APRN ACCNS-P
Final Test Review
(Questions & Solutions)
2025
1
, 1. Viral Myocarditis vs. Sepsis
A 6-year-old previously healthy boy presents with 2 days of fever and
new hepatomegaly. BP 90/50 mm Hg, HR 146, CRP 12 mg/dL, troponin I
1.2 ng/mL, BNP 2,400 pg/mL, lactate 1.9 mmol/L. Bedside echo: LVEF 38
%, no pericardial effusion. Best initial pharmacologic therapy?
A. Ceftriaxone 75 mg/kg IV
B. Milrinone 0.5 µg/kg/min IV
C. Dopamine 7 µg/kg/min IV
D. High-dose IVIG 2 g/kg
Rationale: Depressed systolic function with low SVR favors inodilator
milrinone; vasopressors raise afterload and worsen performance.
---
2. Post–Fontan Plastic Bronchitis
A 9-year-old with extracardiac Fontan completes bronchoscopy for
refractory chylous casts. CVP 20 mm Hg, SpO₂ 88 % on RA. Which
intervention targets the root pathophysiology?
A. Inhaled hypertonic saline TID
B. Lymphatic embolization via dynamic contrast MR lymphangiography
C. High-frequency chest wall oscillation
D. Nebulized t-PA 5 mg q6 h
Rationale: Aberrant thoracic duct leak into airways is now treated
definitively with interventional radiology–guided lymphatic embolization.
---
3. Pulmonary Hypertension Crisis
A 4-year-old with idiopathic PAH deteriorates in the PICU: PAP equals
systemic BP on echo; CO₂ 55 mm Hg; sat 85 % despite FiO₂ 1.0.
2
,Immediate bedside action?
A. Paralysis and higher PEEP
B. Bolus inhaled nitric oxide 20 ppm, titrate
C. Norepinephrine 0.1 µg/kg/min
D. Give furosemide 1 mg/kg IV
Rationale: Selective pulmonary vasodilation rapidly reduces PAP:Psys
ratio and prevents RV ischemia during crisis.
---
4. Kawasaki Disease – Coronary Aneurysm Prevention
A 12-month-old meets complete Kawasaki criteria on day 6 of fever.
Platelets 680 K, ALT 62 IU/L. Optimal regimen?
A. IVIG 2 g/kg once + high-dose aspirin 80 mg/kg/day divided QID
B. IVIG only
C. Low-dose aspirin 3 mg/kg/day
D. Corticosteroids alone
Rationale: Timely IVIG plus high-dose salicylate diminishes coronary
sequelae; steroids reserved for IVIG-refractory disease.
---
5. Heart Block After VSD Patch
A 7-kg infant POD 2 after perimembranous VSD closure develops HR 55,
BP 68/34 mm Hg, intermittent ventricular escape. Next step?
A. Trendelburg positioning
B. Temporary epicardial pacing VVI 120 bpm
C. Atropine 0.02 mg/kg IV
D. Milrinone infusion
Rationale: Post-surgical complete atrioventricular block demands
pacing; chronotropes fail when conduction absent.
3
, ---
6. Severe Status Asthmaticus – Vent Strategy
Intubated 10-year-old, peak 45, plateau 24 cm H₂O, pH 7.17, PaCO₂ 82
mm Hg. Optimal mode change?
A. Volume AC, VT 10 mL/kg, RR 22
B. Pressure-controlled ventilation with prolonged expiratory time (I:E
1:6)
C. Add 10 cm H₂O PEEP
D. APRV
Rationale: Permissive hypercapnia with long exhalation minimizes
dynamic air-trapping and barotrauma.
---
7. CF Pulmonary Exacerbation – Synergy
A 16-year-old CF patient, FEV₁ 38 %, colonized with MRSA & P.
aeruginosa. Febrile 39 °C, infiltrates bilateral. Best empiric IV combo?
A. Cefepime + vancomycin
B. Piperacillin-tazobactam + linezolid
C. Ceftazidime-avibactam + vancomycin + azithromycin
D. Meropenem-vaborbactam + daptomycin
Rationale: New β-lactam/β-lactamase pairs provide anti-pseudomonal
coverage; vancomycin hits MRSA; azithromycin modulates inflammation.
---
8. Apnea of Prematurity – Caffeine Toxicity
A 32-week 1,500-g neonate on caffeine citrate develops HR 208, glucose
53 mg/dL, jitteriness. Serum caffeine 42 µg/mL (goal 20). First
intervention?
