Free CCRN Pediatric Exam Flashcards

Crying or a painful procedure raises the right-to-left shunt across the VSD, so the child turns cyanotic with a quieter murmur. Place the child knee-to-chest immediately: flexing the hips kinks the femoral arteries, raises systemic vascular resistance, and pushes blood back across the VSD into the lungs. Calming and oxygen follow.

PGE1 keeps the ductus arteriosus open so systemic or pulmonary blood flow survives until surgery. Apnea is the classic dose-related side effect, so anticipate intubation and have airway equipment at the bedside whenever the infusion is started or increased.

A narrow-complex tachycardia with AV dissociation appearing in the first postoperative hours; it steals atrial kick and drops cardiac output. Management is cooling toward normothermia or mild hypothermia, deep sedation, correcting electrolytes, weaning catecholamines, and antiarrhythmics such as amiodarone. Cardioversion does not convert JET.

A sudden drop or stop in chest tube output paired with rising CVP, narrowing pulse pressure, tachycardia, and muffled heart sounds. Blood is accumulating rather than draining. Escalate at once, since a child compensates by tachycardia until abruptly decompensating; treatment is drainage, not more fluid.

Infants show tachypnea, diaphoresis and fatigue with feeds, poor weight gain, and hepatomegaly. Hepatomegaly is the pediatric equivalent of jugular venous distension, and crackles and peripheral edema are late or absent. Feeding history and daily weights are therefore key assessment data.

SVT is typically above 220 beats per minute in infants, has a fixed rate with no beat-to-beat variability, and P waves are absent or abnormal; sinus tachycardia varies with stimulation and has an identifiable cause. Treat stable SVT with vagal maneuvers such as ice to the face, then rapid-push adenosine with an immediate flush through a proximal site.

Airway resistance rises inversely with the fourth power of the radius during laminar flow, so a millimeter of circumferential edema in a narrow pediatric airway multiplies resistance and work of breathing. The same edema is trivial in an adult. This is why croup, tracheitis, and post-extubation stridor deteriorate so quickly.

Loss of wheezing with poor air entry means airflow has fallen too low to generate sound, so it signals worsening obstruction and fatigue, not improvement. Combined with a rising or even normalizing PaCO2 in a tachypneic child, it predicts imminent respiratory failure and the need for escalation.

Apnea, which is most common in young infants and former preterm infants and can occur before respiratory distress looks severe. Care is supportive: suctioning, hydration, and escalating respiratory support such as high-flow nasal cannula or noninvasive ventilation. Bronchodilators and steroids are not routinely effective.

Croup is gradual, viral, with a barky cough, inspiratory stridor, and low-grade fever. Epiglottitis is abrupt, with high fever, drooling, dysphagia, a muffled voice, tripod posture, and no barky cough. With suspected epiglottitis, do not inspect the throat or upset the child; keep the parent present and prepare for a controlled airway.

The 2023 PALICC-2 definition stratifies invasively ventilated PARDS at least 4 hours after diagnosis by oxygenation index when an arterial line is present, or by oxygen saturation index when it is not, rather than by the P/F ratio alone. Severe PARDS is an OI of 16 or more (OSI 12 or more); anything below that is mild/moderate. Both indices include mean airway pressure, so severity worsens as more ventilator support is needed to hold the same oxygenation.

Displacement of the tube, Obstruction by secretions or kinking, Pneumothorax, and Equipment failure. Disconnect and hand-ventilate while checking, because it separates the patient from the ventilator circuit and immediately narrows the cause. Short pediatric tracheas make displacement especially likely with repositioning.

Hypoxia, hypercarbia, acidosis, pain, agitation, and suctioning all raise pulmonary vascular resistance and can trigger acute right ventricular failure. Cluster care, pre-oxygenate and sedate before suctioning, and maintain oxygenation and normal pH. Rescue therapy includes oxygen, deep sedation, and inhaled nitric oxide.

Cerebral edema, which is the leading cause of DKA mortality in children and often appears several hours into treatment. Reduce risk by avoiding insulin boluses, correcting fluid deficits gradually, and watching for headache, falling heart rate with rising blood pressure, or altered mental status. Treat with hypertonic saline or mannitol.

