APRN CCNS (Pediatric)
Final Test Review
(Questions & Solutions)
2025
1
, 1. Neurocritical Care – Refractory ICP
A 6-year-old (25 kg) with severe TBI is intubated, ventilated (PaCO₂ 35
mm Hg), and receiving hypertonic saline 3 % at 0.2 mL/kg/min. ICP
remains 28 mm Hg, CPP = 48 mm Hg. Best next maneuver?
A. Increase hypertonic saline to 23.4 % bolus 5 mL over 10 min
B. Initiate mild hypothermia to 33 °C for 48 h
C. Advance hypertonic saline infusion rate to 0.5 mL/kg/min
D. Add mannitol 0.5 g/kg bolus with goal serum osmolality <320
mOsm/kg
ANS C
Rationale – Step-wise escalation within one modality (3 % saline up-
titration) is recommended before introducing second agents; 23.4 %
requires central access and <30 mL dose; combined mannitol risks
osmotic shifts.
---
2. Cardiology – Post-Fontan Low-Output
A 4-year-old 24 h post-Fontan shows lactate 4 mmol/L, CVP 20 mm Hg,
mixed venous O₂ sat 55 %. HR 140, MAP 60. Optimal inotrope/vasoactive
selection?
A. Dopamine 7 µg/kg/min
B. Milrinone 0.5 µg/kg/min infusion
C. Epinephrine 0.05 µg/kg/min
D. Norepinephrine 0.05 µg/kg/min
ANS B
Rationale – Fontan physiology needs low PVR and augmented
ventricular relaxation; milrinone improves cardiac index and decreases
SVR/PVR without raising chronotropy excessively.
2
,---
3. Pulmonology – Ventilator Asynchrony
A 10-year-old on pressure-controlled SIMV + PS exhibits double triggering
and diaphoresis. He is neurologically intact. Which ventilator alteration
corrects reverse triggering ?
A. Increase inspiratory time
B. Reduce mandatory rate
C. Increase PS level
D. Switch to PRVC mode
ANS B
Rationale – Reverse triggering occurs when machine breaths outpace
child’s neural timing; lowering set rate allows spontaneous rhythm
dominance.
---
4. Infectious Disease – Pediatric Septic Shock Fluid Ceiling
A 9-month-old, 8 kg, with meningococcemia has received 60 mL/kg
balanced crystalloid; hepatomegaly now palpable 4 cm below costal
margin. MAP still 45 mm Hg (goal > 55). Next step?
A. Additional 20 mL/kg crystalloid bolus
B. Start norepinephrine 0.1 µg/kg/min
C. Initiate dopamine 10 µg/kg/min
D. Begin epinephrine 0.1 µg/kg/min
ANS D
Rationale – After ≥40–60 mL/kg and signs of fluid overload, early
epinephrine is first-choice catecholamine for cold shock in infants per
ACCM guidelines.
---
5. Hematology/Oncology – Tumor Lysis in ALL
3
, A newly diagnosed 7-year-old ALL patient on rasburicase shows K⁺ 6.2
mEq/L, phosphate 8 mg/dL, Ca²⁺ 6.8 mg/dL. ECG: peaked T-waves. Best
immediate management?
A. Sodium-zirconium cyclosilicate 10 g PO
B. Continuous insulin 0.1 U/kg/h with D10 infusion
C. Emergent hemodialysis
D. IV calcium gluconate 100 mg/kg slow push
ANS D
Rationale – Membrane stabilization with IV calcium precedes
potassium-lowering measures in life-threatening ECG changes; dialysis
follows if refractory.
---
6. Endocrine – DKA Cerebral Edema
A 12-year-old in DKA (pH 7.05) 4 h into therapy develops headache,
bradycardia, and vomiting. Serum Na⁺ is rising appropriately. First
intervention?
A. Mannitol 0.5 g/kg IV over 10 min
B. Reduce insulin infusion to 0.05 U/kg/h
C. Hypertonic saline 3 % 5 mL/kg
D. Head CT before treatment
ANS A
Rationale – Clinical cerebral edema = emergency; mannitol is first-line;
imaging waits until stable.
---
7. Gastroenterology – Acute Liver Failure & Encephalopathy
A 15-year-old with autoimmune hepatitis, INR 3.5, ammonia 160 µmol/L,
Grade II encephalopathy. What bridge therapy most improves transplant-
free survival?
