PALS EXAM 200 ACTUAL QUESTIONS AND
CORRECT ANSWERS ANSWERS WITH
RATIONALE LATEST UPDATE ALREADY
GRADED A+ ASSURED PASS
This comprehensive PALS exam bank contains 200 unique, high-yield
multiple-choice questions designed to mirror the American Heart Association
pediatric advanced life support certification exam. Each question presents a
realistic clinical scenario covering respiratory failure, shock, cardiac
arrhythmias, toxicology, trauma, and congenital heart disease. Every entry
includes one correct answer and a detailed, evidence-based rationale
explaining the underlying pathophysiology and guideline-driven management.
The questions systematically test critical decision-making, medication dosing,
rhythm recognition, and reversible cause identification. This resource is ideal
for self-assessment, remediation, or group study, providing thorough
preparation for PALS provider or renewal courses.
1. A 4-year-old child is brought to the emergency department with respiratory
distress. The child has a hoarse cough, stridor, and drooling. Which intervention is
the priority?
A) Obtain a chest radiograph
B) Prepare for immediate endotracheal intubation
C) Administer racemic epinephrine via nebulizer
D) Perform a flexible nasopharyngoscopy
Answer: C
Rationale: The presentation of hoarseness, stridor, and drooling in a young child is
classic for croup or severe upper airway obstruction. Racemic epinephrine reduces
airway mucosal edema and is the first-line pharmacologic intervention. Intubation
is reserved for impending failure; imaging and scopes delay critical care.
2. A 6-month-old infant has a heart rate of 220 beats per minute, a blood pressure
of 70/40 mmHg, and is lethargic. An ECG shows narrow QRS complex
,tachycardia without visible P waves. What is the most appropriate initial
management?
A) Synchronized cardioversion at 0.5 J/kg
B) Vagal maneuvers with ice to the face
C) Intravenous adenosine rapid push
D) Defibrillation at 2 J/kg
Answer: C
Rationale: This is supraventricular tachycardia with hemodynamic instability but
not in cardiac arrest. Adenosine is the drug of choice for narrow-complex SVT
when vascular access is available. Vagal maneuvers are first-line only if the patient
is stable. Synchronized cardioversion is used if adenosine fails or the patient is in
extremis.
3. A 2-year-old child in cardiac arrest has an advanced airway in place. High-
quality CPR is ongoing. The ventilation rate should be delivered at which
frequency?
A) 10 to 12 breaths per minute
B) 20 to 30 breaths per minute
C) 1 breath every 3 to 5 seconds
D) 2 breaths every 30 compressions
Answer: C
Rationale: For a child with an advanced airway during cardiac arrest, ventilations
are delivered asynchronously at a rate of 1 breath every 3 to 5 seconds, which
equals 12 to 20 breaths per minute. The 2:30 ratio is for patients without an
advanced airway. Over-ventilation is harmful.
4. Which finding on a pediatric ECG is most consistent with hyperkalemia?
A) Prolonged PR interval and peaked T waves
B) ST-segment elevation and wide QRS
C) Deep Q waves in lead III
D) Epsilon waves in V1 through V3
Answer: A
Rationale: Peaked, narrow-based T waves are the earliest sign of hyperkalemia,
followed by PR prolongation, QRS widening, and eventually sine-wave pattern. ST
elevation and wide QRS are more typical of ischemia or toxin exposure. Deep Q
waves suggest myocardial infarction.
5. A 7-year-old child has a suspected anaphylactic reaction after eating peanuts.
The child has stridor, widespread urticaria, and hypotension. Which medication
should be administered first?
,A) Diphenhydramine intravenously
B) Albuterol by nebulizer
C) Epinephrine intramuscularly
D) Methylprednisolone intravenously
Answer: C
Rationale: Intramuscular epinephrine is the first-line treatment for anaphylaxis and
should be given immediately to reverse vasodilation and bronchospasm.
Antihistamines, bronchodilators, and corticosteroids are adjunctive therapies and
do not replace epinephrine.
6. During a pediatric resuscitation, the team leader asks for the dose of epinephrine
for a 10 kg infant in pulseless arrest. What is the correct intravenous dose?
A) 0.01 mg/kg of 1:10,000 solution
B) 0.1 mg/kg of 1:1,000 solution
C) 0.1 mL/kg of 1:10,000 solution
D) 1 mg of 1:1,000 solution
Answer: A
Rationale: The correct IV/IO dose for epinephrine in pediatric cardiac arrest is 0.01
mg/kg of the 1:10,000 (0.1 mg/mL) concentration, which equals 0.1 mL/kg. The
1:1,000 concentration is used for IM anaphylaxis, and a flat 1 mg dose is for adult
arrests only.
7. A 3-year-old child presents with fever, meningismus, and a purpuric rash. The
child becomes unresponsive and has a rhythm of pulseless electrical activity on the
monitor. Which intervention is most important immediately after starting CPR?
