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Quiz Session - Attempts With Random Questions

AACN CCRN (Pediatric) Exam Questions

Page 9 of 20

161.

A 12-year-old patient with sickle cell disease (SCD) has been prescribed hydroxyurea for management of the condition. Which of the following outcomes would indicate this medication is therapeutic? 

  • The patient will require fewer blood transfusions over time 

  • The patient will experience a decrease in fetal hemoglobin (HbF)

  • The patient will experience diuresis 

  • The patient will experience a decrease in hemoglobin S

Correct answer: The patient will require fewer blood transfusions over time 

Hydroxyurea enhances the production of HbF, thereby decreasing the ability of the RBCs with HbSS to sickle. The patient will experience an increase in HbF. Indications for hydroxyurea therapy are limited to severe complications such as frequent pain crises, acute chest syndrome, severe and symptomatic anemia, or other vaso-occlusive events. Because it helps with severe anemia, a therapeutic outcome of hydroxyurea therapy would be fewer blood transfusions required.

Frequent monitoring for toxicities is essential for patients receiving this medication (due to a risk of low white blood cell counts), as well as guidance regarding contraception methods since it is a teratogen. 

Diuresis is not an outcome of successful hydroxyurea therapy. 

162.

A 3-month-old infant is admitted to the emergency department with suspected tricuspid atresia (TA). Which of the following findings on electrocardiogram (ECG) is indicative of this condition?

  • Left axis deviation 

  • Right axis deviation 

  • Increased right ventricular (RV) forces 

  • Diminished left ventricular (LV) forces 

Correct answer: Left axis deviation 

Most forms of congenital heart disease show right axis deviation and right heart strain. With tricuspid atresia (TA), the right ventricle is bypassed, and the left ventricle ends up doing all the work. The lack of tricuspid valve formation results in the absence of blood flow from the right artery (RA) to the right ventricle (RV) and poor RV formation in utero. 

ECG shows a superior and leftward QRS axis, RA enlargement, absent or diminished RV forces, and increased LV forces. Survival is contingent upon the placement of an obligatory right-to-left atrial shunt.  

163.

Which of the following is/are the most common presenting feature(s) of fat embolism syndrome (FES) in a child?

  • Pulmonary manifestations 

  • Neurologic abnormalities 

  • Petechial rash 

  • Anemia and thrombocytopenia 

Correct answer: Pulmonary manifestations 

Fat embolism is defined by the presence of fat globules in the pulmonary circulation. Fat embolism syndrome (FES) follows an identifiable insult that releases fat into the circulation, resulting in pulmonary and systemic symptoms. FES is most commonly associated with long bone and pelvic fractures or after orthopedic surgery.

FES typically manifests 24 to 72 hours after the initial insult but may rarely occur as early as 12 hours or as late as two weeks after the injury. Affected patients develop a classic triad–hypoxemia, neurologic abnormalities, and a petechial rash.

Pulmonary manifestations are the most common presenting features of FES. Hypoxemia, dyspnea, and tachypnea are the most frequent early findings, and respiratory distress is observed in 90% of cases.

164.

A nurse is caring for a 6-month-old infant recovering from a ventricular septal defect (VSD) repair via cardiac catheterization. The nurse must monitor the infant closely for postoperative complications. 

Which type of arrhythmia is the most common complication following this repair? 

  • Atrioventricular (AV) heart block 

  • Ventricular tachycardia

  • Premature ventricular contractions (PVCs)

  • Junctional rhythm

Correct answer: Atrioventricular (AV) heart block 

Potential complications of VSD closure include infection, postoperative bleeding, damage to the valves of the heart (tricuspid, pulmonary, or aortic), pulmonary hypertension with poor cardiac output, AV heart block, residual VSD from unsuccessful closure, and death. 

PVCs are common but benign, and ventricular tachycardia is a risk during the procedure but not postoperatively. Junctional rhythm is not common. 

165.

Functions of surfactant include all the following, EXCEPT:

  • Vasodilating the pulmonary vasculature 

  • Preventing lung collapse during exhalation 

  • Optimizing lung compliance

  • Defending against microorganisms 

Correct answer: Vasodilating the pulmonary vasculature 

Surfactant is a substance produced by type II alveolar epithelial cells in the lungs, consisting of proteins and lipids. It prevents alveolar collapse at end exhalation, lessens the work of breathing, optimizes lung compliance and surface area for gas exchange and ventilation-perfusion (V/Q) matching, protects the lung epithelium, and facilitates clearance of foreign substances. It also prevents capillary leakage of fluid into the alveoli and defends against microorganisms. 

Premature infants have decreased levels of surfactant, which leads to respiratory distress syndrome (RDS). This often necessitates the administration of exogenous surfactant replacement therapy to increase lung compliance. Surfactant is not a vasodilator. 

