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CCRN Pediatric study materials
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CCRN Pediatric practice questions

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Question 1Clinical Judgment

Which three components make up the pediatric assessment triangle used in the first seconds of a pediatric emergency evaluation?

  1. Airway patency, breath sounds, and central pulses
  2. Appearance, work of breathing, and skin circulation Correct answer.
  3. Heart rate, respiratory rate, and blood pressure readings
  4. Pupil size, level of consciousness, and deep tendon reflexes

Explanation

The pediatric assessment triangle is a rapid visual and auditory screen completed before touching the child; it combines appearance, work of breathing, and circulation to skin. An abnormal triangle signals the need to move immediately into the primary survey and resuscitation.

Question 2Clinical Judgment

A 2-year-old has a low-grade fever, a hoarse cry, and a harsh barking cough that worsens at night. Which finding is most consistent with this presentation?

  1. Inspiratory stridor that is worse when the child is agitated Correct answer.
  2. Drooling with the child sitting upright and refusing to swallow fluids
  3. Sudden onset of unilateral wheezing after a coughing fit
  4. High fever with a toxic appearance and a productive cough

Explanation

Croup causes subglottic edema, producing a barking cough, hoarse voice, and inspiratory stridor that intensifies with agitation or crying. Treatment is dexamethasone, with nebulized epinephrine added for moderate to severe distress.

Question 3Clinical Judgment

A 26-kg child needs maintenance intravenous fluids. Using the 4-2-1 rule, what hourly rate should the nurse program?

  1. 66 mL/hr Correct answer.
  2. 78 mL/hr
  3. 52 mL/hr
  4. 44 mL/hr

Explanation

The 4-2-1 rule gives 4 mL/kg/hr for the first 10 kg, 2 mL/kg/hr for the next 10 kg, and 1 mL/kg/hr thereafter. For 26 kg that is 40 + 20 + 6 = 66 mL/hr.

Question 4Clinical Judgment

Which pain scale is most appropriate for assessing a 6-month-old infant after surgery?

  1. Visual analog scale
  2. FLACC behavioral scale Correct answer.
  3. Wong-Baker FACES scale
  4. Numeric rating scale

Explanation

The FLACC scale scores face, legs, activity, cry, and consolability through observation, and it is validated for children from about 2 months to 7 years and for those who cannot self-report. Self-report tools require the child to understand numbers, faces, or a line scale.

Question 5Clinical Judgment

On the pediatric Glasgow Coma Scale, which behavior earns an infant the highest verbal score?

  1. Coos and babbles appropriately Correct answer.
  2. Irritable crying with persistent grimacing
  3. Cries but is consolable by a caregiver
  4. No vocal sounds even with painful stimulation

Explanation

The infant verbal score is 5 for coos and babbles, 4 for irritable crying, 3 for crying to pain, 2 for moaning or grunting to pain, and 1 for no response. The scale is adapted because vocal development, not word use, is assessed.

Question 6Clinical Judgment

A 6-year-old receiving chemotherapy has an absolute neutrophil count of 300/mm3 and a temperature of 38.6 C. What is the priority action?

  1. Withhold antibiotics until the blood culture results are reported
  2. Obtain a chest radiograph before starting any treatment
  3. Give acetaminophen and recheck the temperature in 4 hours
  4. Draw cultures and give empiric IV antibiotics promptly Correct answer.

Explanation

Fever with neutropenia is an oncologic emergency; blood cultures are drawn and broad-spectrum IV antibiotics are started within about 60 minutes of presentation. Delay increases the risk of rapid progression to septic shock.

Question 7Clinical Judgment

A 9-year-old with sickle cell disease develops fever, cough, chest pain, and a new pulmonary infiltrate on chest radiograph. Which complication is most likely?

  1. Hand-foot syndrome from dactylitis
  2. Aplastic crisis caused by parvovirus B19 infection
  3. Splenic sequestration crisis with hypovolemic shock
  4. Acute chest syndrome Correct answer.

