AACN CCRN (Pediatric) Exam Questions

Correct answer: Hold the insulin and notify the physician of the patient's potassium level 

Cautious rehydration in DKA is imperative to prevent cerebral edema and should be done over 48 hours. Potassium and phosphate replacement is also imperative in DKA; if hyperkalemia is present initially, an ECG should be done, and urine output should be achieved before potassium replacement is initiated. 

When insulin is given, it helps move the potassium back into the cell, which will cause potassium blood levels to fall. Therefore, insulin therapy should only be initiated if the patient's potassium level is normal (3.5-5 mEq/L). Since this patient's potassium level is low, the nurse should hold the insulin and notify the doctor of the patient's current hypokalemic status. It is acceptable for the nurse to initiate fluid resuscitation. 

Correct answer: Frequent handwashing

CLABSIs remain a prominent concern in PICU settings. As a subset of nosocomial infections, CLABSI is defined as a bloodstream infection with an initial positive blood culture that occurs at least 2 days after placement or within 2 days before a central line is placed or removed, with the infection not attributable to another site. 

Hand hygiene remains the single most important procedure for controlling infection in the PICU and preventing healthcare-acquired infections. Meticulous and frequent hand hygiene must be implemented to prevent CLABSIs. 

Longer dwell times for catheters are associated with increased CLABSIs. Utilizing the femoral vein for catheter placement increases the risk of infection; thus, the femoral vein should be avoided. Dressings should be changed every 5 to 7 days with a transparent dressing or every 2 days with a gauze dressing. If the dressing becomes moist, loose, or visibly soiled or has a break in the seal, it must be changed immediately. 

Correct answer: Cardiac catheterization 

Performing a right cardiac catheterization is the gold standard for the diagnosis of PH; a catheter is used to measure the pressure in the heart and lungs. However, it is not always necessary during the initial evaluation. Because it is an invasive procedure that carries risks, the test is sometimes deferred until the initiation of targeted PH therapy is under consideration. 

An echocardiogram is a part of the initial evaluation in PH; a CT scan of the chest may yield valuable information on disease pathogenesis. Cardiac MRI remains the gold standard for assessing the right ventricle and may be used as additional testing if needed to better evaluate cardiac and pulmonary function, assess the patient's functional capacity, and identify the underlying etiology of PH if a cause is not identified in the initial evaluation. 

Correct answer: pH > 7.45 and PCO₂ < 35 mm Hg

For an arterial blood gas sample, the normal range for pH is 7.35 to 7.45. For bicarbonate (HCO₃) concentration, it is 21 to 28 mEq/L. For PCO₂, it is 35 to 45 mm Hg. 

Respiratory alkalosis reduces arterial PCO₂ and elevates pH.

Respiratory acidosis elevates arterial PCO₂ and reduces pH.

Metabolic alkalosis elevates serum HCO₃ concentration and pH.

Metabolic acidosis reduces serum HCO₃ concentration and pH.

Correct answer: Dilating the bronchioles 

Beta-adrenergic agonists, such as albuterol, are considered essential bronchodilator drugs in the treatment of acute asthma exacerbations and for the prevention of exercise-induced bronchospasm (EIB). They work by binding with the beta receptors on the smooth muscle of the airways, allowing the smooth muscle to relax, resulting in easier breathing.  

Corticosteroids are anti-inflammatory drugs used as first-line treatment to reverse airflow obstruction, control symptoms, and reduce bronchial hyperresponsiveness in chronic asthma. Anticholinergics may also be used for the relief of acute bronchospasm; they are helpful in acute, severe asthma when used in conjunction with beta-agonists and also work by reducing the amount of mucus produced by the airways. Leukotriene modifiers work by blocking inflammatory and bronchospasm effects; these are used for long-term asthma control. 

Correct answer: Fever 

KD is microvascuitis of medium-sized muscular arteries. This rare disease causes inflammation of the blood vessels throughout the body and is likely a disease of the immune system triggered by an infectious event. It is more prevalent in children of Japanese ancestry and in those younger than 5 years of age. 

Upon discharge of a child with KD, their caregivers should be instructed to check the temperature of the child every 6 hours for the first 48 hours following the last fever and then daily until the follow-up visit. A new fever could indicate a recurrent episode of KD and should warrant an immediate return to the hospital. 

Irritability is a hallmark finding in a child with KD, and parents should be advised that this symptom can last for up to two months following the acute phase of the disease. Temporary joint pain and other manifestations of arthritis may occur and persist for several weeks. ROM exercises and warm baths will help reduce these symptoms and minimize discomfort. Skin peeling is an expected finding. Parents should be informed that the peeling itself is not painful, but the new skin underneath may be red and sore. 

Correct answer: Shaken baby syndrome

Probably the most well-known form of abuse in children is shaken baby syndrome. This occurs in children younger than 2 years. Violent and angry shaking of the child leads to bleeding in the brain, retinal hemorrhages, and metaphyseal chip fractures. The child often presents for treatment, either seizing in cardiac arrest or with a history of a seizure. 

