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Critical Care Register Nurse - Pediatric Practice Test

CCRN-Pediatric exam Format | Course Contents | Course Outline | exam Syllabus | exam Objectives

Exam Code: CCRN-Pediatric
Exam Name: Critical Care Register Nurse - Pediatric
Total Questions: 150 multiple-choice questions.
Scored Questions: 125 questions are scored- 25 questions are unscored.
Time Allotted: 3 hours.
Passing Score: A minimum of 83 correct answers out of the 125 scored questions is required to pass.

Cardiovascular
- Cardiac infection and inflammatory diseases
- Cardiac malformations
- Cardiac surgery
- Cardiac transplant
- Cardiac/vascular catheterization
- Cardiogenic shock
- Cardiomyopathies
- Dysrhythmias
- Heart failure
- Hepertensive crisis
- Myocardial conduction system defects (e.g.-prolonged QT interval- Wolff-Parkinson-White)
- Vascular occlusions
Respiratory
- Acute pulmonary embolus
- Acute respiratory distress syndrome (ARDS)
- Acute respiratory failure
- Acute respiratory infection
- Chronic respiratory failure
- Chrnoic pulmonary conditions
- Airway malformations
- Pulmonary hypertension
- Status asthmaticus
- Thoracic and airway trauma (e.g.- fractured rib-lung contusion- tracheal perforation)
- Thoracic surgery
Endocrine- Hematology/Immunology- GI- Renal/GU- Integumentary
- Endocrine
- Diabetes mellitus
- Diabetic ketoacidosis (DKA)
- Hyperglycemia
- Hypoglycemia
- Diabetes insipidus (DI)- syndrome ofinappropriate antidiuretic hormonesecretion (SIADH)- cerebral salt wasting(CSW)
- Hematology and Immunology
- Anemia
- Bone marrow transplant
- Coagulopathies (e.g.- ITP- DIC- HIT)
- Immune deficiencies
- Myelosuppression (e.g.- thrombocytopenia-neutropenia)
- Oncologic complications (e.g.- tumor lysissyndrome- neutropenia)
- Sickle cell crisis
- Transfusion reactions (e.g.- TRALI- TACO)
- Gastrointestinal
- Abdominal compartment syndrome
- Acute abdominal trauma
- Acute GI hemorrhage
- Bowel infarction/obstruction/perforation(e.g.- mesenteric ischemia- adhesions)
- GI abnormalities
- GI surgeries (e.g.- Whipple- esophagectomy-resections)
- Hepatic disease and failure/coma
- Liver transplant
- Malnutrition and malabsorption
- Peritonitis
- Renal and Genitourinary
- Acute kidney injury (AKI)
- Chronic kidney disease (CKD)
- Hemolytic uremic syndrome (HUS)
- Kidney transplant
- Life-threatening electrolyte imbalances
- Integumentary
- IV infiltration/extravasation
- Pressure injury
- Skin failure (e.g.- hypoperfusion)
- Wounds
Musculoskeletal- Neurological- BehavioralPsychosocial
- Musculoskeletal
- Compartment syndrome
- Musculoskeletal trauma
- Rhabdomyolysis
- Neurological
- Acute spinal cord injury
- Brain death
- Congenital neurological abnormalities
- Delirium
- Encephalopathy
- Intracranial hemorrhage
- Stroke
- Hydrocephalus
- Neurologic infectious disease
- Neuromuscular disorders
- Neurosurgery
- Seizure disorders
- Space-occupying lesions
- Spinal fusion
- Traumatic brain injury
- Behavioral and Psychosocial
- Abuse/neglect/maltreatment
- Medical non-adherence
- Mood disorders- depression- anxiety
- Post-intensive care syndrome (PICS)
- Suicidal ideation and/or behaviors
Multisystem
- Acid-base imbalance
- Burns- thermal injury/exposure
- End-of-life
- Palliative care
- Healthcare-acquired conditions (HAC)
- Multi-organ dysfunction syndrome (MODS)
- Tissue and organ donation
- Pain: acute and chronic
- Systemic inflammatory response syndrome(SIRS)
- Sepsis
- Shock states (e.g.- distributive- hypovolemic-obstructive)
- Submersion injuries (near-drowning)
- Toxic ingestion/inhalation/exposure
General
- Identify signs and symptoms of clinical deterioration-initiate nursing interventions- and seek assistance asneeded
- Conduct a comprehensive physical and psychosocialassessment
- Evaluate diagnostic test results and anticipateinterventions
- Interpret laboratory and blood gas results andanticipate interventions
- Provide family-centered care
- Conduct developmentally appropriate painassessment
- Manage tissue and organ donors
- Manage monitor alarms based on protocols andchanges in patient condition