Explanation

Acute chest syndrome is defined by a new pulmonary infiltrate plus fever, chest pain, cough, or hypoxia in a child with sickle cell disease, and it is a leading cause of death in this population. Management includes oxygen, antibiotics, bronchodilators, incentive spirometry, and transfusion for severe disease.

Question 8Clinical Judgment

A 10-month-old has episodes of inconsolable screaming with drawing up of the legs, vomiting, and a sausage-shaped mass in the right upper abdomen. Which finding on the diaper is most consistent with this condition?

  1. Pale, clay-colored stools
  2. Hard, pellet-like stools
  3. Profuse watery stools without blood
  4. Currant jelly stools Correct answer.

Explanation

These findings describe intussusception, in which bowel telescopes into itself and the involved mucosa becomes ischemic. Ischemia and mucosal sloughing produce the classic blood-tinged mucus stool.

Question 9Clinical Judgment

A 3-year-old in septic shock has mottled skin, a capillary refill of 4 seconds, and a blood pressure at the 5th percentile. What is the most appropriate initial fluid resuscitation?

  1. Maintenance fluids at twice the calculated rate
  2. Transfusion of packed red blood cells at 10 mL/kg over one hour
  3. 5 mL/kg of 5% albumin over 30 minutes
  4. 20 mL/kg isotonic crystalloid bolus over 5 to 10 minutes Correct answer.

Explanation

Pediatric septic shock is treated with rapid isotonic crystalloid boluses of 20 mL/kg, reassessing after each bolus for hepatomegaly, crackles, and improvement in perfusion. Up to 40 to 60 mL/kg may be needed before vasoactive support is added.

Question 10Clinical Judgment

Which set of findings best describes compensated shock in a 5-year-old?

  1. Hypotension with bradycardia and absent peripheral pulses
  2. Tachycardia, cool extremities, and a normal blood pressure Correct answer.
  3. Widened pulse pressure with bounding peripheral pulses
  4. Hypotension with a narrowed pulse pressure and progressive lethargy

Explanation

Children maintain blood pressure through tachycardia and vasoconstriction, so cool extremities, delayed capillary refill, and tachycardia appear while the blood pressure is still normal. Hypotension marks decompensated shock and is a late, ominous finding.

Question 11Clinical Judgment

A 7-year-old in diabetic ketoacidosis is alert with deep, rapid respirations and a glucose of 480 mg/dL. After airway and monitoring are addressed, which order should the nurse anticipate first?

  1. Sodium bicarbonate to correct the acidosis
  2. A bolus of 0.45% saline at 20 mL/kg
  3. An isotonic saline bolus of 10 to 20 mL/kg Correct answer.
  4. Subcutaneous insulin glargine 0.5 units/kg

Explanation

Initial DKA management is volume expansion with an isotonic crystalloid bolus of 10 to 20 mL/kg, followed by deficit replacement over about 48 hours with an insulin infusion started after fluid resuscitation. Bicarbonate is avoided because it can worsen hypokalemia and cerebral edema.

Question 12Clinical Judgment

A 3-month-old has a heart rate of 260 beats/min with narrow QRS complexes and no visible P waves; the infant is alert but feeding poorly. After ensuring a patent airway, which intervention should the nurse anticipate first?

  1. Application of an ice pack to the face for 15 to 20 seconds Correct answer.
  2. Adenosine 0.1 mg/kg rapid IV push
  3. Immediate synchronized cardioversion at 0.5 to 1 J/kg under sedation
  4. Defibrillation at 2 J/kg

Explanation

The infant has supraventricular tachycardia and is hemodynamically stable, so vagal stimulation with a cold stimulus to the face is the first intervention. Adenosine follows if vagal maneuvers fail, and synchronized cardioversion is used for an unstable infant.

Question 13Clinical Judgment

A 4-year-old develops urticaria, wheezing, and hypotension minutes after eating peanuts. Which order should the nurse implement first?