Neglect is the most prevalent type of child maltreatment, occurring when the caregiver fails to provide for the child's basic needs. Psychological abuse and burns are also seen in the health care setting but are not as prominent as shaken baby syndrome. 

Correct answer: 6 

Iron in the form of adult-strength supplements and prenatal vitamins with iron causes dangerous overdose in children younger than 6 years old. Iron supplements are occasionally used in suicide attempts by others, especially pregnant adolescents. When toxicity occurs, iron causes significant corrosive injury to the GI tract, injures blood vessels, damages hepatocytes, and produces metabolic acidosis. 

Severe iron poisoning typically is described in five sequential phases, although individual patients may not always exhibit each phase. Phase I usually occurs within the first 6 hours after ingestion and includes GI tract symptoms (often severe), consisting of hemorrhagic gastritis, vomiting, hematemesis, diarrhea, lethargy, and pallor. A patient first experiences GI symptoms, which are then followed by systemic toxicity. 

Phase II occurs about 6 to 12 hours after ingestion. Phase III occurs about 12 to 24 hours after ingestion. Phase IV occurs 2 to 3 days post-ingestion. Phase V occurs 2 to 6 weeks post-ingestion. 

Correct answer: Randomized controlled trials (RCTs)

Surfactant replacement therapy in premature neonates has been well studied in RCTs. Surfactant is not used in pediatric acute respiratory distress syndrome (PARDS) and is only used in neonates. 

Studies have evaluated the use of surfactants in the treatment of RDS, and morbidity and mortality rates in treatment and control groups have been compared. Systematic reviews of surfactant therapy confirm the effect of surfactant therapy in reducing the risk of morbidity and mortality.

Correct answer: Hypoxia

Sinus bradycardia is characterized by a heart rate that is low for the patient's age and clinical state, with a normal rhythm. The most common cause is hypoxia, but other causes can include increased ICP, hypothermia, use of digoxin or beta-blockers, hypothyroidism, anorexia, and surgical disruption of the SA node. 

Correct answer: Decreased cardiac output (CO) 

Optimal PEEP improves CO by decreasing left ventricular transmural pressure and decreasing afterload, making the ejection of blood from the left ventricle easier. 

Decreased CO caused by compression of the great vessels secondary to elevated intrathoracic pressures (most often from high levels of PEEP) is a potential complication of mechanical ventilation. This can be remedied with adequate volume (preload) expansion. 

Correct answer: Elevated carboxyhemoglobin levels of >20% via arterial blood 

CO is a colorless, odorless, tasteless, nonirritating, and highly toxic gas. It has an affinity for hemoglobin 200 times greater than that of oxygen, and it both displaces oxygen at hemoglobin receptor sites and inhibits the release of oxygen from hemoglobin. The effects of CO poisoning are related to hypoxemia and resultant direct tissue hypoxia. While a carboxyhemoglobin level of 10% or greater may be associated with symptoms (headache, nausea, vomiting, lethargy), the diagnosis is based on clinical presentation and carboxyhemoglobin levels of >20%. Physical exam findings include tachycardia, dyspnea, confusion, cherry-red skin, headache, nausea/vomiting, and lethargy. 

Measuring carboxyhemoglobin levels via arterial blood is preferred for the diagnosis of CO poisoning due to its precision in the assessment of acidosis (particularly lactic acidosis), which informs the severity and management of CO poisoning. 

Correct answer: A recent group A beta-hemolytic streptococcal (GABHS) infection 

Rheumatic fever is an inflammatory disorder of the heart, blood vessels, and joints. A partially treated or untreated GABHS infection, otherwise known as "strep throat," can lead to rheumatic fever, as this is the most common type of bacteria causing acute rheumatic fever. With rheumatic fever, a child has an abnormal immune response to a "strep throat" infection, which causes widespread inflammation. This can lead to long-term cardiac damage, which is known as rheumatic heart disease.

Erythema marginatum is a major manifestation of acute rheumatic fever and involves a rash characterized by pink, raised, small irregular macules that are nonpruritic and appear on the trunk and limbs (not the face). 

Correct answer: Assess apical pulse rate 

Digoxin is used for the treatment of mild to moderate heart failure and has inotropic effects from the inhibition of the sodium-potassium pump. The nurse should assess heart rate (HR) prior to dose administration to assure the HR is greater than 60 beats per minute. In addition, assess the potassium level, watching for hypokalemia (evidenced by serum levels that fall below 3.5 mEq/L), the calcium level for hypercalcemia (evidenced by serum levels that rise above 10 mg/dL). and the magnesium level for hypomagnesia (evidenced by serum levels that fall below 1.4 mEq/L). These may aggravate digoxin cardiotoxicity, even if the digoxin level is normal (therapeutic trough range is 0.5 to 2 ng/mL). 

