1. A 4-year-old with respiratory distress has nasal flaring, grunting, and O2 saturation 88%
on room air. What is the priority intervention?
A) Obtain a chest radiograph
B) Start high-flow nasal cannula at 2 L/kg/min
C) Administer albuterol via nebulizer
D) Initiate noninvasive positive pressure ventilation
Noninvasive ventilation reduces work of breathing and prevents intubation in moderate to
severe distress; albuterol alone is insufficient for hypoxemia with grunting.
2. A previously healthy 10-year-old presents with altered mental status, Kussmaul
breathing, and capillary blood glucose 450 mg/dL. Which intervention should occur first?
A) Intravenous regular insulin bolus
B) Sodium bicarbonate infusion
C) Cranial computed tomography
*D) Normal saline 20 mL/kg rapid bolus*
Hypovolemic shock from diabetic ketoacidosis requires volume resuscitation first; insulin
without volume can worsen cardiovascular collapse.
3. A 2-month-old with fever 38.9°C, bulging anterior fontanel, and poor feeding has a
cerebrospinal fluid white blood cell count of 1,200/µL with 90% neutrophils. Which
therapy is most appropriate empirically?
A) Ceftriaxone alone
B) Ampicillin and gentamicin
C) Ampicillin plus cefotaxime
In young infants, ampicillin covers Listeria and Group B Streptococcus; cefotaxime
covers gram-negative rods; ceftriaxone is avoided due to biliary sludging risk.
,4. A 6-year-old post-appendectomy develops sudden desaturation to 82%, hypotension, and
distended neck veins. What is the priority diagnostic test?
A) Chest radiograph
B) Bedside echocardiogram
C) Ventilation-perfusion scan
D) Lower extremity Doppler ultrasound
Echocardiogram rapidly identifies massive pulmonary embolism or pericardial effusion;
in postoperative child, PE is suspected with this triad.
5. A 14-year-old with sickle cell disease reports chest pain, fever, and hypoxemia. Chest x-
ray shows new infiltrate. What is the essential first step?
A) Exchange transfusion
B) Hematopoietic growth factor
C) Broad-spectrum antibiotics including macrolide
Acute chest syndrome treatment includes antibiotics for atypical and typical pathogens;
exchange transfusion reserved for severe hypoxia or progression.
6. A 3-year-old with neck stiffness and petechial rash has a bloody lumbar puncture with
gram-negative diplococci. Which isolation precaution is required?
A) Contact precautions only
B) Droplet precautions for first 24 hours of antibiotics
C) Airborne precautions
D) Reverse isolation
Meningococcal meningitis requires droplet precautions until 24 hours of effective
antibiotics; airborne is for tuberculosis or measles.
7. A 5-year-old with traumatic brain injury has ICP 28 mmHg, CPP 45 mmHg, and GCS 6.
Which intervention should be added next?
A) Phenytoin loading
B) Hyperventilation to PaCO2 28 mmHg
C) Hyperosmolar therapy with 3% saline
Elevated ICP with low CPP requires osmotic therapy; hyperventilation is temporary
rescue; 3% saline reduces ICP without hypovolemia.
,8. A 9-month-old with vomiting and lethargy has serum sodium 118 mEq/L. Which fluid
should be administered?
A) 0.9% normal saline with 40 mEq/L KCl
B) 3% hypertonic saline infusion
C) D5 0.45% saline
D) Lactated Ringer’s solution
Severe symptomatic hyponatremia with CNS symptoms requires hypertonic saline to
slowly raise sodium and prevent herniation.
9. A 16-year-old with blunt abdominal trauma has hypotension despite 60 mL/kg
crystalloid. Next best action?
A) Repeat abdominal exam
B) Infusion of packed red blood cells
C) Administer vasopressin
D) Place a nasogastric tube
Hemorrhagic shock unresponsive to fluids needs blood transfusion; ongoing fluid alone
dilutes clotting factors and worsens outcomes.
10. A newborn with cyanosis, tachypnea, and absent femoral pulses has preductal SpO2 95%
and postductal 70%. What is the initial pharmacologic intervention?