  1. Methylprednisolone 2 mg/kg IV
  2. Diphenhydramine 1 mg/kg given intravenously over several minutes
  3. Epinephrine 0.01 mg/kg IM of the 1:1000 concentration Correct answer.
  4. Albuterol by nebulizer

Explanation

Intramuscular epinephrine into the anterolateral thigh is the first-line treatment for anaphylaxis because it reverses vasodilation and airway edema within minutes. Antihistamines, steroids, and bronchodilators are adjuncts that do not treat the underlying reaction.

Question 14Clinical Judgment

A 12-kg child with acute respiratory failure is being started on mechanical ventilation. Which tidal volume setting best reflects a lung-protective strategy?

  1. 36 mL (3 mL/kg)
  2. 156 mL (13 mL/kg)
  3. 240 mL (20 mL/kg)
  4. 72 mL (6 mL/kg) Correct answer.

Explanation

Lung-protective ventilation targets roughly 6 to 8 mL/kg of predicted body weight, with lower volumes of about 5 to 6 mL/kg in ARDS. This limits volutrauma and ventilator-induced lung injury.

Question 15Clinical Judgment

A 4-year-old with a recent episode of bloody diarrhea now has pallor, petechiae, oliguria, and a platelet count of 40,000/mm3. Which action is most appropriate?

  1. Transfuse platelets prophylactically to keep the count above 50,000/mm3
  2. Start a heparin infusion to prevent further microvascular thrombosis
  3. Maintain fluid and electrolyte balance and monitor renal function Correct answer.
  4. Give intravenous ceftriaxone to eradicate the E. coli O157:H7 organism

Explanation

This is hemolytic uremic syndrome, which is managed with meticulous supportive care, including fluid and electrolyte management, blood pressure control, and monitoring for acute kidney injury. Platelet transfusion is reserved for active bleeding or invasive procedures, and antibiotics may increase toxin release.

Question 16Clinical Judgment

Which finding in a 5-month-old should prompt suspicion of physical abuse?

  1. A Mongolian spot over the lower back
  2. A torn labial frenulum in a pre-mobile infant Correct answer.
  3. Petechiae on the face after a coughing spell
  4. A single bruise on the shin of a newly walking toddler

Explanation

Injuries in pre-mobile infants, torn frenula, patterned bruises, and injuries inconsistent with the stated history are red flags for abuse. Such findings warrant a thorough examination, documentation, and reporting per mandatory reporting laws.

Question 17Clinical Judgment

A 2-year-old is brought in 3 hours after ingesting an unknown amount of acetaminophen. The child is asymptomatic, but the serum level is above the treatment line on the nomogram. Which antidote should the nurse prepare?

  1. Naloxone
  2. N-acetylcysteine Correct answer.
  3. Fomepizole
  4. Deferoxamine

Explanation

N-acetylcysteine replenishes hepatic glutathione and detoxifies the reactive metabolite NAPQI; it is most effective when given within 8 to 10 hours of ingestion. The nomogram guides treatment even when the child remains asymptomatic.

Question 18Clinical Judgment

A 5-week-old has projectile nonbilious vomiting, a palpable olive-shaped mass, and weight loss. Which laboratory pattern is expected?

  1. Metabolic acidosis with hyperkalemia
  2. Hyperchloremic metabolic acidosis
  3. Respiratory alkalosis with hypernatremia and hyperglycemia
  4. Hypochloremic, hypokalemic metabolic alkalosis Correct answer.

Explanation

Pyloric stenosis causes loss of gastric hydrochloric acid, leading to hypochloremic metabolic alkalosis, while volume depletion drives potassium wasting and hypokalemia. These derangements are corrected with isotonic saline and potassium before surgery.

Question 19Clinical Judgment

A 5-month-old with respiratory syncytial virus bronchiolitis has a respiratory rate of 60, mild retractions, and an oxygen saturation of 92% on room air. Which intervention is best supported by current evidence?