A. Intubate and ventilate
B. Hold caffeine and give IV fluids 10 mL/kg D5 NS
4
Final Test Review
(Questions & Solutions)
2025
1
, 1. Viral Myocarditis vs. Sepsis
A 6-year-old previously healthy boy presents with 2 days of fever and
new hepatomegaly. BP 90/50 mm Hg, HR 146, CRP 12 mg/dL, troponin I
1.2 ng/mL, BNP 2,400 pg/mL, lactate 1.9 mmol/L. Bedside echo: LVEF 38
%, no pericardial effusion. Best initial pharmacologic therapy?
A. Ceftriaxone 75 mg/kg IV
B. Milrinone 0.5 µg/kg/min IV
C. Dopamine 7 µg/kg/min IV
D. High-dose IVIG 2 g/kg
Rationale: Depressed systolic function with low SVR favors inodilator
milrinone; vasopressors raise afterload and worsen performance.
---
2. Post–Fontan Plastic Bronchitis
A 9-year-old with extracardiac Fontan completes bronchoscopy for
refractory chylous casts. CVP 20 mm Hg, SpO₂ 88 % on RA. Which
intervention targets the root pathophysiology?
A. Inhaled hypertonic saline TID
B. Lymphatic embolization via dynamic contrast MR lymphangiography
C. High-frequency chest wall oscillation
D. Nebulized t-PA 5 mg q6 h
Rationale: Aberrant thoracic duct leak into airways is now treated
definitively with interventional radiology–guided lymphatic embolization.
---
3. Pulmonary Hypertension Crisis
A 4-year-old with idiopathic PAH deteriorates in the PICU: PAP equals
systemic BP on echo; CO₂ 55 mm Hg; sat 85 % despite FiO₂ 1.0.
2
,Immediate bedside action?
A. Paralysis and higher PEEP
B. Bolus inhaled nitric oxide 20 ppm, titrate
C. Norepinephrine 0.1 µg/kg/min
D. Give furosemide 1 mg/kg IV
Rationale: Selective pulmonary vasodilation rapidly reduces PAP:Psys
ratio and prevents RV ischemia during crisis.
---
4. Kawasaki Disease – Coronary Aneurysm Prevention
A 12-month-old meets complete Kawasaki criteria on day 6 of fever.
Platelets 680 K, ALT 62 IU/L. Optimal regimen?
A. IVIG 2 g/kg once + high-dose aspirin 80 mg/kg/day divided QID
B. IVIG only
C. Low-dose aspirin 3 mg/kg/day
D. Corticosteroids alone
Rationale: Timely IVIG plus high-dose salicylate diminishes coronary
sequelae; steroids reserved for IVIG-refractory disease.
---
5. Heart Block After VSD Patch
A 7-kg infant POD 2 after perimembranous VSD closure develops HR 55,
BP 68/34 mm Hg, intermittent ventricular escape. Next step?
A. Trendelburg positioning
B. Temporary epicardial pacing VVI 120 bpm
C. Atropine 0.02 mg/kg IV
D. Milrinone infusion
Rationale: Post-surgical complete atrioventricular block demands
pacing; chronotropes fail when conduction absent.
3
, ---
6. Severe Status Asthmaticus – Vent Strategy
Intubated 10-year-old, peak 45, plateau 24 cm H₂O, pH 7.17, PaCO₂ 82
mm Hg. Optimal mode change?
A. Volume AC, VT 10 mL/kg, RR 22
B. Pressure-controlled ventilation with prolonged expiratory time (I:E
1:6)
C. Add 10 cm H₂O PEEP
D. APRV
Rationale: Permissive hypercapnia with long exhalation minimizes
dynamic air-trapping and barotrauma.
---
7. CF Pulmonary Exacerbation – Synergy
A 16-year-old CF patient, FEV₁ 38 %, colonized with MRSA & P.
aeruginosa. Febrile 39 °C, infiltrates bilateral. Best empiric IV combo?
A. Cefepime + vancomycin
B. Piperacillin-tazobactam + linezolid
C. Ceftazidime-avibactam + vancomycin + azithromycin
D. Meropenem-vaborbactam + daptomycin
Rationale: New β-lactam/β-lactamase pairs provide anti-pseudomonal
coverage; vancomycin hits MRSA; azithromycin modulates inflammation.
---
8. Apnea of Prematurity – Caffeine Toxicity
A 32-week 1,500-g neonate on caffeine citrate develops HR 208, glucose
53 mg/dL, jitteriness. Serum caffeine 42 µg/mL (goal 20). First
intervention?
A. Intubate and ventilate
B. Hold caffeine and give IV fluids 10 mL/kg D5 NS
4