- Prevention and management of healthcare acquiredconditions/events
- Recognize indications for and manage patients with/requiring:
- complementary alternative medicine and/ornon-pharmacologic interventions
- intra-procedural and post-procedural care
- medications (e.g.- safe administration-monitoring- polypharmacy- sedation)
- fluid and electrolyte replacement
- palliative care
- end-of-life care
- pre- and post-operative care
- procedural sedation
- temperature monitoring and regulation devices
- bone fracture prevention and/or treatment
- vascular access
- Cardiovascular
- Identify- interpret and respond to cardiac rhythms
- Monitor hemodynamic status and recognize signsand symptoms of hemodynamic instability
- Recognize indications for and manage patients with/requiring:
- 12-lead ECG
- cardioversion (pharmacologic- nonpharmacologic- electrical)
- defibrillation
- invasive hemodynamic monitoring (e.g.- arterialcatheter- central venous pressure monitoring)
- near infrared spectroscopy (NIRS)
- temporary pacing
- ventricular assist device (VAD)
- Respiratory
- Assess and prevent complications related tomechanical ventilation
- Recognize indications for and manage patients with/requiring:
- artificial airways (e.g.- endotracheal tube-tracheostomy- LMA)
- non-invasive ventilation (e.g.- BiPAP- CPAP- high-flow nasal cannula)
- invasive ventilation (e.g.- conventionalmechanical ventilation)
- non-conventional mechanical ventilation (e.g.-high-frequency- jet)
- chest tubes
- prone positioning
- rapid sequence itubation (RSI)
- therapeutic gases (e.g.- oxygen- nitric oxide-heliox- CO2)
- Hematology and Immunology
- Recognize indications for and manage patients with/requiring:
- plasmapheresis- exchange transfusion- orleukocyte depletion
- transfusion of blood and blood products
- Neurological
- Recognize indications for and manage patients with/requiring:
- neuroprotective protocols
- neurologic monitoring devices and drains (e.g.-ICP- ventricular drain)
- seizure precautions
- spinal precautions
- brain death assessment
- Integumentary
- Prevent and manage surgical site infection
- Manage patients requiring wound prevention and/ortreatment
- Gastrointestinal
- Recognize indications for and manage patients with/requiring:
- intra-abdominal pressure monitoring
- inadequate nutrition and fluid intake
- enteral and parenteral nutrition
- enteral tubes
- gastrointestinal drains
- necrotizing enterocolitis (NEC)
- Renal and Genitourinary
- Recognize indications for and manage patients requiring renal therapeutic intervention (e.g.hemodialysis- CRRT- peritoneal dialysis)
- Multisystem
- Early and late sepsis identification and treatment
- Monitor and implement strategies to preventhospital acquired infections
- Recognize indications for and manage patientsrequiring progressive mobility
- Manage patients requiring extracorporeal membraneoxygenation (ECMO)
- Behavioral and Psychosocial
- Conduct behavioral assessment (e.g.- delirium-withdrawal)
- Manage patients requiring behavioral and mentalhealth interventions
- Respond to behavioral emergencies (e.g.- nonviolentcrisis intervention- de-escalation techniques)
- Recognize indications for and manage patientsrequiring restraints

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Critical Care Register Nurse - Pediatric
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Question: 1409
A 7-year-old with end-stage renal disease (ESRD) on peritoneal dialysis develops cloudy dialysate
effluent and abdominal pain. What is the priority nursing action?
A. Increase dwells per hour
B. Perform manual drainage to empty the abdomen
C. Change dialysate solution to one with higher dextrose concentration
D. Notify healthcare provider for possible peritonitis
Answer: D
Explanation: Cloudy peritoneal dialysis effluent with abdominal pain is suggestive of peritonitis, a
common and serious complication. Early identification and notification for antibiotic therapy is essential.
Increasing dwells or changing dialysate are inappropriate and drainage may worsen symptoms. The
priority is to notify the healthcare provider for diagnosis and treatment.