  1. Nebulized albuterol treatments scheduled every 4 hours and as needed
  2. Routine chest physiotherapy plus prophylactic antibiotics
  3. A three-day course of oral corticosteroids started in the emergency department
  4. Supportive care with nasal suctioning and supplemental oxygen as needed Correct answer.

Explanation

Bronchiolitis is managed with supportive care: suctioning secretions, maintaining hydration, and providing oxygen for hypoxemia. Bronchodilators, corticosteroids, chest physiotherapy, and antibiotics are not routinely recommended because they have not been shown to alter the course.

Question 20Clinical Judgment

A 6-month-old with tetralogy of Fallot becomes deeply cyanotic and irritable during a crying episode. Which action should the nurse take first?

  1. Place the infant in a knee-to-chest position Correct answer.
  2. Give furosemide 1 mg/kg IV
  3. Place the child in a semi-Fowler position and give oxygen
  4. Start an epinephrine infusion

Explanation

The knee-to-chest position increases systemic vascular resistance, which reduces the right-to-left shunt and improves pulmonary blood flow. Oxygen, morphine, fluid boluses, and phenylephrine may follow, and agitation must be minimized.

Question 21Clinical Judgment

Twelve hours into treatment of diabetic ketoacidosis, a 9-year-old develops a new headache, confusion, bradycardia, and a rising blood pressure. Which action is most appropriate?

  1. Give 3% hypertonic saline or mannitol and reduce the fluid rate Correct answer.
  2. Increase the insulin infusion rate to lower the glucose faster
  3. Give a rapid 20 mL/kg bolus of isotonic saline
  4. Administer IV morphine for the headache and reassess the child in 1 hour

Explanation

Headache, altered mental status, bradycardia, and hypertension during DKA treatment indicate cerebral edema, a life-threatening complication. Immediate treatment is hypertonic saline or mannitol with elevation of the head of the bed and slowing of fluid administration.

Question 22Clinical Judgment

A 2-week-old with a modified Blalock-Taussig shunt has an oxygen saturation of 78%, warm extremities, and is feeding normally. How should the nurse interpret these findings?

  1. The infant has a large left-to-right shunt causing pulmonary overcirculation
  2. The saturation is dangerously low and requires immediate 100% oxygen
  3. These values are expected for a shunt-dependent circulation Correct answer.
  4. The shunt has thrombosed and the infant needs urgent revision

Explanation

Infants with shunt-dependent pulmonary blood flow typically have oxygen saturations in the mid-70s to mid-80s, and a value of 78% with good perfusion and feeding is expected. Sudden desaturation, acidosis, or poor feeding would suggest shunt obstruction.

Question 23Clinical Judgment

A 10-year-old with a severe traumatic brain injury has an intracranial pressure of 22 mm Hg and a mean arterial pressure of 60 mm Hg. Which action is most appropriate?

  1. Hyperventilate to a PaCO2 of 25 mm Hg and continue for 24 hours
  2. Place the head of the bed flat to improve venous return
  3. Give isotonic fluid and vasopressor support to raise the MAP Correct answer.
  4. Restrict fluids to two-thirds maintenance to reduce cerebral edema

Explanation

Cerebral perfusion pressure equals mean arterial pressure minus intracranial pressure, so this child's CPP is about 38 mm Hg, below the target for age. Supporting the mean arterial pressure with isotonic fluid and vasopressors is the priority, along with head elevation and midline positioning.

Question 24Clinical Judgment

A 2-year-old in fluid-refractory septic shock has mottled, cool extremities, a capillary refill of 5 seconds, and a normal blood pressure. Which vasoactive infusion should the nurse anticipate?

  1. A low-dose dobutamine infusion alone
  2. Epinephrine as the first-line vasoactive infusion Correct answer.
  3. Norepinephrine infused peripherally as the first-line agent
  4. A nitroprusside infusion to reduce afterload

Explanation

Cool extremities with delayed capillary refill after adequate fluid resuscitation indicate cold shock, for which epinephrine is the first-line vasoactive agent. Norepinephrine is preferred for warm shock with vasodilation and low systemic vascular resistance.

