NURS 5210 Sentinel U: Alia Ghannam pediatric
simulation case report - 2026 Update | 100% Correct.
1. A pediatric patient with a history of asthma presents with acute respiratory distress. Initial
assessment reveals intercostal retractions, prolonged expiration, and an SpO2 of 88% on room air.
Auscultation reveals diffuse expiratory wheezing. Which of the following sets of arterial blood gas
values would be most consistent with impending respiratory failure in this patient?
A. pH 7.48, PaCO2 30 mmHg, PaO2 60 mmHg, HCO3- 24 mEq/L
B. pH 7.35, PaCO2 50 mmHg, PaO2 55 mmHg, HCO3- 26 mEq/L
C. pH 7.25, PaCO2 55 mmHg, PaO2 50 mmHg, HCO3- 24 mEq/L
D. pH 7.40, PaCO2 40 mmHg, PaO2 70 mmHg, HCO3- 24 mEq/L
Answer: B
Rationale: Impending respiratory failure in asthma is indicated by a normalizing PaCO2 (due to fatigue)
and hypoxemia. Option B shows a PaCO2 of 50 mmHg (rising from low to normal) with hypoxemia,
signaling decompensation. Option A shows respiratory alkalosis (compensated hyperventilation), C
shows acidosis (late failure), D is normal.
2. A pediatric patient with septic shock requires fluid resuscitation. After administering 40 mL/kg
of isotonic crystalloid, the patient remains hypotensive with poor perfusion. Which of the following
vasoactive agents is most appropriate as first-line therapy in this scenario?
A. Dopamine at 5 mcg/kg/min
B. Epinephrine at 0.1 mcg/kg/min
C. Norepinephrine at 0.05 mcg/kg/min
D. Vasopressin at 0.0003 units/kg/min
Answer: C
Rationale: Current pediatric septic shock guidelines recommend norepinephrine as the first-line
vasopressor after fluid resuscitation for cold shock with hypotension. Epinephrine is an alternative for
warm shock. Dopamine is less preferred due to arrhythmia risk. Vasopressin is second-line.
3. A pediatric patient with diabetic ketoacidosis (DKA) has a serum potassium of 3.2 mEq/L on
admission. Which of the following actions is most appropriate regarding insulin therapy?
A. Administer regular insulin 0.1 units/kg IV bolus immediately
B. Hold insulin until potassium is corrected to >3.3 mEq/L
C. Start insulin infusion at 0.05 units/kg/hr and monitor potassium hourly
D. Give potassium 0.5 mEq/kg IV over 1 hour then start insulin
Answer: B
Rationale: In DKA, insulin drives potassium intracellularly, worsening hypokalemia. Current guidelines
recommend correcting potassium to >3.3 mEq/L before starting insulin to prevent cardiac arrhythmias.
Option D is incorrect because insulin should not be started before potassium correction; potassium
replacement should be given first.
Page 1
,4. A pediatric patient with suspected bacterial meningitis has a lumbar puncture performed. CSF
analysis shows: WBC 1200 cells/mm³ (80% neutrophils), glucose 25 mg/dL (serum glucose 100
mg/dL), protein 150 mg/dL. Which empiric antibiotic regimen is most appropriate for this patient,
considering likely pathogens and age?
A. Ceftriaxone plus vancomycin
B. Ampicillin plus gentamicin
C. Cefotaxime plus ampicillin
D. Meropenem plus acyclovir
Answer: A
Rationale: CSF profile (elevated WBC with neutrophils, low glucose, high protein) is consistent with
bacterial meningitis. In children beyond neonatal period, Streptococcus pneumoniae and Neisseria
meningitidis are common; ceftriaxone plus vancomycin provides coverage for resistant S. pneumoniae.
Ampicillin/gentamicin is for neonates; cefotaxime/ampicillin is alternative but vancomycin needed for
resistance.
5. A pediatric patient with a ventriculoperitoneal shunt presents with fever, headache, and altered
mental status. CSF obtained via shunt tap shows Gram-positive cocci in clusters. Which empiric
antibiotic should be initiated?
A. Ceftriaxone
B. Vancomycin
C. Metronidazole
D. Cefepime
Answer: B
Rationale: Shunt infections are commonly caused by coagulase-negative staphylococci (e.g.,
Staphylococcus epidermidis) which are often methicillin-resistant. Vancomycin provides coverage for
MRSA and coagulase-negative staph. Ceftriaxone and cefepime do not cover MRSA; metronidazole is
for anaerobes.