A) Prostaglandin E1 infusion
B) Inhaled nitric oxide
C) Epinephrine bolus
D) Indomethacin
*Prostaglandin E1 maintains ductal patency in ductal-dependent lesions like coarctation
or interrupted arch; nitric oxide is for pulmonary hypertension.*
11. A 12-year-old post- bone marrow transplant presents with fever, rash, and watery
diarrhea. What is the most likely etiology?
A) Adenovirus
B) Graft-versus-host disease
C) Clostridioides difficile
D) Rotavirus
, *Acute GVHD typically occurs within 100 days of transplant with rash, diarrhea, and
hepatitis; infectious causes also possible but GVHD is distinct post-transplant.*
12. A 7-year-old with status epilepticus has received midazolam and lorazepam without
cessation. Which medication should be given next?
A) Levetiracetam IV
B) Fosphenytoin or valproate IV
C) Carbamazepine PO
D) Phenobarbital IM
After benzodiazepines, second-line agents include fosphenytoin or valproate;
phenobarbital is third-line due to respiratory depression risk.
13. A 15-month-old with stridor, barking cough, and retractions at rest fails to improve with
racemic epinephrine. What is the appropriate next step?
A) Dexamethasone 0.6 mg/kg IM
B) Heliox therapy
C) Prepare for elective intubation
D) Nebulized budesonide
Impending airway failure from severe croup after epinephrine failure requires intubation;
steroids take hours and heliox is temporizing.
14. A 3-year-old with new tracheostomy has sudden respiratory distress and cannot pass a
suction catheter. What is the priority action?
A) Remove and replace the tracheostomy tube
B) Call for bronchoscopy
C) Increase suction depth
D) Manually ventilate through stoma
Obstructed or dislodged tube requires immediate replacement; forcing suction can
worsen obstruction; oxygen via stoma is ineffective if tube is blocked.
15. A 6-week-old with projectile vomiting, olive-shaped mass, and hypochloremic metabolic
alkalosis. What study confirms diagnosis?
A) Upper GI series
B) Abdominal ultrasound
on room air. What is the priority intervention?
A) Obtain a chest radiograph
B) Start high-flow nasal cannula at 2 L/kg/min
C) Administer albuterol via nebulizer
D) Initiate noninvasive positive pressure ventilation
Noninvasive ventilation reduces work of breathing and prevents intubation in moderate to
severe distress; albuterol alone is insufficient for hypoxemia with grunting.
2. A previously healthy 10-year-old presents with altered mental status, Kussmaul
breathing, and capillary blood glucose 450 mg/dL. Which intervention should occur first?
A) Intravenous regular insulin bolus
B) Sodium bicarbonate infusion
C) Cranial computed tomography
*D) Normal saline 20 mL/kg rapid bolus*
Hypovolemic shock from diabetic ketoacidosis requires volume resuscitation first; insulin
without volume can worsen cardiovascular collapse.
3. A 2-month-old with fever 38.9°C, bulging anterior fontanel, and poor feeding has a
cerebrospinal fluid white blood cell count of 1,200/µL with 90% neutrophils. Which
therapy is most appropriate empirically?
A) Ceftriaxone alone
B) Ampicillin and gentamicin
C) Ampicillin plus cefotaxime
In young infants, ampicillin covers Listeria and Group B Streptococcus; cefotaxime
covers gram-negative rods; ceftriaxone is avoided due to biliary sludging risk.
,4. A 6-year-old post-appendectomy develops sudden desaturation to 82%, hypotension, and
distended neck veins. What is the priority diagnostic test?
A) Chest radiograph
B) Bedside echocardiogram
C) Ventilation-perfusion scan
D) Lower extremity Doppler ultrasound
Echocardiogram rapidly identifies massive pulmonary embolism or pericardial effusion;
in postoperative child, PE is suspected with this triad.
5. A 14-year-old with sickle cell disease reports chest pain, fever, and hypoxemia. Chest x-
ray shows new infiltrate. What is the essential first step?