DI gives high-volume dilute urine, high serum sodium, and hypovolemia. SIADH gives low-volume concentrated urine, low serum sodium, and euvolemia or mild hypervolemia. Cerebral salt wasting gives high urine output with low serum sodium and true hypovolemia. Volume status is the discriminator: SIADH is fluid-restricted, but restricting a salt-wasting child worsens the deficit.

A new pulmonary infiltrate with fever, chest pain, hypoxemia, or respiratory distress; it is a leading cause of death in sickle cell disease and can be mistaken for a simple pain crisis. Treat with oxygen, antibiotics covering atypical organisms, adequate analgesia, incentive spirometry, and transfusion or exchange transfusion for severe disease.

High potassium, high phosphate, and high uric acid with LOW calcium, because released phosphate binds circulating calcium. The hypocalcemia risks tetany and arrhythmia while hyperkalemia and urate crystals threaten the heart and kidneys. Management is aggressive hydration plus rasburicase or allopurinol with close electrolyte monitoring.

TRALI is non-cardiogenic pulmonary edema within about 6 hours of transfusion, with normal or low filling pressures and no response to diuretics; it needs respiratory support. TACO is volume overload, with hypertension, elevated filling pressures, and improvement after diuresis. Children have small blood volumes, so TACO can follow a modest volume given too fast.

Sudden colicky abdominal pain with an infant drawing the legs up, episodes of lethargy between attacks, a sausage-shaped right-sided mass, and late currant jelly stool. Air or contrast enema is both diagnostic and therapeutic. Watch for recurrence and for perforation signs after reduction.

Pneumatosis intestinalis, gas within the bowel wall, on abdominal x-ray; portal venous gas and free air indicate advanced disease. Stop enteral feeds, decompress the stomach, start broad-spectrum antibiotics, and get surgery involved. Feeding intolerance with bloody stools and abdominal distension precedes the film.

Sustained intra-abdominal hypertension, measured indirectly by a bladder pressure transducer, causing new organ dysfunction. It presents as a tense distended abdomen with falling urine output and rising peak inspiratory pressures as the diaphragm is splinted. Escalate for decompression rather than simply increasing ventilator support.

Bilious emesis means obstruction distal to the ampulla of Vater and signals malrotation with midgut volvulus until proven otherwise. The twisted mesentery can infarct the entire midgut within hours. Keep the infant NPO, decompress, and expedite imaging and surgical evaluation rather than treating it as reflux.

Microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury, most often after Shiga toxin-producing E. coli diarrhea. Care is supportive with careful fluid and electrolyte management and dialysis when needed. Antibiotics and antimotility agents in suspected STEC infection may increase the risk of progressing to HUS.

Intravenous calcium, which stabilizes the myocardium without lowering the potassium level. Shifting agents such as insulin with glucose, an inhaled beta-agonist, and bicarbonate come next, and only binders or dialysis actually remove potassium. Giving a shifting agent first leaves the heart unprotected during the delay.

Stop the infusion at once and disconnect the tubing, but do not flush. Aspirate residual drug through the catheter, then follow the antidote protocol before removing the catheter if an antidote is instilled through it, elevate the limb, and mark the borders. Thin pediatric skin and small vessels make full-thickness injury and compartment syndrome real risks.

Pain out of proportion to the injury and pain on passive stretch of the compartment. Pallor, paresthesia, paralysis, and pulselessness are late and mean tissue is already dying. Keep the limb at heart level rather than elevating it, since elevation lowers the perfusion gradient, and escalate for pressure measurement and fasciotomy.

CPP equals mean arterial pressure minus intracranial pressure, so perfusion can fail from a rising ICP or a falling MAP. The 2019 Brain Trauma Foundation pediatric guideline suggests treating ICP above 20 mmHg and keeping CPP at a minimum of 40 mmHg, targeting 40 to 50 with infants at the low end and adolescents at the high end. Treat the ICP and the blood pressure together.

Hypertension with a widening pulse pressure, bradycardia, and irregular respirations. It is a LATE brainstem response to critically high intracranial pressure and often means herniation is underway, so it is a resuscitation trigger, not an early warning. Act on subtler earlier changes in level of consciousness and pupils.