6. A pediatric patient with acute respiratory distress syndrome (ARDS) is on mechanical
ventilation. Which ventilator strategy has been shown to reduce mortality in pediatric ARDS?
A. Tidal volume 10 mL/kg, plateau pressure <30 cmH2O
B. Tidal volume 6 mL/kg, plateau pressure <28 cmH2O, with high PEEP
C. Tidal volume 8 mL/kg, permissive hypercapnia, PEEP 5 cmH2O
D. Tidal volume 12 mL/kg, inverse ratio ventilation
Answer: B
Rationale: Lung-protective ventilation with low tidal volumes (6 mL/kg predicted body weight) and
limited plateau pressure (<28-30 cmH2O) reduces mortality in ARDS. High PEEP helps recruit alveoli.
Option A uses high tidal volume; C uses lower PEEP; D uses high tidal volume and inverse ratio not
proven.
Page 2
,7. A pediatric patient with severe traumatic brain injury (TBI) has an intracranial pressure (ICP)
of 28 mmHg and cerebral perfusion pressure (CPP) of 45 mmHg. After sedation and head
elevation, the ICP remains elevated. Which intervention should be initiated next?
A. Administer mannitol 0.25-1 g/kg IV bolus
B. Start hyperventilation to PaCO2 of 25 mmHg
C. Place an external ventricular drain for CSF diversion
D. Initiate therapeutic hypothermia to 32-34°C
Answer: A
Rationale: For elevated ICP with preserved CPP, osmotic therapy with mannitol or hypertonic saline is
first-line. Hyperventilation is reserved for acute herniation due to risk of ischemia. CSF drainage is
second-line if ICP persists. Therapeutic hypothermia is not routinely recommended in pediatric TBI.
8. A pediatric patient with acute kidney injury (AKI) secondary to hemolytic uremic syndrome
(HUS) has a serum potassium of 6.8 mEq/L with peaked T waves on ECG. Which of the following
is the most appropriate immediate intervention?
A. Intravenous furosemide 1 mg/kg
B. Intravenous calcium gluconate 100 mg/kg
C. Intravenous sodium bicarbonate 1 mEq/kg
D. Intravenous regular insulin 0.1 units/kg with dextrose
Answer: B
Rationale: In life-threatening hyperkalemia with ECG changes, calcium gluconate is given first to
stabilize cardiac membranes. This is followed by measures to shift potassium intracellularly
(insulin+glucose, bicarbonate). Furosemide promotes excretion but is slower. Sodium bicarbonate alone
is less effective.
9. A pediatric patient with bronchiolitis is being considered for high-flow nasal cannula (HFNC)
therapy. Which of the following clinical findings would most strongly support initiation of HFNC?
A. SpO2 94% on room air, mild retractions, respiratory rate 40/min
B. SpO2 88% on 2 L/min nasal cannula, moderate retractions, grunting
C. SpO2 92% on 0.5 L/min nasal cannula, mild subcostal retractions
D. SpO2 96% on room air, no retractions, occasional cough
Answer: B
Rationale: HFNC is indicated for moderate to severe respiratory distress with hypoxemia despite
low-flow oxygen. Option B shows hypoxemia (88% on 2 L/min) with increased work of breathing
(moderate retractions, grunting), meeting criteria. Option A is mild, C is mild, D is normal.
10. A pediatric patient with suspected intussusception undergoes an air enema. The reduction is
successful, but the patient develops abdominal distension and bilious vomiting shortly after. Which
of the following complications should be suspected?
A. Recurrent intussusception
B. Intestinal perforation
C. Necrotizing enterocolitis
Page 3
, D. Post-reduction ileus
Answer: B
Rationale: Bilious vomiting and abdominal distension after air enema reduction are concerning for
intestinal perforation, a known complication. Recurrent intussusception typically presents with colicky
pain and currant-jelly stools. Necrotizing enterocolitis is unlikely in this context. Post-reduction ileus
causes distension but not bilious vomiting.
11. During a pediatric simulation, a nursing student observes that the manikin's respiratory rate
increases from 20 to 40 breaths per minute while oxygen saturation drops from 98% to 85% over
10 minutes. The student auscultates diminished breath sounds on the right side and notes tracheal
deviation to the left. Which intervention should the nurse anticipate performing first?