Question: 1410
In a post-operative pediatric patient with an arterial catheter in place, the nurse notes the following
arterial waveform changes: a dicrotic notch is absent, and the waveform has a broad, rounded peak with a
slow upstroke. This pattern most likely indicates:
A. Aortic valve insufficiency
B. Increased systemic vascular resistance
C. Hypovolemia with diminished stroke volume
D. Increased arterial compliance
Answer: A
Explanation: Absence of the dicrotic notch and a broad, rounded waveform suggests aortic valve
insufficiency (regurgitation). The dicrotic notch represents aortic valve closure, and its absence points to
valve incompetence. Increased systemic vascular resistance would produce a higher systolic peak;
hypovolemia leads to narrow pulses, and increased compliance causes a dampened waveform but with
preserved notch.
Question: 1411
What is the most reliable method for diagnosing compartment syndrome in pediatric patients?
A. Measuring capillary refill time
B. Measuring intracompartmental pressure
C. Assessing skin temperature
D. Pain location on palpation
Answer: B
Explanation: Intracompartmental pressure monitoring provides objective, quantitative diagnosis. Clinical
findings are important but less reliable alone.
Question: 1412
A child with severe neutropenia develops fever and diffuse swelling and tenderness in the lower leg
without trauma history. What imaging modality is most useful to evaluate for osteomyelitis?
A. Bone scintigraphy (nuclear medicine scan)
B. Plain radiograph (X-ray) of the leg
C. Magnetic resonance imaging (MRI) of the leg
D. Ultrasound of the leg
Answer: C
Explanation: MRI is the gold standard for early detection of osteomyelitis because of high sensitivity in
soft tissue and bone marrow changes. X-rays may be normal early. Bone scan is sensitive but less
specific. Ultrasound helps to detect fluid collections but not bone involvement directly.
Question: 1413
In pediatric patients, which serum parameter is most predictive of risk for skin failure due to
hypoperfusion?
A. Serum lactate concentration
B. Serum albumin concentration
C. Serum creatinine concentration
D. Serum potassium concentration
Answer: A
Explanation: Elevated serum lactate indicates tissue hypoxia and hypoperfusion, which is a key
pathogenic factor in skin failure. Low albumin may affect skin healing but is less predictive of acute skin
failure. Creatinine and potassium levels relate to kidney function and electrolyte balance but not
specifically to skin perfusion.
Question: 1414
Which lab finding is most suggestive of delirium secondary to sepsis-associated encephalopathy in a
pediatric patient?
A. Reduced blood ammonia
B. Normal white blood cell count
C. Low serum creatinine
D. Elevated C-reactive protein (CRP) and procalcitonin
Answer: D
Explanation: Elevated CRP and procalcitonin indicate systemic inflammation and sepsis, which can cause
sepsis-associated encephalopathy presenting as delirium. Normal WBC, low creatinine, or reduced
ammonia are less relevant.
Question: 1415
A 4-year-old post-colectomy with ileostomy has output 40 mL/kg/day (600 mL for 15 kg). Replace with
ORS (Na 75 mEq/L) PO if tolerating. Calculate Na replacement if serum Na 130 mEq/L (deficit 12
mEq/kg=180 mEq).
A. 1.8 L ORS over 48h
B. 2.4 L ORS over 24h
C. 3.0 L ORS over 24h
D. 1.2 L ORS over 24h
Answer: B
Explanation: Output 600 mL replaces with equal ORS volume for isotonic losses, providing 45 mEq Na
(75 mEq/L x 0.6 L), plus deficit correction 50%/24h=90 mEq (1.2 L ORS), total 2.4 L/24h gradual to
avoid rapid shifts. Slower risks persistence; more overcorrects.
Question: 1416
A child with DKA has the following labs: glucose 520 mg/dL, sodium 130 mEq/L, potassium 4.8
mEq/L, bicarbonate 15 mEq/L. After initiation of insulin and fluids, which electrolyte should be
monitored most closely to prevent potential cardiac arrhythmias?
A. Magnesium
B. Calcium
C. Potassium
D. Phosphorus
Answer: C
Explanation: Potassium decreases as insulin drives potassium intracellularly, risking hypokalemia and
cardiac arrhythmias in DKA treatment, requiring close monitoring.
Question: 1417
A child receiving continuous positive airway pressure (CPAP) via tracheostomy has a sudden
desaturation episode. The nurse notes the device was disconnected briefly. What is the expected
immediate physiological effect?