166.

To determine brain death in a child, apnea testing must be performed in conjunction with a clinical examination, following disconnection from the ventilator. What is a positive apnea test? 

  • Absence of respiratory effort, PaCO2 20 mm Hg above baseline PaCO2 and >60 mm Hg

  • Absence of respiratory effort, PaCO2 30 mm Hg above baseline PaCO2 and >70 mm Hg

  • Absence of respiratory effort, PaCO2 10 mm Hg above baseline PaCO2 and >50 mm Hg

  • Absence of respiratory effort, PaCO2 40 mm Hg above baseline PaCO2 and >80 mm Hg

Correct answer: Absence of respiratory effort, PaCO2 20 mm Hg above baseline PaCO2 and >60 mm Hg

To determine brain death, the physical examination should demonstrate that coma and apnea coexist. Apnea testing must be performed with the clinical examination, and the patient must have a complete absence of respiratory effort with standardized apnea testing. 

Following disconnection from the ventilator, allow at least 5-10 minutes for PaCO2 to increase. A positive apnea test is a PaCO2 that is 20 mm Hg above the baseline PaCO2 and ≥60 mm Hg. 

167.

Pediatric acute respiratory distress syndrome (PARDS) is characterized by which of the following? 

  • Increased airway resistance

  • Increased lung compliance

  • Increased chest wall compliance

  • Decreased airway resistance

Correct answer: Increased airway resistance

ARDS in children is different than ARDS in adults. Pediatric ARDS occurs when fluid fills the lungs due to an infection or injury, causing increased airway resistance. This prevents air from filling the lungs efficiently and deprives the body of oxygen. 

When lungs are inflamed and filled with fluid, they become stiff and unable to expand properly when breathing (decreased lung and chest wall compliance). Oxygen saturation levels decline rapidly, and other organs are at risk of failure. These patients need ventilatory support and management to allow the lungs to heal. 

168.

Which of the following statements is accurate regarding pain and pain relief in the pediatric population? 

  • Infants manifest responses to invasive procedures more intensely than adults

  • A child who is not crying is not in pain

  • Potent medications such as analgesics and anesthetics are dangerous to a critically ill child 

  • Pain is a highly subjective experience that is difficult to assess objectively for nonverbal infants and children 

Correct answer: Infants manifest responses to invasive procedures more intensely than adults

Infants exhibit physiologic, hormonal, behavioral, and metabolic responses to invasive procedures (e.g., heel and intravenous stick, intubation, lumbar puncture, chest or nasogastric tube placement) that are similar to, but more intense than, adult responses. 

Just because a child does not cry does not mean they are not in pain; children express pain in varying ways at different ages. New methods, techniques, and devices for monitoring infants' responses to drugs should enable all children to be safely anesthetized and medicated while maintaining a stable condition. Many pain assessment scales are available to assess nonverbal infants and children. In addition, pediatric patients exhibit a wide variety of behavioral indicators that objectively demonstrate pain. 

169.

Which of the following medications is NOT implicated as a trigger for Stevens-Johnson syndrome (SJS)? 

  • Acyclovir 

  • Amoxicillin

  • Trimethoprim/sulfamethoxazole 

  • Phenytoin

Correct answer: Acyclovir 

SJS is a potentially life-threatening, exfoliative skin disease that occurs from an immunologic reaction in the child's body to a drug or virus or can be completely idiopathic. Children are typically admitted to the pediatric intensive care unit (PICU) or burn unit for wound care, management of hydration and electrolyte issues, nutritional support, and pain control. 

The most important first treatment is the removal of the causative agent if known. IVIG can be started to reverse the blistering and sloughing of the skin. The use of systemic corticosteroids is contraindicated in the treatment of SJS because of the increased risk of sepsis.  

Acyclovir has not been shown to induce SJS. All the other options (penicillins including amoxicillin, sulfonamides including Bactrim, and anticonvulsants including phenytoin) are potential triggers. 

170.

Which important drug should all seizing patients receive? 

  • Oxygen 

  • Lorazepam 

  • Phenobarbital

  • Levetiracetam 

Correct answer: Oxygen 

The management goals for a child with a seizure are to stop both clinical and electrographic seizure activity emergently; prevent injury; and maintain airway, breathing, and circulation. While benzodiazepines (lorazepam, midazolam, and diazepam) are used in the initial therapy phase based on age, oxygen should be administered to all seizing patients (despite a normal pulse oximetry reading), as seizure activity always decreases perfusion to the brain. 

Phenobarbital and levetiracetam are indicated as the second therapy of choice, after first-line treatments fail to stop the seizing. 