The other choices are not necessary. 

Correct answer: Increase in systolic pressure greater than diastolic pressure and bradycardia 

Elevated ICP is a potentially devastating complication of neurologic injury. In children, increased ICP is most often a complication of traumatic brain injury (TBI) but can also occur in other conditions. The successful management of children with elevated ICP requires prompt recognition and therapy directed at both reducing ICP and reversing its underlying cause. Early recognition of elevated ICP can prevent neurologic sequelae and death.

Assessing vital signs and ABCs is crucial for initial stabilization. It may provide clues about the underlying etiology and can avert later signs of increased ICP. Changes in pulse and blood pressure are late, ominous signs of neurologic dysfunction. Cushing's reflex is an increase in systolic blood pressure (systolic hypertension) greater than diastolic blood pressure (i.e., a widening pulse pressure) and bradycardia. 

Correct answer: Fever persisting for at least 5 days + the presence of four or more of the five principal features 

KD is microvasculitis of the medium-sized muscular arteries. It is most likely a disease of the immune system triggered by an infectious event. Multisystem vasculitis (particularly in the coronary arteries) is followed by pancarditis with inflammation of the conduction system, myocardium, pericardium, and endocardium. Myocarditis develops within 3 to 4 weeks and is associated with white blood cell infiltration, elevated platelet counts, and edema of the conduction system and myocardial muscle. 

Diagnostic criteria include a fever that persists for at least 5 days, plus the presence of four or more of the following five principal features:

• polymorphous exanthema of the trunk
• swollen lymph nodes
• strawberry tongue, diffuse injection of the oral mucosa, erythema, and cracking of lips
• edema and erythema of the hands and feet (acute phase) with membranous desquamation of fingertips (convalescent phase)
• bilateral conjunctival injection of the eyes without exudate

Correct answer: Unilateral hyperlucency 

Children with significant intrathoracic injuries may not have suggestive external evidence of these injuries. Therefore, radiographic evaluation of the chest is standard in thoracic trauma cases. Pediatric nurses should observe for chest-wall ecchymosis, bruising, abrasions, a sensation of crepitus, point tenderness over a rib, or a displaced trachea. 

A sharp edge sign, in which the cardiac border and the diaphragm are seen in sharp contrast, is an x-ray finding of a pneumothorax (the most common air leak). Other findings of pneumothorax include unilateral hyperlucency (blackness indicating air), an overall increase in size, a flattened diaphragm on the affected side, widened intercostal spaces, and decreased or absent pulmonary vascular markings. 

A tension pneumothorax results in mediastinal shifts with decreased volume, increased opacity of the opposite lung, and deviation of the heart and trachea to the opposite side (shifted away from the side of the pneumothorax). If a tension pneumothorax is left untreated, the underlying lung will collapse. 

Correct answer: A recent Escherichia coli infection of the digestive system 

HUS is a thrombotic microangiopathic disease involving endothelial damage leading to platelet and fibrin deposits in small vessels. It is the simultaneous occurrence of hemolytic anemia, thrombocytopenia, and renal failure. It characteristically affects young children. Typical HUS peaks from June to September with gastrointestinal prodromes (vomiting, diarrhea, abdominal pain) during the days to weeks preceding onset. 

Escherichia coli (E. coli) causes many cases of typical HUS and is the most common cause of HUS in children. 

Correct answer: Drowsiness, headache, nausea 

The postictal period is the recovery period after a seizure. Some children recover quicker than others, but most take minutes to hours to return to their baseline behaviors; the process is rarely immediate. The seizure this child experienced was violent, and therefore the child is expected to be tired or even lethargic in this phase. Headaches and nausea are also very common symptoms. The best intervention at this point is to allow the child to sleep while keeping a close eye on him. 

The other choices are commonly seen in the prodromal period (loss of appetite, insomnia) and the ictal period (aura, "pins-and-needles" sensation, tachycardia). The sudden contraction of the muscles and vocal cords in a tonic-clonic seizure may result in a cry that is heard during the seizure (ictal phase). 

Correct answer: Fluid bolus of 20 mL/kg with isotonic normal saline 

CSW is a transient condition that presents within the first 10 days of diagnosis of an acute neurologic condition involving hyponatremia and hypovolemia. CSW is often seen in children with neurologic and neurosurgical injuries, infection (such as bacterial meningitis), or oncologic processes. CSW can have life-threatening effects secondary to hypovolemia if not differentiated from other disease states, making prompt recognition vital. 

Fluid should be given in CSW to replete the hypovolemic state caused by diuresis and natriuresis. An IV bolus of 20 mL/kg of isotonic normal saline (NS) should be given initially and promptly. Once euvolemia is reached, the fluid type and rate should be near maintenance levels, and the composition should reflect urine sodium losses. Sodium should be normalized slowly over 24 to 48 hours, no faster than 0.5 to 1 mEq/hr or no more than 10 mEq/day.