A) Exchange transfusion
B) Hematopoietic growth factor
C) Broad-spectrum antibiotics including macrolide
Acute chest syndrome treatment includes antibiotics for atypical and typical pathogens;
exchange transfusion reserved for severe hypoxia or progression.
6. A 3-year-old with neck stiffness and petechial rash has a bloody lumbar puncture with
gram-negative diplococci. Which isolation precaution is required?
A) Contact precautions only
B) Droplet precautions for first 24 hours of antibiotics
C) Airborne precautions
D) Reverse isolation
Meningococcal meningitis requires droplet precautions until 24 hours of effective
antibiotics; airborne is for tuberculosis or measles.
7. A 5-year-old with traumatic brain injury has ICP 28 mmHg, CPP 45 mmHg, and GCS 6.
Which intervention should be added next?
A) Phenytoin loading
B) Hyperventilation to PaCO2 28 mmHg
C) Hyperosmolar therapy with 3% saline
Elevated ICP with low CPP requires osmotic therapy; hyperventilation is temporary
rescue; 3% saline reduces ICP without hypovolemia.
,8. A 9-month-old with vomiting and lethargy has serum sodium 118 mEq/L. Which fluid
should be administered?
A) 0.9% normal saline with 40 mEq/L KCl
B) 3% hypertonic saline infusion
C) D5 0.45% saline
D) Lactated Ringer’s solution
Severe symptomatic hyponatremia with CNS symptoms requires hypertonic saline to
slowly raise sodium and prevent herniation.
9. A 16-year-old with blunt abdominal trauma has hypotension despite 60 mL/kg
crystalloid. Next best action?
A) Repeat abdominal exam
B) Infusion of packed red blood cells
C) Administer vasopressin
D) Place a nasogastric tube
Hemorrhagic shock unresponsive to fluids needs blood transfusion; ongoing fluid alone
dilutes clotting factors and worsens outcomes.
10. A newborn with cyanosis, tachypnea, and absent femoral pulses has preductal SpO2 95%
and postductal 70%. What is the initial pharmacologic intervention?
A) Prostaglandin E1 infusion
B) Inhaled nitric oxide
C) Epinephrine bolus
D) Indomethacin
*Prostaglandin E1 maintains ductal patency in ductal-dependent lesions like coarctation
or interrupted arch; nitric oxide is for pulmonary hypertension.*
11. A 12-year-old post- bone marrow transplant presents with fever, rash, and watery
diarrhea. What is the most likely etiology?
A) Adenovirus
B) Graft-versus-host disease
C) Clostridioides difficile
D) Rotavirus
, *Acute GVHD typically occurs within 100 days of transplant with rash, diarrhea, and
hepatitis; infectious causes also possible but GVHD is distinct post-transplant.*
12. A 7-year-old with status epilepticus has received midazolam and lorazepam without
cessation. Which medication should be given next?
A) Levetiracetam IV
B) Fosphenytoin or valproate IV
C) Carbamazepine PO
D) Phenobarbital IM
After benzodiazepines, second-line agents include fosphenytoin or valproate;
phenobarbital is third-line due to respiratory depression risk.
13. A 15-month-old with stridor, barking cough, and retractions at rest fails to improve with
racemic epinephrine. What is the appropriate next step?
A) Dexamethasone 0.6 mg/kg IM
B) Heliox therapy
C) Prepare for elective intubation
D) Nebulized budesonide
Impending airway failure from severe croup after epinephrine failure requires intubation;
steroids take hours and heliox is temporizing.
14. A 3-year-old with new tracheostomy has sudden respiratory distress and cannot pass a
suction catheter. What is the priority action?
A) Remove and replace the tracheostomy tube
B) Call for bronchoscopy
C) Increase suction depth
D) Manually ventilate through stoma
Obstructed or dislodged tube requires immediate replacement; forcing suction can
worsen obstruction; oxygen via stoma is ineffective if tube is blocked.
15. A 6-week-old with projectile vomiting, olive-shaped mass, and hypochloremic metabolic
alkalosis. What study confirms diagnosis?
A) Upper GI series
B) Abdominal ultrasound