171.

The presence of a large, isolated patent ductus arteriosus (PDA) in which the ductus fails to close normally results in which condition? 

  • Low diastolic pressure 

  • High diastolic pressure 

  • Low systolic pressure 

  • High systolic pressure 

Correct answer: Low diastolic pressure 

In isolated PDA, blood shunts from left to right into the pulmonary artery (PA) and lungs. This occurs as the PVR drops and the pressure in the aorta exceeds that of the PA. Clinical presentation depends on the size and diameter of the ductus; the degree of shunting, compensatory mechanisms, and the stage of lung development. 

The presence of a large PDA results in low diastolic pressure, leading to low cardiac output and poor coronary perfusion. Surgical closure is required to restore adequate diastolic pressure and myocardial perfusion.  

172.

Which of the following types of skin grafts is considered to be a permanent wound-closure method for pediatric burn-wound management? 

  • Autograft 

  • Allograft

  • Heterograft 

  • Homograft 

Correct answer: Autograft 

Once a burn wound has been debrided, a skin graft that is taken from the patient's unburned or healed skin can be transferred to the injured area. This is referred to as an autograft and is utilized for permanent wound coverage. Autografts can be described based on the thickness of the graft as well as the meshing ratio (i.e., full-thickness or split-thickness grafts). 

An allograft (also known as a homograft) is a biological skin graft dressing from a human donor (often cadaver skin). It provides a temporary wound covering until the area is able to be covered with a permanent wound-closure method. A heterograft is a temporary skin graft from a different species (usually pig); it is often used to cover a superficial partial-thickness burn while the underlying wound heals. 

173.

A nurse is caring for an infant with a meningocele. After performing a routine assessment, feeding, and a diaper change, the nurse should ensure the infant is placed in which position? 

  • Prone with the hips flexed 

  • Side-lying with a pad placed between the infant's legs 

  • Supine with linen rolls anchored at either side of the infant 

  • Supine with the crib or incubator in a slight Trendelenburg slope 

Correct answer: Prone with the hips flexed 

A meningocele is a saclike protrusion on the back containing meninges and cerebrospinal fluid (CSF), which bulge through a gap in the spine secondary to a congenital vertebral defect. Correct positioning of the patient with a meningocele is vitally important in treating and managing this condition.

Because this sac can be easily damaged or injured, pressure on the sac should be avoided at all costs. The infant should be kept prone with the hips slightly flexed to protect the defect (the defect is covered with saline moistened gauze), promote the best possible spinal alignment, and decrease the risk of hip dysplasia and/or foot deformities. In addition to keeping the infant prone, a slight Trendelenburg slope of the crib or incubator helps reduce spinal fluid pressure in the meningocele. Once the infant has undergone surgical repair, and the back is sufficiently healed, the infant can be picked up and held prone for feedings. 

174.

An infant receiving mechanical ventilation is suddenly deteriorating. The nurse auscultates the infant's chest and notes air entry over the left upper abdominal quadrant. What does this finding indicate? 

  • The esophagus has been intubated

  • The endotracheal tube (ETT) is too high in the trachea

  • The endotracheal tube (ETT) is too low in the trachea and is likely down the right mainstem bronchus 

  • This is an expected finding and indicates correct tube positioning

Correct answer: The esophagus has been intubated

Auscultating an infant's chest for the quality of breath sounds is an important tool when assessing an infant's condition, especially if they are deteriorating. If an infant is not improving with manual ventilation, there is likely a problem with the ETT (it is most likely malpositioned).  

Air entry heard over the left upper abdominal quadrant (stomach) indicates the esophagus is intubated. The ETT will need to be repositioned or replaced. If the ETT is too high, there will be diminished air entry heard over the chest upon auscultation. If the ETT is too low, the nurse would expect to hear unequal air entry. If it is down the right mainstream bronchus, the right chest will be better aerated than the left chest. 

175.

A nurse is caring for a child who is intubated and mechanically ventilated. The ventilator's FiO2 parameter is set at 50. What does this mean? 

  • The child is using 50% oxygen 

  • The child is breathing 50 mL of air with each breath

  • The oxygen flow rate for this child is 5 L/min

  • The child is breathing at a rate of 50 breaths per minute (bpm) 

Correct answer: The child is using 50% oxygen 

The FiO2 describes the percentage of inspired oxygen that the patient receives through the ventilator. This amount can be increased based on the child's response. Room air is 21% FiO2, so this patient is requiring more oxygen (at 50%) via the ventilator than is in room air. 

176.

A nurse is caring for a child in the PICU who has been intubated and mechanically ventilated for 12 days due to pediatric acute respiratory distress syndrome (PARDS). The child's FiO2 has been at 60% for the last 48 hours. 