A) Administer empiric antibiotics
B) Administer a fluid bolus of 20 mL/kg
C) Administer epinephrine every 3 to 5 minutes
D) Obtain a head CT scan
Answer: C
Rationale: In pulseless arrest, epinephrine is the primary vasopressor and should be
given as soon as possible regardless of etiology. While fluids and antibiotics are
important for sepsis, they do not take priority over epinephrine in a pulseless state.
CT scan is not appropriate during active arrest.
8. An 8-year-old child has a witnessed sudden collapse during a soccer game. The
initial rhythm is ventricular fibrillation. The first defibrillation dose is given. After
2 minutes of CPR, the rhythm remains VF. What is the next energy dose for
defibrillation?
A) 2 J/kg
, B) 4 J/kg
C) 6 J/kg
D) 8 J/kg
Answer: B
Rationale: The initial defibrillation dose for pediatric VF/pVT is 2 J/kg. For
subsequent shocks, the dose is increased to 4 J/kg, up to a maximum of 10 J/kg or
the adult dose. Doubling the energy is the recommended strategy.
9. A 12-month-old infant has respiratory failure due to bronchiolitis. The heart rate
is 180, respiratory rate is 70, and oxygen saturation is 85% on high-flow nasal
cannula. The infant is grunting and has severe nasal flaring. Which action is the
next appropriate step?
A) Continue high-flow nasal cannula and observe
B) Administer a trial of continuous positive airway pressure
C) Perform awake nasotracheal intubation
D) Administer racemic epinephrine
Answer: B
Rationale: This infant shows signs of impending respiratory failure with increased
work of breathing and hypoxemia. CPAP or bilevel positive airway pressure can
provide noninvasive support to recruit alveoli and reduce the work of breathing,
potentially avoiding intubation. Intubation is indicated if noninvasive fails.
10. A child with a known heart defect develops sudden onset of tachypnea,
cyanosis, and a new systolic murmur. A chest X-ray shows cardiomegaly and
pulmonary edema. Which medication is most appropriate to reduce afterload in
this setting?
A) Sodium nitroprusside
B) Dobutamine
C) Atropine
D) Phenylephrine
Answer: A
Rationale: Sodium nitroprusside is a potent arterial and venous vasodilator that
reduces afterload, which is beneficial in heart failure and acute decompensated
congenital heart disease. Dobutamine increases contractility but also increases
heart rate, which may not reduce afterload. Phenylephrine increases afterload.
11. A 5-year-old child is in septic shock. An initial fluid bolus of 40 mL/kg has
been given, but the blood pressure remains low. The child is now developing rales
and hepatomegaly. What should the provider do next?
A) Continue giving fluid boluses until blood pressure normalizes
CORRECT ANSWERS ANSWERS WITH
RATIONALE LATEST UPDATE ALREADY
GRADED A+ ASSURED PASS
This comprehensive PALS exam bank contains 200 unique, high-yield
multiple-choice questions designed to mirror the American Heart Association
pediatric advanced life support certification exam. Each question presents a
realistic clinical scenario covering respiratory failure, shock, cardiac
arrhythmias, toxicology, trauma, and congenital heart disease. Every entry
includes one correct answer and a detailed, evidence-based rationale
explaining the underlying pathophysiology and guideline-driven management.
The questions systematically test critical decision-making, medication dosing,
rhythm recognition, and reversible cause identification. This resource is ideal
for self-assessment, remediation, or group study, providing thorough
preparation for PALS provider or renewal courses.
1. A 4-year-old child is brought to the emergency department with respiratory
distress. The child has a hoarse cough, stridor, and drooling. Which intervention is
the priority?
A) Obtain a chest radiograph
B) Prepare for immediate endotracheal intubation
C) Administer racemic epinephrine via nebulizer
D) Perform a flexible nasopharyngoscopy
Answer: C
Rationale: The presentation of hoarseness, stridor, and drooling in a young child is
classic for croup or severe upper airway obstruction. Racemic epinephrine reduces
airway mucosal edema and is the first-line pharmacologic intervention. Intubation
is reserved for impending failure; imaging and scopes delay critical care.
2. A 6-month-old infant has a heart rate of 220 beats per minute, a blood pressure
of 70/40 mmHg, and is lethargic. An ECG shows narrow QRS complex
,tachycardia without visible P waves. What is the most appropriate initial
management?
A) Synchronized cardioversion at 0.5 J/kg
B) Vagal maneuvers with ice to the face
C) Intravenous adenosine rapid push
D) Defibrillation at 2 J/kg
Answer: C
Rationale: This is supraventricular tachycardia with hemodynamic instability but
not in cardiac arrest. Adenosine is the drug of choice for narrow-complex SVT
when vascular access is available. Vagal maneuvers are first-line only if the patient
is stable. Synchronized cardioversion is used if adenosine fails or the patient is in
extremis.
3. A 2-year-old child in cardiac arrest has an advanced airway in place. High-
quality CPR is ongoing. The ventilation rate should be delivered at which
frequency?