A. Improved oxygenation due to recruitment maneuvers
B. Increased airway pressure causing barotrauma
C. Elevated PaCO2 due to hyperventilation
D. Decreased functional residual capacity leading to alveolar collapse
Answer: D
Explanation: Brief CPAP disconnection decreases end-expiratory pressure, causing loss of functional
residual capacity and alveolar collapse, leading to desaturation. Increased pressure or hyperventilation
would not result from disconnection. Recruitment maneuvers are active interventions, not spontaneous
effects.
Question: 1418
A 2-year-old girl post-cardiac arrest from hypoplastic left heart syndrome variant requires extracorporeal
membrane oxygenation (ECMO) for refractory cardiogenic shock. On ECMO day 2, she exhibits anuric
AKI with pH 7.15, bicarbonate 12 mEq/L, lactate 8.2 mmol/L, and fluid overload of 15% estimated
blood volume. Ammonia level is 250 �mol/L due to suspected inborn error of metabolism unmasked by
ischemia. The ECMO circuit blood flow is 1.5 L/min. What is the most appropriate integration of renal
replacement therapy to address metabolic derangements while minimizing circuit interruptions?
A. Use prolonged intermittent renal replacement therapy (PIRRT) at dialysate flow 100 mL/min for 10
hours daily
B. Initiate peritoneal dialysis with icodextrin dwell for 6 hours to enhance diffusive clearance without
vascular access
C. Perform intermittent hemodialysis via separate double-lumen catheter with Kt/V target of 1.4 per
session
D. Connect continuous venovenous hemofiltration (CVVH) inline to ECMO circuit at 2000 mL/h
replacement fluid with post-filter calcium infusion
Answer: D
Explanation: Integrating continuous venovenous hemofiltration (CVVH) directly into the ECMO circuit
is optimal for this anuric patient with severe metabolic acidosis, hyperammonemia, and fluid overload, as
it leverages the existing high-flow ECMO access for convective clearance of middle molecules like
lactate and ammonia without additional vascular complications or circuit disconnections that could
destabilize ECMO support. The replacement fluid rate of 2000 mL/h (approximately 40 mL/kg/h for a 10
kg child) targets intensive dosing for toxin removal, with post-filter calcium to counteract citrate if used,
though pre-filter replacement suffices for hemolysis prevention in ECMO. Peritoneal dialysis is
contraindicated post-arrest due to poor clearance of ammonia (requiring >100 mL/kg/h dialysate
equivalent) and risk of impaired peritoneal perfusion from ECMO-related abdominal congestion;
intermittent hemodialysis demands separate access with hypotension risks in cardiogenic shock; PIRRT,
while flexible, interrupts ECMO priming and offers less continuous control in ECMO-dependent patients.
Pediatric ECMO-CRRT studies report 50-60% survival with inline CVVH improving acid-base recovery.
Question: 1419
A child with a tracheostomy develops subcutaneous emphysema around the neck with rising ventilator
peak pressures and decreased tidal volume. What should the nurse immediately assess?
A. Tracheostomy tube cuff integrity and position
B. Chest X-ray for pneumothorax diagnosis
C. Endotracheal suctioning frequency and technique
D. Ventilator settings for tidal volume adjustment
Answer: A
Explanation: Subcutaneous emphysema with rising airway pressures and decreased volumes suggests air
leak from cuff rupture or tube malposition. Assessing cuff integrity and tube placement helps identify the
cause. Chest X-ray will confirm but immediate tube-related issues are addressed first. Suctioning
frequency or ventilator changes do not explain subcutaneous emphysema.
Question: 1420
An 8-month-old infant born at 32 weeks gestation presents with bulging fontanelle, sunset eyes, and
apneic episodes. Head ultrasound shows ventricular dilation with Evans' index of 0.45 (normal <0.3).
Recent lumbar puncture revealed CSF pressure of 28 cm H2O, protein 80 mg/dL, and RBC 5/�L. Per
2024 pediatric hydrocephalus management updates, the infant undergoes endoscopic third
ventriculostomy (ETV) with success score of 0.8 on the ETV Success Score calculator. Postoperatively,
ICP monitoring shows mean ICP of 15 mmHg, but the infant develops hyponatremia (Na 128 mEq/L).
