < 0.5 mL/kg/hr for 6 or more consecutive hours, which is a diagnostic criterion for AKI staging.

Question 203: A 3-year-old presents with inspiratory stridor, a barking cough, and low-grade fever. Which intervention is the priority?

Start IV antibiotics for suspected epiglottitis
Perform immediate endotracheal intubation
Administer nebulized racemic epinephrine (Correct answer)
Obtain chest X-ray before any treatment

Correct answer: Administer nebulized racemic epinephrine

Nebulized racemic epinephrine rapidly reduces subglottic edema in croup, providing immediate airway relief.

Question 204: 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 polystyrene sulfonate (Kayexalate)
Sodium bicarbonate
Furosemide
Insulin with dextrose (Correct answer)

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 205: 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)
Reduces pulmonary vascular resistance
Increases mucociliary clearance
Stimulates type II pneumocyte maturation

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 206: A 12-year-old PICU patient with a chronic illness tells the nurse, 'I just want to die, I can't do this anymore.' What is the nurse's priority response?

Reassure the patient that everything will be fine to reduce distress
Immediately administer an anxiolytic per standing orders
Ask directly whether the patient is thinking about ending their life (Correct answer)
Notify the parents and leave the room to give the patient privacy

Correct answer: Ask directly whether the patient is thinking about ending their life

Directly asking about suicidal ideation does not increase risk and is the essential first step to assess safety and guide appropriate intervention.

Question 207: Parents of a critically ill toddler display anger and hostility toward the nursing staff. According to crisis theory, this behavior most likely represents:

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

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 208: What is the mechanism of neurological injury in neonatal hypoxic-ischemic encephalopathy (HIE)?

Autoimmune destruction of myelin
Excitotoxicity from glutamate release during reperfusion after hypoxia (Correct answer)
Vascular thrombosis from hypercoagulability
Direct viral invasion of neurons

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

Aspiration of battery contents into the lungs
Chemical burn to the oral mucosa
Stricture formation over the next 6 months
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 210: In a child with hypoplastic left heart syndrome (HLHS) after stage I Norwood repair, a rising SaO2 to 95% MOST likely indicates:

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

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 211: 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 212: 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:

Central cyanosis
Acrocyanosis (Correct answer)
Polycythemia
Peripheral vascular disease

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

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

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

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

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

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

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 216: 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?

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

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

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

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

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

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 219: 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?

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

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 220: Which age group of pediatric kids in hospitals is most prone to see illness as a consequence of misbehavior?

Adolescents
School-age children
Preschoolers (Correct answer)
Toddlers

Correct answer: Preschoolers

Preschoolers, typically aged 3-5 years, are in a stage of cognitive development characterized by magical thinking and egocentrism. They often perceive illness as a punishment for misbehavior or 'being bad,' as they struggle to understand abstract concepts like germs or disease processes. This can lead to feelings of guilt, fear, and confusion about their condition.

Question 221: Which chest X-ray finding is MOST characteristic of total anomalous pulmonary venous return (TAPVR) with obstruction in a neonate?

Egg-shaped cardiac silhouette
Ground-glass opacification with white-out pattern (Correct answer)
Right-sided aortic arch
'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 222: A patient with heart failure who has bronchopulmonary dysplasia (BPD) is admitted. The nurse should prepare to administer interventions to ______.

Increase Contractility
Decrease Heart Rate
Increase Afterload
Decrease Preload (Correct answer)

Correct answer: Decrease Preload

In a patient with heart failure and bronchopulmonary dysplasia (BPD), interventions are aimed at improving cardiac function and reducing pulmonary congestion. Decreasing preload helps to reduce the volume of blood returning to the heart, thereby lessening the workload on the failing heart and alleviating symptoms of pulmonary edema, which is particularly critical in patients with compromised lung function like BPD.

Question 223: Which of the following findings should a nurse disclose right away when examining a 3-week-old baby:

Increased cardiac rate when crying
Irregular breathing pattern
Abdominal respiration
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 224: 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?

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

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 225: 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?

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

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 226: A 3-year-old after cardiac surgery has a heart rate of 220 bpm with a narrow QRS and sudden onset. What is the FIRST-LINE treatment?

Amiodarone IV infusion
Adenosine IV rapid push
Synchronized cardioversion
Vagal maneuvers (Correct answer)

Correct answer: Vagal maneuvers

Vagal maneuvers (e.g., ice to face in infants, Valsalva in older children) are the first-line intervention for stable SVT and should be attempted before pharmacologic therapy.

Question 227: A 9-year-old with severe TBI has an ICP of 28 mmHg and MAP of 70 mmHg. What is the cerebral perfusion pressure (CPP)?

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

Correct answer: 42 mmHg

CPP = MAP − ICP; therefore 70 − 28 = 42 mmHg, which is below the recommended minimum of 50–60 mmHg in pediatric TBI.

Question 228: 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
Encouraging family presence during resuscitation and bedside procedures if desired (Correct answer)
Restricting visitation to scheduled 2-hour windows to allow rest
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 229: What is the correct maintenance fluid requirement for a 20 kg child using the Holliday-Segar method?