Question 25Clinical Judgment

A 6-year-old in status asthmaticus has become quiet with minimal wheezing, a PaCO2 of 52 mm Hg, and drowsiness. How should the nurse interpret these findings?

  1. An adequate response to therapy if oxygen saturation is above 90%
  2. Impending respiratory failure requiring urgent ventilatory support Correct answer.
  3. A mild exacerbation that can be managed with inhaled albuterol alone
  4. Improvement of airflow obstruction because wheezing has decreased

Explanation

A quiet chest, rising PaCO2, and decreasing level of consciousness signal fatigue and impending respiratory failure in a child with severe asthma. A normal or elevated CO2 in a tachypneic asthmatic is a warning sign, not reassurance.

Question 26Clinical Judgment

A 3-year-old has a temperature of 39.5°C, is drooling, and sits leaning forward with the neck extended. He has no cough. Which action should the nurse take first?

  1. Keep the child calm and prepare for airway management. Correct answer.
  2. Place the child supine for a lateral neck radiograph.
  3. Inspect the posterior pharynx with a tongue blade.
  4. Obtain a throat culture for group A streptococcus.

Explanation

Drooling, high fever, tripod positioning, and absence of cough suggest epiglottitis, which can progress to complete airway obstruction. Any throat examination or forced supine positioning may trigger laryngospasm, so the priority is minimal handling and preparation for a controlled emergency airway.

Question 27Clinical Judgment

A parent of a 2-month-old asks how to reduce the risk of sudden infant death syndrome. Which instruction should the nurse give?

  1. Use a firm pillow to keep the head elevated.
  2. Keep the room warm with several blankets.
  3. Allow the infant to sleep in the parents' bed for the first year.
  4. Place the infant on the back for every sleep. Correct answer.

Explanation

Supine positioning on a firm, flat surface for every sleep is the single most effective SIDS risk-reduction measure. Soft bedding, overheating, and bed-sharing all increase risk, while room-sharing without bed-sharing is recommended.

Question 28Clinical Judgment

A 4-year-old has had a fever of 39°C for 6 days, with red cracked lips, a strawberry tongue, nonexudative conjunctivitis, a rash, and swollen hands and feet. Which order should the nurse anticipate?

  1. Oral penicillin V four times daily.
  2. Intravenous immune globulin and high-dose aspirin. Correct answer.
  3. Acetaminophen alone with outpatient follow-up.
  4. Intramuscular streptococcal vaccine.

Explanation

The prolonged fever plus mucocutaneous findings meet criteria for Kawasaki disease. Intravenous immune globulin with high-dose aspirin during the acute febrile phase reduces the risk of coronary artery aneurysms.

Question 29Clinical Judgment

A 5-year-old with type 1 diabetes is brought in confused and sweaty. He is awake but unable to cooperate with drinking. Which action should the nurse take first?

  1. Start a dextrose infusion at a maintenance rate.
  2. Give 15 g of oral glucose gel.
  3. Check the blood glucose with a point-of-care meter. Correct answer.
  4. Administer the next scheduled insulin dose.

Explanation

Altered mental status in a child with diabetes requires immediate glucose measurement to confirm hypoglycemia before treatment. Oral intake is unsafe in a confused child because of aspiration risk, and intravenous dextrose is given once the low value is documented.

Question 30Clinical Judgment

A 2-year-old suddenly choked while eating peanuts and now has a cough and decreased breath sounds on the right. He is awake and speaking. Which action should the nurse take?

  1. Perform blind finger sweeps of the mouth.
  2. Prepare for bronchoscopic removal of the object. Correct answer.
  3. Place the child in Trendelenburg position and give back blows.
  4. Administer nebulized albuterol and observe for 4 hours.

Explanation

A witnessed choking episode with unilateral decreased breath sounds indicates an airway foreign body, and bronchoscopy is the definitive treatment. Blind finger sweeps can push the object deeper, and bronchodilators do not remove a mechanical obstruction.