A) 10 to 12 breaths per minute
B) 20 to 30 breaths per minute
C) 1 breath every 3 to 5 seconds
D) 2 breaths every 30 compressions
Answer: C
Rationale: For a child with an advanced airway during cardiac arrest, ventilations
are delivered asynchronously at a rate of 1 breath every 3 to 5 seconds, which
equals 12 to 20 breaths per minute. The 2:30 ratio is for patients without an
advanced airway. Over-ventilation is harmful.
4. Which finding on a pediatric ECG is most consistent with hyperkalemia?
A) Prolonged PR interval and peaked T waves
B) ST-segment elevation and wide QRS
C) Deep Q waves in lead III
D) Epsilon waves in V1 through V3
Answer: A
Rationale: Peaked, narrow-based T waves are the earliest sign of hyperkalemia,
followed by PR prolongation, QRS widening, and eventually sine-wave pattern. ST
elevation and wide QRS are more typical of ischemia or toxin exposure. Deep Q
waves suggest myocardial infarction.
5. A 7-year-old child has a suspected anaphylactic reaction after eating peanuts.
The child has stridor, widespread urticaria, and hypotension. Which medication
should be administered first?
,A) Diphenhydramine intravenously
B) Albuterol by nebulizer
C) Epinephrine intramuscularly
D) Methylprednisolone intravenously
Answer: C
Rationale: Intramuscular epinephrine is the first-line treatment for anaphylaxis and
should be given immediately to reverse vasodilation and bronchospasm.
Antihistamines, bronchodilators, and corticosteroids are adjunctive therapies and
do not replace epinephrine.
6. During a pediatric resuscitation, the team leader asks for the dose of epinephrine
for a 10 kg infant in pulseless arrest. What is the correct intravenous dose?
A) 0.01 mg/kg of 1:10,000 solution
B) 0.1 mg/kg of 1:1,000 solution
C) 0.1 mL/kg of 1:10,000 solution
D) 1 mg of 1:1,000 solution
Answer: A
Rationale: The correct IV/IO dose for epinephrine in pediatric cardiac arrest is 0.01
mg/kg of the 1:10,000 (0.1 mg/mL) concentration, which equals 0.1 mL/kg. The
1:1,000 concentration is used for IM anaphylaxis, and a flat 1 mg dose is for adult
arrests only.
7. A 3-year-old child presents with fever, meningismus, and a purpuric rash. The
child becomes unresponsive and has a rhythm of pulseless electrical activity on the
monitor. Which intervention is most important immediately after starting CPR?
A) Administer empiric antibiotics
B) Administer a fluid bolus of 20 mL/kg
C) Administer epinephrine every 3 to 5 minutes
D) Obtain a head CT scan
Answer: C
Rationale: In pulseless arrest, epinephrine is the primary vasopressor and should be
given as soon as possible regardless of etiology. While fluids and antibiotics are
important for sepsis, they do not take priority over epinephrine in a pulseless state.
CT scan is not appropriate during active arrest.
8. An 8-year-old child has a witnessed sudden collapse during a soccer game. The
initial rhythm is ventricular fibrillation. The first defibrillation dose is given. After
2 minutes of CPR, the rhythm remains VF. What is the next energy dose for
defibrillation?
A) 2 J/kg
, B) 4 J/kg
C) 6 J/kg
D) 8 J/kg
Answer: B
Rationale: The initial defibrillation dose for pediatric VF/pVT is 2 J/kg. For
subsequent shocks, the dose is increased to 4 J/kg, up to a maximum of 10 J/kg or
the adult dose. Doubling the energy is the recommended strategy.
9. A 12-month-old infant has respiratory failure due to bronchiolitis. The heart rate
is 180, respiratory rate is 70, and oxygen saturation is 85% on high-flow nasal
cannula. The infant is grunting and has severe nasal flaring. Which action is the
next appropriate step?
A) Continue high-flow nasal cannula and observe
B) Administer a trial of continuous positive airway pressure
C) Perform awake nasotracheal intubation
D) Administer racemic epinephrine
Answer: B
Rationale: This infant shows signs of impending respiratory failure with increased
work of breathing and hypoxemia. CPAP or bilevel positive airway pressure can
provide noninvasive support to recruit alveoli and reduce the work of breathing,
potentially avoiding intubation. Intubation is indicated if noninvasive fails.
10. A child with a known heart defect develops sudden onset of tachypnea,
cyanosis, and a new systolic murmur. A chest X-ray shows cardiomegaly and
pulmonary edema. Which medication is most appropriate to reduce afterload in
this setting?
A) Sodium nitroprusside
B) Dobutamine
C) Atropine
D) Phenylephrine
Answer: A
Rationale: Sodium nitroprusside is a potent arterial and venous vasodilator that
reduces afterload, which is beneficial in heart failure and acute decompensated
congenital heart disease. Dobutamine increases contractility but also increases
heart rate, which may not reduce afterload. Phenylephrine increases afterload.
11. A 5-year-old child is in septic shock. An initial fluid bolus of 40 mL/kg has
been given, but the blood pressure remains low. The child is now developing rales
and hepatomegaly. What should the provider do next?
A) Continue giving fluid boluses until blood pressure normalizes