What is the nurse's priority concern at this time? 

  • Oxygen toxicity 

  • Ventilator-associated pneumonia 

  • Aspiration 

  • Acute lung injury

Correct answer: Oxygen toxicity 

Children with PARDS often require higher levels of oxygen; those receiving greater than 50% FiO2 for prolonged periods may develop parenchymal changes from oxygen exposure, resulting in oxygen toxicity. 

Oxygen should be treated as a medication with strict adherence to prescription guidelines. Cautious monitoring of O2 is strongly recommended. The lowest acceptable SpO2 measurement for the child should be clearly established while FiO2 is maintained at the lowest possible level.

177.

The AACN Synergy Model identifies eight nurse competencies, including clinical judgment, caring practices, advocacy, response to diversity, clinical inquiry, systems thinking, facilitator of learning, and which of the following?

  • Collaboration 

  • Non-maleficence 

  • Autonomy 

  • Justice 

Correct answer: Collaboration 

The AACN Synergy Model for Patient Care was initially developed to serve as the foundation for certifying critical care nursing practice. Nurse competencies are driven by the needs of patients and families and reflect the integration of nursing knowledge, skills, and experiences that are required to meet the needs of patients and families and optimize their outcomes. 

Competencies include clinical judgment, caring practices, advocacy/moral agency, collaboration, systems thinking, response to diversity, clinical inquiry, and facilitating learning. 

Non-maleficence, autonomy, and justice are some of the ethical principles that guide nursing practice, along with optimizing patient care and outcomes. 

178.

Decision-making in the PICU often relates to which concept?

  • Personhood

  • Patienthood

  • Professional-patient relationship

  • Informed consent

Correct answer: Personhood

Personhood is the quality or condition of being an individual. Decision-making often involves this concept in the PICU: when is someone a person? Determining what this means depends on which moral community is consulted. The designation of personhood is morally significant because it determines whether and which duties and obligations are owed to a pediatric patient. 

Patienthood asks: who is the patient? For children, the "patient" has been considered the child, the family, and even society. 

The professional-patient relationship is the human context in which decision-making occurs. In pediatrics, this involves a relationship between caregivers and the healthcare team. 

Informed consent involves a voluntary agreement by a competent legal guardian for decisions regarding their child.

179.

A child with acute respiratory distress syndrome (ARDS) is intubated and mechanically ventilated. The positive end-expiratory pressure (PEEP) for this child needs to remain above which level?

  • 15 cm H2O

  • 10 cm H2O

  • 20 cm H2O

  • 25 cm H2O

Correct answer: 15 cm H2O

Pediatric ARDS is characterized by respiratory failure due to diffuse alveolar-capillary membrane injury, causing permeability or elevated protein pulmonary edema. Causes leading to lung injury include pneumonia, aspiration, and sepsis. 

Management may involve high PEEP (levels at or above 15 cm H2O) with low tidal volume, high-frequency oscillation ventilation (HFOV), permissive hypercapnia, prone positioning in severe cases, hemodynamic monitoring, treatment of infection or the precipitating cause, and maintenance of adequate cardiac output. 

180.

A 9-year-old male is brought to the emergency department by his mother with complaints of chest discomfort and shortness of breath with exertion. The patient's mother reports he fainted during his soccer game, which prompted her to bring him in right away. The triage nurse auscultates a harsh-sounding systolic murmur at the upper right sternal border and notes that the murmur is best heard at the second intercostal space. The patient is afebrile, and his vital signs at rest are otherwise normal. 

The nurse suspects the child may have which of the following heart conditions? 

  • Valvular aortic stenosis 

  • Patent ductus arteriosus (PDA)

  • Ventricular septal defect (VSD)

  • Coarctation of the aorta 

Correct answer: Valvular aortic stenosis 

In valvular aortic stenosis (AS), the aortic valve (which separates the left ventricle and the aorta) is stenosed, leading to decreased orifice size because of the thickening and rigidity of the valve leaflets. This malformation of the aortic valve (narrowing) causes obstruction to ejection of blood from the left ventricle, occurring at the valve annulus of the LV. 

Critical AS is a severe form of AS that presents at birth with symptoms of circulatory shock from obstruction to systemic blood flow, but most children with AS are asymptomatic and grow and develop normally. As symptoms occur, they usually include fatigue, exertional dyspnea, angina pectoris, and syncope. Examination reveals a systolic, harsh-sounding murmur that is best heard at the upper right sternal border, at the second intercostal space. 

Associated cardiac lesions—PDA, VSD, or coarctation—are common with AS, but they are not the same. Congenital AS is a progressive lesion, and most affected children will require surgical intervention at least once to repair the stenosed aortic valve. 

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