Question 31Clinical Judgment

A 3-year-old has periorbital edema, ascites, and a serum albumin of 1.8 g/dL. Which urinalysis finding should the nurse expect?

  1. Positive leukocyte esterase.
  2. Red blood cell casts.
  3. Specific gravity of 1.035 with glycosuria.
  4. 3+ proteinuria. Correct answer.

Explanation

Nephrotic syndrome is characterized by heavy proteinuria, hypoalbuminemia, and generalized edema from low oncotic pressure. Red blood cell casts point to glomerulonephritis, and leukocyte esterase suggests infection.

Question 32Clinical Judgment

A newborn with cyanosis has an oxygen saturation of 65% that does not improve with supplemental oxygen. Echocardiography shows pulmonary atresia with an intact ventricular septum. Which medication should the nurse anticipate?

  1. Alprostadil infusion. Correct answer.
  2. Digoxin.
  3. Indomethacin.
  4. Propranolol.

Explanation

Pulmonary atresia with an intact ventricular septum is a ductal-dependent lesion, and alprostadil (prostaglandin E1) keeps the ductus arteriosus open so blood can reach the lungs. Indomethacin closes the ductus and would be harmful in this setting.

Question 33Clinical Judgment

A 6-month-old is admitted with bacterial meningitis. Which precaution should the nurse maintain?

  1. Contact precautions until the CSF culture is negative.
  2. Droplet precautions for 24 hours after antibiotics start. Correct answer.
  3. Standard precautions only once the fever resolves.
  4. Airborne precautions for the entire hospitalization.

Explanation

Bacterial meningitis caused by organisms such as Neisseria meningitidis or Haemophilus influenzae requires droplet precautions until 24 hours of effective antibiotic therapy has been completed. Standard precautions alone are insufficient during that period.

Question 34Clinical Judgment

A 9-year-old has periumbilical pain that migrated to the right lower quadrant, anorexia, and a temperature of 38°C. Which nursing action is appropriate?

  1. Apply a warm compress to the abdomen for comfort.
  2. Administer a phosphate enema to relieve constipation.
  3. Give oral acetaminophen and reassess in 2 hours.
  4. Keep the child NPO and prepare for surgery. Correct answer.

Explanation

Migratory pain to the right lower quadrant with anorexia and fever suggests appendicitis, and the child should remain NPO in preparation for appendectomy. Heat, enemas, and laxatives can precipitate perforation and should be avoided.

Question 35Clinical Judgment

A 3-week-old has bilious vomiting and a distended abdomen. Which action should the nurse take first?

  1. Insert an NG tube and notify the surgeon. Correct answer.
  2. Feed the infant small amounts of Pedialyte to assess tolerance.
  3. Administer an antiemetic and position the infant prone.
  4. Obtain a stool sample for occult blood and observe.

Explanation

Bilious emesis in a neonate is malrotation with midgut volvulus until proven otherwise, a surgical emergency. The nurse should keep the infant NPO, decompress the stomach with an NG tube, replace fluids intravenously, and notify the surgeon urgently.

Question 36Clinical Judgment

A 4-year-old is having a generalized tonic-clonic seizure that has lasted 6 minutes. IV access is present. Which medication should the nurse give first?

  1. Lorazepam 0.1 mg/kg IV. Correct answer.
  2. Mannitol 0.5 g/kg IV.
  3. Levetiracetam 60 mg/kg IV.
  4. Phenytoin 20 mg/kg IV.

Explanation

A seizure lasting 5 minutes or longer meets the definition of status epilepticus, and a benzodiazepine such as lorazepam is the first-line agent. Phenytoin and levetiracetam are second-line drugs used if benzodiazepines fail.

Question 37Clinical Judgment

A 3-year-old is found unresponsive with pinpoint pupils and a respiratory rate of 6/min after possible ingestion of a parent's opioid. Which medication should the nurse prepare?