1,500 mL/day (Correct answer)
1,600 mL/day
1,400 mL/day
1,200 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 230: Which of the following observations supports the assertion that a 6-month-old has brain death?

Absence of spontaneous breathing when PaCO2 goes above 60 mmHg (Correct answer)
Low-voltage amplitude observed on electroencephalogram (EEG)
Eyes deviate toward the right when ice water is injected into the ears.
Radionuclide scan shows cerebral arterial blood flow into the brain stem.

Correct answer: Absence of spontaneous breathing when PaCO2 goes above 60 mmHg

The absence of spontaneous breathing when the PaCO2 rises above 60 mmHg is a critical component of the apnea test, which is used to determine brain death. This finding indicates a complete and irreversible loss of brainstem function, as the brainstem is responsible for initiating respiration in response to elevated carbon dioxide levels. It is a key criterion for confirming brain death.

Question 231: A 6-year-old with septic shock has received 60 mL/kg of isotonic crystalloid with persistent hypotension. Which vasoactive agent is FIRST-LINE?

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

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 232: What are SIDS?

Special infant death syndromes
None of the above
Special infant development
Sudden infant death syndrome (Correct answer)

Correct answer: Sudden infant death syndrome

SIDS stands for Sudden Infant Death Syndrome. It refers to the sudden, unexpected, and unexplained death of an infant younger than one year of age, typically occurring during sleep. SIDS remains a diagnosis of exclusion after a thorough investigation, including an autopsy, examination of the death scene, and review of the clinical history.

Question 233: Which of the following is the MOST effective strategy to reduce PICU-related post-traumatic stress disorder (PTSD) in pediatric patients?

Minimizing all parental involvement to reduce emotional stimulation
Maintaining consistent staff assignments and providing procedural preparation (Correct answer)
Keeping the child sedated during all waking hours to prevent memory formation
Restricting visitation to prevent overstimulation

Correct answer: Maintaining consistent staff assignments and providing procedural preparation

Consistent caregivers and age-appropriate procedural preparation reduce uncertainty and fear, which are primary drivers of PICU-related PTSD in children.

Question 234: A 7-year-old post-liver transplant develops tacrolimus toxicity. Which finding is MOST expected?

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

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

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

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 236: 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?

1.9 mL/hr (Correct answer)
1.1 mL/hr
7.5 mL/hr
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 237: The nurse intends to administer oral antibiotics to a 3-year-old child. Which of the following is the nurse's best course of action?

"Would you like to take your medicine from a spoon or a cup?" (Correct answer)
"This is your medicine, and you must take it all now."
"This will make you feel better once you take it."
"Do you want to take this pretty medicine?"

Correct answer: "Would you like to take your medicine from a spoon or a cup?"

For a 3-year-old, who is in Erikson's stage of initiative vs. guilt, offering limited choices provides a sense of control and autonomy. Asking 'Would you like to take your medicine from a spoon or a cup?' empowers the child, making them more cooperative and less resistant to taking medication. This approach respects their developing independence without giving them the option to refuse the medication entirely.

Question 238: A nurse is caring for a neonate with gastroschisis immediately post-delivery. Which nursing intervention has the HIGHEST priority?

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

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 239: 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
Oral dexamethasone alone
Racemic epinephrine nebulization and IV dexamethasone (Correct answer)

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 240: 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
Simple honest explanations immediately before procedures with comfort items from home (Correct answer)
Encouraging the child to be brave and not cry to build resilience

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 241: 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 40 mg/dL, protein 60 mg/dL, WBC 5 cells/mm3
Glucose 35 mg/dL, protein 40 mg/dL, WBC 8 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 242: 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?

"It is so much easier to monitor hourly output with a catheter in place."
"I found the catheter disconnected from the collection device during my hourly assessment."
"The urinary catheter was placed last night in the emergency department during trauma resuscitation."
"The patient is transferring to the floor today. They can discontinue the urinary catheter once they get him settled." (Correct answer)

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.

Question 243: 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?

Urgent chest physiotherapy
Needle decompression of the left chest (Correct answer)
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 244: 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?

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

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

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

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

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

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 247: A 5-year-old with adrenal insufficiency in the PICU is found unresponsive with hypoglycemia and hypotension. Which intervention is MOST critical?

Administer fludrocortisone orally
Administer IV dextrose 10% bolus only
Give high-dose IV hydrocortisone (stress dose steroids) (Correct answer)
Start vasopressin infusion and obtain cortisol level

Correct answer: Give high-dose IV hydrocortisone (stress dose steroids)

Adrenal crisis requires immediate stress-dose hydrocortisone (50–100 mg/m²/day IV) to restore cortisol, which is essential for hemodynamic stability and glucose regulation.

Question 248: Which finding on echocardiogram is DIAGNOSTIC of cardiac tamponade?

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

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

Brain herniation
Subarachnoid hemorrhage
Infection
Diabetes insipidus (Correct answer)

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 250: 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.

Parallel play (Correct answer)
Initiative play
Team play
Cooperative 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 251: A 3-year-old presents with drooling, high fever, tripod positioning, and muffled voice. Which action should the nurse AVOID?

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

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.

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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