A. Perform needle decompression at the second intercostal space, midclavicular line on the right side.
B. Administer a bolus of normal saline 20 mL/kg intravenously.
C. Prepare for endotracheal intubation with rapid sequence intubation medications.
D. Apply a non-rebreather mask at 15 L/min and reposition the child.
Answer: A
Rationale: The presentation is classic for tension pneumothorax: respiratory distress, hypoxia,
diminished breath sounds, and tracheal deviation away from the affected side. Immediate needle
decompression is the priority to relieve pressure. Saline bolus is for shock; intubation may be needed
later but decompression is first; oxygen alone will not relieve the tension.
12. In a pediatric simulation scenario, a child is receiving IV fluids for dehydration. The nurse
notes that the child's serum sodium level has increased from 135 mEq/L to 152 mEq/L over 12
hours. The child's urine output is 0.5 mL/kg/hr, and urine specific gravity is 1.030. Which
condition is most likely causing these findings?
A. Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
B. Diabetes insipidus (DI)
C. Acute kidney injury (AKI)
D. Hyperglycemic hyperosmolar state (HHS)
Answer: B
Rationale: Hypernatremia with concentrated urine (high specific gravity) and low urine output suggests
the kidney is conserving water, but the serum sodium is rising, indicating a lack of ADH effect (DI) or
inadequate water replacement. SIADH would cause hyponatremia. AKI typically causes isosthenuria.
HHS includes hyperglycemia, not just hypernatremia.
13. A pediatric patient with a history of asthma presents with acute respiratory distress. The nurse
administers albuterol via nebulizer. Ten minutes later, the patient's heart rate increases from 100 to
140 bpm, and the patient complains of palpitations. Which mechanism best explains this adverse
effect?
A. Beta-2 receptor activation leading to increased cAMP in cardiac myocytes
B. Beta-1 receptor cross-activation due to high dose of albuterol
C. Alpha-1 receptor stimulation causing vasoconstriction and reflex tachycardia
D. Muscarinic receptor blockade resulting in unopposed sympathetic activity
Page 4
simulation case report - 2026 Update | 100% Correct.
1. A pediatric patient with a history of asthma presents with acute respiratory distress. Initial
assessment reveals intercostal retractions, prolonged expiration, and an SpO2 of 88% on room air.
Auscultation reveals diffuse expiratory wheezing. Which of the following sets of arterial blood gas
values would be most consistent with impending respiratory failure in this patient?
A. pH 7.48, PaCO2 30 mmHg, PaO2 60 mmHg, HCO3- 24 mEq/L
B. pH 7.35, PaCO2 50 mmHg, PaO2 55 mmHg, HCO3- 26 mEq/L
C. pH 7.25, PaCO2 55 mmHg, PaO2 50 mmHg, HCO3- 24 mEq/L
D. pH 7.40, PaCO2 40 mmHg, PaO2 70 mmHg, HCO3- 24 mEq/L
Answer: B
Rationale: Impending respiratory failure in asthma is indicated by a normalizing PaCO2 (due to fatigue)
and hypoxemia. Option B shows a PaCO2 of 50 mmHg (rising from low to normal) with hypoxemia,
signaling decompensation. Option A shows respiratory alkalosis (compensated hyperventilation), C
shows acidosis (late failure), D is normal.
2. A pediatric patient with septic shock requires fluid resuscitation. After administering 40 mL/kg
of isotonic crystalloid, the patient remains hypotensive with poor perfusion. Which of the following
vasoactive agents is most appropriate as first-line therapy in this scenario?
A. Dopamine at 5 mcg/kg/min
B. Epinephrine at 0.1 mcg/kg/min
C. Norepinephrine at 0.05 mcg/kg/min
D. Vasopressin at 0.0003 units/kg/min
Answer: C
Rationale: Current pediatric septic shock guidelines recommend norepinephrine as the first-line
vasopressor after fluid resuscitation for cold shock with hypotension. Epinephrine is an alternative for
warm shock. Dopamine is less preferred due to arrhythmia risk. Vasopressin is second-line.
3. A pediatric patient with diabetic ketoacidosis (DKA) has a serum potassium of 3.2 mEq/L on
admission. Which of the following actions is most appropriate regarding insulin therapy?