What is the most likely cause of this electrolyte imbalance, and what is the target correction rate?
A. Cerebral salt wasting with correction at 0.5 mEq/L/hour
B. SIADH with correction at 0.5 mEq/L/hour
C. Diabetes insipidus with correction at 1 mEq/L/hour
D. Hypernatremia from overcorrection with correction at 0.25 mEq/L/hour
Answer: B
Explanation: Post-ETV hyponatremia in pediatric hydrocephalus is commonly due to syndrome of
inappropriate antidiuretic hormone (SIADH) from hypothalamic manipulation or CSF dynamic changes,
leading to euvolemic hyponatremia. Diagnosis is confirmed by urine osmolality >300 mOsm/kg and
serum osmolality <275 mOsm/kg. The 2024 updates from the Pediatric Hydrocephalus Research
Foundation emphasize fluid restriction (50-75% maintenance) and monitoring free water clearance.
Correction should not exceed 0.5 mEq/L/hour or 12 mEq/L/day to prevent osmotic demyelination, using
3% saline boluses (2 mL/kg) if symptomatic (seizures). Serial labs every 4-6 hours guide therapy, with
goal Na 135-145 mEq/L over 48 hours.
Question: 1421
A 3-year-old with acute renal failure due to toxic mushroom ingestion has hyperkalemia of 6.8 mEq/L
and peaked T waves on ECG. What is the next priority intervention?
A. IV furosemide bolus
B. Sodium bicarbonate infusion
C. IV calcium gluconate
D. Oral potassium binder administration
Answer: C
Explanation: Hyperkalemia with ECG changes (peaked T waves) requires immediate administration of
calcium gluconate to stabilize cardiac membranes. Other treatments follow but are secondary to this
urgent step.
Question: 1422
A 4-year-old with known diabetes insipidus presents with sudden onset confusion and serum sodium of
165 mEq/L. Which is the most appropriate initial step in management?
A. Immediate hypertonic saline administration
B. Rapid correction with hypotonic fluids
C. Initiate fluid restriction to decrease sodium
D. Administer desmopressin (DDAVP) intravenously
Answer: D
Explanation: In central DI with severe hypernatremia, administration of desmopressin replaces deficient
ADH and helps concentrate urine. Correcting sodium must be done gradually to prevent cerebral edema,
so rapid correction is contraindicated.
Question: 1423
A 11-year-old with TTP on plasmapheresis receives adjunct PRBCs for Hb 6.5 g/dL. Post: worsening
microangiopathy (schistocytes 12%). Why avoid transfusion in TTP, and alternative?
A. Fluid overload; diuretics
B. Dilutes ADAMTS13; add rituximab
C. Causes alloimmunization; irradiated units
D. Increases viscosity exacerbating thrombosis; use plasma exchange only
Answer: D
Explanation: RBC transfusion in TTP raises hematocrit, worsening microvascular occlusion; restrict to
symptomatic <6 g/dL, per 2024 ISTH TTP guidelines. Plasma exchange provides ADAMTS13.
Question: 1424
An infant presents with signs of shock and an ECG shows ST segment elevation in leads II, III, and aVF.
Cardiac enzymes show elevated troponin I. What is the most likely cause?
A. Ventricular septal defect rupture
B. Viral myocarditis
C. Myocardial infarction secondary to coronary artery occlusion
D. Wolff-Parkinson-White syndrome
Answer: C
Explanation: ST elevation in inferior leads with elevated troponin suggests myocardial infarction likely
due to coronary artery occlusion or anomalous coronary artery. Myocarditis may have nonspecific ECG
changes but not classic ST elevation. Septal defect rupture causes volume overload, not infarction. WPW
is an arrhythmia syndrome, unrelated.
Question: 1425
A 6-year-old post operative spinal surgery patient complains of severe back pain and progressive lower
limb weakness. MRI shows epidural hematoma. What is the immediate priority?
A. Bed rest and observation
B. Pain medication adjustment
C. Initiation of corticosteroids
D. Urgent surgical decompression
Answer: D
Explanation: Epidural hematoma compresses the spinal cord causing neurological damage; urgent
decompression prevents permanent injury. Pain meds and corticosteroids are supportive but do not
relieve compression. Observation risks neurological deterioration.