  1. Physostigmine.
  2. Flumazenil.
  3. Atropine.
  4. Naloxone. Correct answer.

Explanation

Pinpoint pupils, depressed respirations, and unresponsiveness form the opioid toxidrome, which is reversed with naloxone. Ventilation must also be supported while the antidote takes effect.

Question 38Clinical Judgment

On the first night after a tonsillectomy, a 6-year-old is restless and swallows frequently. Which action should the nurse take?

  1. Inspect the throat and notify the surgeon. Correct answer.
  2. Place an ice collar and administer an antiemetic.
  3. Reassure the child and document the behavior.
  4. Give a sip of water and encourage coughing.

Explanation

Frequent swallowing after tonsillectomy is a classic sign of bleeding in the posterior pharynx, because the child is swallowing blood. The nurse should inspect the throat, obtain vital signs, and notify the surgeon promptly.

Question 39Clinical Judgment

A 5-year-old with cystic fibrosis has bulky, foul-smelling stools and poor weight gain. Which instruction should the nurse include?

  1. Give the pancreatic enzymes once daily at bedtime.
  2. Crush the enzymes and mix them with hot cereal.
  3. Withhold enzymes when the child has diarrhea.
  4. Give pancreatic enzymes with every meal and snack. Correct answer.

Explanation

Pancreatic enzyme replacement is dosed with every meal and snack to compensate for pancreatic insufficiency and improve absorption. Enzymes should not be crushed into hot food because heat inactivates them.

Question 40Clinical Judgment

A 7-year-old has cola-colored urine, facial edema, and a blood pressure of 130/90 mm Hg after a streptococcal infection. Which finding should the nurse monitor most closely?

  1. Weight and blood pressure trends. Correct answer.
  2. Deep tendon reflexes and muscle strength.
  3. Pupillary response and level of consciousness.
  4. Serum amylase and lipase levels.

Explanation

Acute glomerulonephritis causes fluid retention, hypertension, and edema, so daily weights, blood pressure, and urine output are the key monitoring parameters. Worsening hypertension or edema can signal fluid overload or hypertensive encephalopathy.

Question 41Clinical Judgment

A 2-month-old with heart failure is receiving digoxin. Which action is essential before each dose?

  1. Count the apical pulse for a full minute. Correct answer.
  2. Check the blood pressure while the infant cries.
  3. Obtain a 12-lead ECG.
  4. Measure the serum potassium.

Explanation

The apical pulse is counted for a full minute before each digoxin dose because bradycardia is a sign of toxicity and the dose is held when the rate is below the age-specific threshold. Potassium is monitored periodically but is not required before every dose.

Question 42Clinical Judgment

A 2-year-old has a barking cough and inspiratory stridor at rest with suprasternal retractions. Which medication should the nurse anticipate first?

  1. Nebulized racemic epinephrine. Correct answer.
  2. Intravenous furosemide.
  3. Oral amoxicillin.
  4. Nebulized albuterol.

Explanation

Croup with stridor at rest indicates significant subglottic edema, and nebulized racemic epinephrine rapidly reduces airway swelling. Dexamethasone is also given, and the child is observed for rebound symptoms after the epinephrine wears off.

Question 43Clinical Judgment

A 3-week-old breastfed infant did not pass meconium until 72 hours after birth and now has abdominal distension and poor feeding. Which diagnostic finding should the nurse expect?

  1. Air-fluid levels with a double bubble.
  2. A palpable olive-shaped mass.
  3. A transition zone on contrast enema. Correct answer.
  4. Free air under the diaphragm.

Explanation

Delayed passage of meconium with distension suggests Hirschsprung disease, in which a contrast enema shows a narrow aganglionic segment with a transition to dilated bowel. Rectal biopsy confirms the diagnosis.

Question 44Clinical Judgment

A 6-year-old with hemophilia A has a tooth extraction scheduled. Which action should the nurse anticipate?