A. Administer regular insulin 0.1 units/kg IV bolus immediately
B. Hold insulin until potassium is corrected to >3.3 mEq/L
C. Start insulin infusion at 0.05 units/kg/hr and monitor potassium hourly
D. Give potassium 0.5 mEq/kg IV over 1 hour then start insulin
Answer: B
Rationale: In DKA, insulin drives potassium intracellularly, worsening hypokalemia. Current guidelines
recommend correcting potassium to >3.3 mEq/L before starting insulin to prevent cardiac arrhythmias.
Option D is incorrect because insulin should not be started before potassium correction; potassium
replacement should be given first.
Page 1
,4. A pediatric patient with suspected bacterial meningitis has a lumbar puncture performed. CSF
analysis shows: WBC 1200 cells/mm³ (80% neutrophils), glucose 25 mg/dL (serum glucose 100
mg/dL), protein 150 mg/dL. Which empiric antibiotic regimen is most appropriate for this patient,
considering likely pathogens and age?
A. Ceftriaxone plus vancomycin
B. Ampicillin plus gentamicin
C. Cefotaxime plus ampicillin
D. Meropenem plus acyclovir
Answer: A
Rationale: CSF profile (elevated WBC with neutrophils, low glucose, high protein) is consistent with
bacterial meningitis. In children beyond neonatal period, Streptococcus pneumoniae and Neisseria
meningitidis are common; ceftriaxone plus vancomycin provides coverage for resistant S. pneumoniae.
Ampicillin/gentamicin is for neonates; cefotaxime/ampicillin is alternative but vancomycin needed for
resistance.
5. A pediatric patient with a ventriculoperitoneal shunt presents with fever, headache, and altered
mental status. CSF obtained via shunt tap shows Gram-positive cocci in clusters. Which empiric
antibiotic should be initiated?
A. Ceftriaxone
B. Vancomycin
C. Metronidazole
D. Cefepime
Answer: B
Rationale: Shunt infections are commonly caused by coagulase-negative staphylococci (e.g.,
Staphylococcus epidermidis) which are often methicillin-resistant. Vancomycin provides coverage for
MRSA and coagulase-negative staph. Ceftriaxone and cefepime do not cover MRSA; metronidazole is
for anaerobes.
6. A pediatric patient with acute respiratory distress syndrome (ARDS) is on mechanical
ventilation. Which ventilator strategy has been shown to reduce mortality in pediatric ARDS?
A. Tidal volume 10 mL/kg, plateau pressure <30 cmH2O
B. Tidal volume 6 mL/kg, plateau pressure <28 cmH2O, with high PEEP
C. Tidal volume 8 mL/kg, permissive hypercapnia, PEEP 5 cmH2O
D. Tidal volume 12 mL/kg, inverse ratio ventilation
Answer: B
Rationale: Lung-protective ventilation with low tidal volumes (6 mL/kg predicted body weight) and
limited plateau pressure (<28-30 cmH2O) reduces mortality in ARDS. High PEEP helps recruit alveoli.
Option A uses high tidal volume; C uses lower PEEP; D uses high tidal volume and inverse ratio not
proven.
Page 2
,7. A pediatric patient with severe traumatic brain injury (TBI) has an intracranial pressure (ICP)
of 28 mmHg and cerebral perfusion pressure (CPP) of 45 mmHg. After sedation and head
elevation, the ICP remains elevated. Which intervention should be initiated next?
A. Administer mannitol 0.25-1 g/kg IV bolus
B. Start hyperventilation to PaCO2 of 25 mmHg
C. Place an external ventricular drain for CSF diversion
D. Initiate therapeutic hypothermia to 32-34°C
Answer: A
Rationale: For elevated ICP with preserved CPP, osmotic therapy with mannitol or hypertonic saline is
first-line. Hyperventilation is reserved for acute herniation due to risk of ischemia. CSF drainage is
second-line if ICP persists. Therapeutic hypothermia is not routinely recommended in pediatric TBI.
8. A pediatric patient with acute kidney injury (AKI) secondary to hemolytic uremic syndrome
(HUS) has a serum potassium of 6.8 mEq/L with peaked T waves on ECG. Which of the following
is the most appropriate immediate intervention?