Question: 1426
A 2-year-old toddler with suspected brain death following hypoxic-ischemic injury from near-drowning
undergoes initial evaluation. Per the 2023 AAN/AAP/CNS/SCCM consensus guideline, what is the
minimum observation period required after resolving confounding factors like hypothermia before
proceeding to apnea testing?
A. 24 hours
B. 12 hours
C. 48 hours
D. No minimum specified
Answer: A
Explanation: The 2023 pediatric brain death/death by neurologic criteria (BD/DNC) consensus guideline
mandates a minimum 24-hour observation period post-resolution of reversible confounders (e.g., core
temperature >36�C, normotension) to ensure irreversibility, based on evidence from longitudinal EEG
and outcome studies showing rare delayed recovery beyond this window, allowing time for ancillary
testing if clinical exam is incomplete.
Question: 1427
A child in the ICU develops signs of restraint-induced anxiety and agitation after prolonged sedation.
Which physiologic parameter best indicates the child�s stress response?
A. Serum calcium concentration
B. Blood glucose levels
C. Serum cortisol levels
D. Blood pH level
Answer: C
Explanation: Serum cortisol is a primary marker of physiologic stress response, elevated in anxiety and
agitation caused by environmental stressors such as restraints and prolonged ICU sedation.
Question: 1428
A 10-year-old is admitted with acute pulmonary embolism confirmed by CT angiography. The patient is
hemodynamically stable but hypoxemic. Which of the following lab values best indicates the success of
anticoagulation therapy?
A. Anti-factor Xa level within therapeutic range
B. Elevated D-dimer concentration
C. Prolonged prothrombin time (PT) with INR > 3
D. Decreased platelet count
Answer: A
Explanation: Monitoring anti-factor Xa levels is the preferred method to confirm adequate
anticoagulation in patients receiving low molecular weight heparin for pulmonary embolism. Elevated D-
dimer confirms diagnosis but does not monitor therapy success. Excessive PT/INR or thrombocytopenia
suggest bleeding risks rather than effective treatment.
Question: 1429
In the PICU, a 5-year-old post-cardiac surgery patient's central venous pressure (CVP) rises to 15 mm
Hg, with muffled heart sounds and pulsus paradoxus >12 mm Hg. Echo shows pericardial effusion. The
nurse notes jugular venous distension and dyspnea. Which intervention addresses this deterioration first?
A. Diuretics furosemide 1 mg/kg IV to reduce preload
B. Increase positive end-expiratory pressure to 8 cm H2O
C. Pericardiocentesis under ultrasound guidance
D. Inotropes milrinone 0.5 mcg/kg/min infusion
Answer: C
Explanation: Rising CVP, muffled sounds, and pulsus paradoxus indicate tamponade physiology with
hemodynamic compromise. Emergent pericardiocentesis drains effusion, restoring cardiac output (target
CVP 8-12 mm Hg post-procedure), per 2026 AHA pediatric guidelines. Diuretics/inotropes worsen
preload issues; PEEP risks further compromise.
Question: 1430
After surgical wound infection with Pseudomonas aeruginosa is confirmed, the child is started on
ciprofloxacin. What adverse effect must be closely monitored in pediatric patients receiving this
medication?
A. Hypoglycemia
B. Hepatic failure
C. Nephrotoxicity
D. Tendonitis or tendon rupture
Answer: D
Explanation: Fluoroquinolones like ciprofloxacin can cause tendonitis and tendon rupture, especially in
pediatric patients with developing tissues. Hepatic failure, nephrotoxicity, and hypoglycemia are less
common or unrelated adverse effects for this antibiotic class.
Question: 1431
A 6-year-old with Evans syndrome (autoimmune hemolytic anemia + ITP) has hemoglobin 5.5 g/dL,
platelets 10,000/�L, positive direct antiglobulin test. The nurse calculates the absolute reticulocyte count:
200,000/�L (retic 8%, RBC 2.5 million/�L). Despite rituximab, hemolysis persists. What second-line
agent?
A. High-dose IVIG 1 g/kg �2 days
B. Cyclophosphamide 750 mg/m2 monthly
C. Splenectomy at age >6 years
D. Mycophenolate mofetil 600 mg/m2/day
Answer: D
Explanation: Refractory Evans syndrome requires immunosuppression; mycophenolate (600 mg/m2/day)
inhibits purine synthesis, effective in 70% pediatric autoimmune cytopenias with steroid-sparing. IVIG
acute, splenectomy after vaccination/immunization, cyclophosphamide alkylating with toxicity.