A. Lactulose 25 mL q2h
4
Final Test Review
(Questions & Solutions)
2025
1
, 1. Neurocritical Care – Refractory ICP
A 6-year-old (25 kg) with severe TBI is intubated, ventilated (PaCO₂ 35
mm Hg), and receiving hypertonic saline 3 % at 0.2 mL/kg/min. ICP
remains 28 mm Hg, CPP = 48 mm Hg. Best next maneuver?
A. Increase hypertonic saline to 23.4 % bolus 5 mL over 10 min
B. Initiate mild hypothermia to 33 °C for 48 h
C. Advance hypertonic saline infusion rate to 0.5 mL/kg/min
D. Add mannitol 0.5 g/kg bolus with goal serum osmolality <320
mOsm/kg
ANS C
Rationale – Step-wise escalation within one modality (3 % saline up-
titration) is recommended before introducing second agents; 23.4 %
requires central access and <30 mL dose; combined mannitol risks
osmotic shifts.
---
2. Cardiology – Post-Fontan Low-Output
A 4-year-old 24 h post-Fontan shows lactate 4 mmol/L, CVP 20 mm Hg,
mixed venous O₂ sat 55 %. HR 140, MAP 60. Optimal inotrope/vasoactive
selection?
A. Dopamine 7 µg/kg/min
B. Milrinone 0.5 µg/kg/min infusion
C. Epinephrine 0.05 µg/kg/min
D. Norepinephrine 0.05 µg/kg/min
ANS B
Rationale – Fontan physiology needs low PVR and augmented
ventricular relaxation; milrinone improves cardiac index and decreases
SVR/PVR without raising chronotropy excessively.
2
,---
3. Pulmonology – Ventilator Asynchrony
A 10-year-old on pressure-controlled SIMV + PS exhibits double triggering
and diaphoresis. He is neurologically intact. Which ventilator alteration
corrects reverse triggering ?
A. Increase inspiratory time
B. Reduce mandatory rate
C. Increase PS level
D. Switch to PRVC mode
ANS B
Rationale – Reverse triggering occurs when machine breaths outpace
child’s neural timing; lowering set rate allows spontaneous rhythm
dominance.
---
4. Infectious Disease – Pediatric Septic Shock Fluid Ceiling
A 9-month-old, 8 kg, with meningococcemia has received 60 mL/kg
balanced crystalloid; hepatomegaly now palpable 4 cm below costal
margin. MAP still 45 mm Hg (goal > 55). Next step?
A. Additional 20 mL/kg crystalloid bolus
B. Start norepinephrine 0.1 µg/kg/min
C. Initiate dopamine 10 µg/kg/min
D. Begin epinephrine 0.1 µg/kg/min
ANS D
Rationale – After ≥40–60 mL/kg and signs of fluid overload, early
epinephrine is first-choice catecholamine for cold shock in infants per
ACCM guidelines.
---
5. Hematology/Oncology – Tumor Lysis in ALL
3
, A newly diagnosed 7-year-old ALL patient on rasburicase shows K⁺ 6.2
mEq/L, phosphate 8 mg/dL, Ca²⁺ 6.8 mg/dL. ECG: peaked T-waves. Best
immediate management?
A. Sodium-zirconium cyclosilicate 10 g PO
B. Continuous insulin 0.1 U/kg/h with D10 infusion
C. Emergent hemodialysis
D. IV calcium gluconate 100 mg/kg slow push
ANS D
Rationale – Membrane stabilization with IV calcium precedes
potassium-lowering measures in life-threatening ECG changes; dialysis
follows if refractory.
---
6. Endocrine – DKA Cerebral Edema
A 12-year-old in DKA (pH 7.05) 4 h into therapy develops headache,
bradycardia, and vomiting. Serum Na⁺ is rising appropriately. First
intervention?
A. Mannitol 0.5 g/kg IV over 10 min
B. Reduce insulin infusion to 0.05 U/kg/h
C. Hypertonic saline 3 % 5 mL/kg
D. Head CT before treatment
ANS A
Rationale – Clinical cerebral edema = emergency; mannitol is first-line;
imaging waits until stable.
---
7. Gastroenterology – Acute Liver Failure & Encephalopathy
A 15-year-old with autoimmune hepatitis, INR 3.5, ammonia 160 µmol/L,
Grade II encephalopathy. What bridge therapy most improves transplant-
free survival?
A. Lactulose 25 mL q2h
4