A. Intravenous furosemide 1 mg/kg
B. Intravenous calcium gluconate 100 mg/kg
C. Intravenous sodium bicarbonate 1 mEq/kg
D. Intravenous regular insulin 0.1 units/kg with dextrose
Answer: B
Rationale: In life-threatening hyperkalemia with ECG changes, calcium gluconate is given first to
stabilize cardiac membranes. This is followed by measures to shift potassium intracellularly
(insulin+glucose, bicarbonate). Furosemide promotes excretion but is slower. Sodium bicarbonate alone
is less effective.
9. A pediatric patient with bronchiolitis is being considered for high-flow nasal cannula (HFNC)
therapy. Which of the following clinical findings would most strongly support initiation of HFNC?
A. SpO2 94% on room air, mild retractions, respiratory rate 40/min
B. SpO2 88% on 2 L/min nasal cannula, moderate retractions, grunting
C. SpO2 92% on 0.5 L/min nasal cannula, mild subcostal retractions
D. SpO2 96% on room air, no retractions, occasional cough
Answer: B
Rationale: HFNC is indicated for moderate to severe respiratory distress with hypoxemia despite
low-flow oxygen. Option B shows hypoxemia (88% on 2 L/min) with increased work of breathing
(moderate retractions, grunting), meeting criteria. Option A is mild, C is mild, D is normal.
10. A pediatric patient with suspected intussusception undergoes an air enema. The reduction is
successful, but the patient develops abdominal distension and bilious vomiting shortly after. Which
of the following complications should be suspected?
A. Recurrent intussusception
B. Intestinal perforation
C. Necrotizing enterocolitis
Page 3
, D. Post-reduction ileus
Answer: B
Rationale: Bilious vomiting and abdominal distension after air enema reduction are concerning for
intestinal perforation, a known complication. Recurrent intussusception typically presents with colicky
pain and currant-jelly stools. Necrotizing enterocolitis is unlikely in this context. Post-reduction ileus
causes distension but not bilious vomiting.
11. During a pediatric simulation, a nursing student observes that the manikin's respiratory rate
increases from 20 to 40 breaths per minute while oxygen saturation drops from 98% to 85% over
10 minutes. The student auscultates diminished breath sounds on the right side and notes tracheal
deviation to the left. Which intervention should the nurse anticipate performing first?
A. Perform needle decompression at the second intercostal space, midclavicular line on the right side.
B. Administer a bolus of normal saline 20 mL/kg intravenously.
C. Prepare for endotracheal intubation with rapid sequence intubation medications.
D. Apply a non-rebreather mask at 15 L/min and reposition the child.
Answer: A
Rationale: The presentation is classic for tension pneumothorax: respiratory distress, hypoxia,
diminished breath sounds, and tracheal deviation away from the affected side. Immediate needle
decompression is the priority to relieve pressure. Saline bolus is for shock; intubation may be needed
later but decompression is first; oxygen alone will not relieve the tension.
12. In a pediatric simulation scenario, a child is receiving IV fluids for dehydration. The nurse
notes that the child's serum sodium level has increased from 135 mEq/L to 152 mEq/L over 12
hours. The child's urine output is 0.5 mL/kg/hr, and urine specific gravity is 1.030. Which
condition is most likely causing these findings?
A. Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
B. Diabetes insipidus (DI)
C. Acute kidney injury (AKI)
D. Hyperglycemic hyperosmolar state (HHS)
Answer: B
Rationale: Hypernatremia with concentrated urine (high specific gravity) and low urine output suggests
the kidney is conserving water, but the serum sodium is rising, indicating a lack of ADH effect (DI) or
inadequate water replacement. SIADH would cause hyponatremia. AKI typically causes isosthenuria.
HHS includes hyperglycemia, not just hypernatremia.
13. A pediatric patient with a history of asthma presents with acute respiratory distress. The nurse
administers albuterol via nebulizer. Ten minutes later, the patient's heart rate increases from 100 to
140 bpm, and the patient complains of palpitations. Which mechanism best explains this adverse
effect?
A. Beta-2 receptor activation leading to increased cAMP in cardiac myocytes
B. Beta-1 receptor cross-activation due to high dose of albuterol
C. Alpha-1 receptor stimulation causing vasoconstriction and reflex tachycardia
D. Muscarinic receptor blockade resulting in unopposed sympathetic activity
Page 4