Question: 1432
A 6-month-old infant with congenital diaphragmatic hernia repair develops AKI on ECMO (creatinine
0.8 mg/dL from 0.15 mg/dL). Urine output 0.2 mL/kg/hour, sodium 145 mEq/L, potassium 5.8 mEq/L.
Circuit pressure alarms frequently. Which CRRT modality integrates best with ECMO for hyperkalemia
management?
A. Integrate dialyzer into ECMO circuit for diffusive clearance
B. Continuous venovenous hemodiafiltration via separate access
C. Peritoneal dialysis with low-volume exchanges
D. Slow continuous ultrafiltration only
Answer: A
Explanation: In neonatal ECMO-AKI, hyperkalemia risks arrhythmias; integrating a dialyzer (e.g., AN69
0.2 m�) into the ECMO circuit provides continuous diffusive clearance (35 mL/kg/hour) without
additional vascular access, reducing circuit interruptions, per 2024 ELSO guidelines, achieving K+ drop
1-2 mEq/L/hour. Separate CVVHDF risks clots; PD is inefficient in post-op abdomen; SCUF removes
fluid only. Monitor pre/post-dialyzer K+ gradient.
Question: 1433
A 9-year-old patient with hemophilia B requires urgent correction of bleeding diathesis. Which blood
product is most appropriate for transfusion?
A. Platelet concentrate
B. Fresh frozen plasma
C. Cryoprecipitate
D. Prothrombin complex concentrate (PCC)
Answer: D
Explanation: Hemophilia B is factor IX deficiency. Prothrombin complex concentrate contains factors II,
VII, IX, and X, making it the optimal product for rapid factor IX replacement. Fresh frozen plasma
contains all factors but is less concentrated. Cryoprecipitate is rich in factor VIII and fibrinogen, which
do not correct factor IX deficiency. Platelets do not address coagulation factor deficiencies.
Question: 1434
A 1-year-old post-cardiac arrest (ROSC after 20 min CPR) is sedated (RASS -2), FiO2 0.6, PEEP 10
cmH2O, with Pediatric Cerebral Performance Category 3 baseline. 2024 BMC Pediatrics scoping review
barriers include staffing; what indication and tool enable early prone positioning mobility?
A. Indication: Boost oxygenation; tool: Pressure-mapping mat for interface pressure <32 mmHg
B. Indication: Reduce ventilator days; tool: Mobility checklist with 10 safety screens
C. Indication: Neuroprotection; tool: Near-infrared spectroscopy cerebral oximetry >50%
D. Indication: Family empowerment; tool: Parental satisfaction survey post-session
Answer: B
Explanation: 2024 BMC scoping reviews identify early prone mobility in post-arrest patients to reduce
ventilation duration by 20%, indicated by stability (no high vasopressors), using standardized checklists
(e.g., SCCM 10-item safety screen: HR stability, no lines dislodgement) to overcome barriers like
perceived risk in 60% nurses. NIRS for monitoring, pressure mats adjunctive, surveys outcome.
Question: 1435
Temporary pacing wire infection in 2-year-old: purulent drainage, WBC 18k, threshold 10 mA high.
DDD mode failing, CI 2.0 L/min/m�, sepsis lactate 2.8 mmol/L. Remove wire, start vancomycin. Bridge
with?
A. Isoproterenol 0.05 mcg/kg/min
B. External transcutaneous pacing
C. Dobutamine 10 mcg/kg/min
D. Atropine drip 0.02 mg/kg/hr
Answer: B
Explanation: Transcutaneous pacing maintains rate/AV synchrony during sepsis-induced loss, avoiding
infection spread until permanent implant. Isoproterenol risks tachyarrhythmia; dobutamine inotrope only;
atropine unreliable.
Question: 1436
A 10-year-old with exertional rhabdo has CK 15,000 U/L, urine myoglobin 300 �g/L (> threshold 100
�g/L for pigmenturia). Fluid goal: urine output 2 mL/kg/h for 20 kg child = 40 mL/h. If output 25 mL/h,
increase infusion by what % using standard adjustment formula (deficit / goal x 100)?
A. 25%
B. 50%
C. 38%
D. 75%
Answer: C
Explanation: Adjustment (15 mL deficit / 40 mL goal) x 100 = 37.5% �38%, targeting 2 mL/kg/h to
dilute myoglobin per 2024 exertional rhabdo protocols. Threshold myoglobin >100 �g/L with high CK
confirms need for escalated hydration.