  1. Administer aspirin for pain afterward.
  2. Apply warm compresses to the gums.
  3. Withhold all analgesia to avoid bleeding.
  4. Give factor VIII before the procedure. Correct answer.

Explanation

Factor VIII concentrate is given before invasive dental procedures to raise clotting factor levels and prevent hemorrhage. Aspirin and other NSAIDs are avoided because they further impair platelet function.

Question 45Clinical Judgment

A 2-year-old is 6 hours after surgery and cannot describe pain. Which tool should the nurse use to assess pain?

  1. Wong-Baker FACES scale.
  2. Visual analog scale.
  3. FLACC behavioral scale. Correct answer.
  4. Numeric rating scale.

Explanation

The FLACC scale assesses behavior in children from 2 months to about 7 years who cannot self-report pain. The Wong-Baker FACES scale requires a child to point to a face and is better suited to older preschoolers.

Question 46Clinical Judgment

A newborn has respiratory distress, a scaphoid abdomen, and bowel sounds in the left chest. Which action should the nurse take first?

  1. Place an NG tube to low intermittent suction. Correct answer.
  2. Begin bag-mask ventilation with high pressure.
  3. Position the infant on the affected side.
  4. Give a bolus of 20 mL/kg of normal saline.

Explanation

Congenital diaphragmatic hernia presents with respiratory distress, a scaphoid abdomen, and bowel sounds in the chest. Immediate nasogastric decompression prevents further bowel distension and lung compression, and bag-mask ventilation should be avoided because it fills the stomach with air.

Question 47Clinical Judgment

A 5-year-old with newly diagnosed Burkitt lymphoma has a potassium of 6.2 mEq/L, phosphate of 7.8 mg/dL, and calcium of 7.1 mg/dL. Which complication should the nurse suspect?

  1. Diabetic ketoacidosis.
  2. Reye syndrome.
  3. Syndrome of inappropriate antidiuretic hormone.
  4. Tumor lysis syndrome. Correct answer.

Explanation

Tumor lysis syndrome results from rapid destruction of malignant cells and produces hyperkalemia, hyperphosphatemia, hyperuricemia, and hypocalcemia. Aggressive hydration and monitoring for arrhythmia and renal injury are priorities.

Question 48Clinical Judgment

A 10-year-old with acute kidney injury has a potassium of 7.4 mEq/L. The ECG shows tall peaked T waves. Which medication should the nurse give first?

  1. Sodium polystyrene sulfonate.
  2. Furosemide.
  3. Regular insulin with dextrose.
  4. Calcium gluconate. Correct answer.

Explanation

Hyperkalemia with ECG changes threatens lethal arrhythmias, so calcium gluconate is given first to stabilize the myocardium. Insulin with dextrose is then used to shift potassium intracellularly, while binders and diuretics remove potassium over time.

Question 49Clinical Judgment

A 3-year-old with pulmonary hypertension suddenly becomes cyanotic and hypotensive after suctioning. Which action should the nurse take first?

  1. Administer a beta-agonist nebulizer.
  2. Give 100% oxygen and notify the provider. Correct answer.
  3. Reposition the child flat and suction again.
  4. Give a bolus of normal saline.

Explanation

Suctioning can trigger a pulmonary hypertensive crisis, with acute right-sided heart failure and hypoxemia. The immediate response is to maximize oxygenation, minimize stimulation, and notify the provider for pulmonary vasodilator therapy such as inhaled nitric oxide.

Question 50Clinical Judgment

A 2-year-old develops cyanosis and chocolate-colored blood after receiving benzocaine spray. Oxygen saturation remains 85% despite 100% oxygen. Which medication should the nurse anticipate?

  1. Hydroxocobalamin.
  2. N-acetylcysteine.
  3. Naloxone.
  4. Methylene blue. Correct answer.

Explanation

Benzocaine can induce methemoglobinemia, which causes cyanosis unresponsive to oxygen and dark chocolate-colored blood. Methylene blue 1 to 2 mg/kg intravenously reduces methemoglobin back to hemoglobin.