Question: 1437
A 13-year-old boy with T-cell ALL post-Vincristine/cyclophosphamide develops abdominal pain,
hyperuricemia (14 mg/dL), and AKI (creatinine 1.8 mg/dL). Labs: LDH 1,800 U/L, phosphate 6.8
mg/dL, potassium 5.9 mEq/L. The nurse calculates the uric acid-to-creatinine ratio in urine: 1.2 (elevated
>1.0 indicating TLS). What preventive measure was omitted?
A. Rasburicase prior to chemotherapy
B. Allopurinol 300 mg/m2/day started 2 days pre-chemo
C. Hyperhydration at 3 L/m2/day
D. Urine alkalinization with sodium bicarbonate
Answer: A
Explanation: High-burden T-ALL requires rasburicase (0.2 mg/kg IV) prophylaxis for TLS, reducing uric
acid faster than allopurinol; omission led to clinical TLS with AKI. Allopurinol prevents but doesn't treat
established hyperuricemia, hydration essential but insufficient alone, alkalinization obsolete due to
precipitation risks.
Question: 1438
A 1-year-old former 28-week preterm infant with NEC on peritoneal dialysis via a left lower quadrant
catheter develops skin hypoperfusion at the catheter site during an episode of cardiogenic shock (echo EF
35%, lactate 5.1 mmol/L, ScvO2 55%). The site shows mottled, cool skin with delayed capillary refill >4
seconds and a 2 cm area of dusky discoloration despite pressure redistribution. Braden Q is 10. What
distinguishes this from a stage 2 pressure injury, and what hemodynamic parameter calculation guides
fluid bolus decision?
A. It's hypoperfusion-related ulcer; compute cardiac index (CI) = CO/BSA, target >3.3 L/min/m�
B. It's a device-related injury; use CVP trend: if <8 mmHg, bolus 10 mL/kg crystalloid
C. It's skin failure due to multiorgan dysfunction; calculate stroke volume variation (SVV) as (SBPmax -
SBPmin)/SBPmean * 100% targeting <13%
D. It's moisture-associated damage; assess lactate clearance: (initial - current)/initial * 100% >10%/hr
Answer: A
Explanation: In critically ill preterm infants, skin hypoperfusion during shock manifests as acute skin
failure, an end-organ manifestation of multiorgan dysfunction syndrome (MODS), distinct from pressure
injuries which require sustained interface pressure/shear. Here, dusky mottling without full-thickness loss
amid low EF and rising lactate indicates ischemic failure, not device pressure alone. Differentiating
requires context: pressure injuries Boost with offloading, while skin failure persists with hemodynamic
instability. For management, calculate cardiac index (CI = cardiac output [L/min] / body surface area
[m�]) using echo or pulse contour; target CI >3.3 L/min/m� in pediatric shock per recent Surviving Sepsis
guidelines. BSA for this 1-year-old (~8 kg) is ~0.4 m�; if CO 1.2 L/min, CI=3 L/min/m� prompts
inotrope escalation or bolus. SVV is for ventilated fluid responsiveness; CVP alone is unreliable; lactate
clearance monitors response post-resuscitation. Supportive care includes optimizing perfusion (fluids 10-
20 mL/kg boluses) and nutrition to prevent progression.
Question: 1439
A 8-year-old with leukemia on 30 days opioids (total 50 mg/kg morphine equivalent) has WAT-1 6:
gooseflesh 1, tremors 2, diarrhea 1, hypertension 1, pupil dilation 1. Methadone start: 0.2 mg/kg q6h
(morphine ratio 4:1). Calculate day 3 dose after 10% taper: 0.2 mg/kg * 0.9 * 0.9 = 0.162 mg/kg/day.
Which symptom persistence requires re-escalation?
A. Single episode diarrhea
B. Mild irritability
C. Transient mydriasis
D. Recurrent tremors despite dose
Answer: D
Explanation: Taper calculation ensures gradual reduction; recurrent tremors (WAT-1 component score 2)
despite adherence indicate inadequate suppression, requiring 10-20% dose re-escalation and evaluation
for confounders like infection, per longitudinal studies showing 30% rebound risk without adjustment.
Isolated symptoms resolve spontaneously.
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