Open fontanelles and unfused sutures let the skull expand, buffering pressure and delaying classic signs. Early clues are irritability, poor feeding, a high-pitched cry, a full or bulging fontanelle, split sutures, increasing head circumference, and sunsetting eyes. By the time posturing appears, compensation has been exhausted.

A benzodiazepine first, repeated once if needed, then a second-line agent such as levetiracetam, fosphenytoin, or valproate. Check a point-of-care glucose early, because hypoglycemia is a reversible cause. Protect the airway and monitor for respiratory depression, which increases with each benzodiazepine dose.

Use a validated age-appropriate tool such as the Cornell Assessment of Pediatric Delirium at scheduled intervals. Hypoactive delirium is the most common form and is routinely missed because a quiet child looks comfortable. Management targets the cause: minimize deliriogenic sedatives, restore sleep and day-night cues, mobilize, and involve family.

An injury inconsistent with the child's developmental stage, a history that changes or does not match the injury pattern, delayed presentation, patterned bruising or burns, and injuries in non-mobile infants. Document objectively in the child's own words where possible, preserve evidence, and follow mandatory reporting duties. Reporting requires reasonable suspicion, not proof.

Children defend blood pressure by raising heart rate and systemic vascular resistance, so compensated shock shows tachycardia, delayed capillary refill, cool mottled extremities, a narrow pulse pressure, and falling urine output while the blood pressure stays normal. Hypotension is a late decompensated finding that often precedes arrest.

Cold shock, with low cardiac output and high systemic vascular resistance, is the more common presentation in community-acquired pediatric septic shock: cool extremities, delayed capillary refill, and narrow pulse pressure. Warm shock shows flash refill, bounding pulses, and a wide pulse pressure. Traditional ACCM teaching pairs epinephrine with cold shock and norepinephrine with warm shock; the 2020 Surviving Sepsis pediatric guideline prefers either drug over dopamine and makes no first-line choice between them, so titrate to reassessment rather than to the label.

Where intensive care is available, the 2020 Surviving Sepsis pediatric guideline suggests 10 to 20 mL/kg crystalloid boluses up to 40 to 60 mL/kg in the first hour, reassessing after every bolus and stopping for hepatomegaly, new crackles, or increased work of breathing. Obtain cultures and start antimicrobials within 1 hour of recognizing septic shock, and within 3 hours for sepsis-associated organ dysfunction without shock.

N-acetylcysteine, which replenishes glutathione and is most effective when started within about 8 hours of ingestion. Risk is plotted using a level drawn at or after 4 hours post-ingestion; a level drawn earlier cannot be interpreted. When ingestion time is unknown or staggered, treat rather than wait.

A young child's head is proportionally much larger and the legs smaller than an adult's, so the adult rule of nines misestimates burn size and therefore fluid orders. Use an age-adjusted Lund-Browder chart. Children also need maintenance fluid containing glucose in addition to burn resuscitation fluid, because glycogen stores are small.

Use a behavioral observation scale such as FLACC for preverbal, nonverbal, or cognitively impaired children, a faces scale for most preschool and early school-age children, and a numeric rating scale for older children who can grasp ordinal numbers. Applying an adult numeric scale to a toddler produces a number that does not measure pain.

Under the 2023 AAN/AAP/CNS/SCCM guideline, pediatric brain death requires two examinations, each with an apnea test, separated by at least 12 hours at every age, and the child is legally dead once the second is complete. Decoupling means the team informs the family of death first and lets trained organ procurement organization staff make the donation request separately. Coupling the two conversations reduces family understanding and consent.

Hypoxia drives the primary injury, so restoring oxygenation and ventilation comes first. Hypothermia can be neuroprotective, and neurologic prognosis cannot be judged while the child is cold, so continue resuscitation and active rewarming before deciding futility. Watch for delayed pulmonary deterioration after apparent recovery.

Care is optimal when the nurse's competencies match the patient's and family's characteristics and needs. The model shifts assessment away from a body-systems view toward the patient's own capacity and vulnerability, so staffing, assignment, and care planning follow patient need rather than diagnosis alone. All AACN certification test plans are organized around it.

Resiliency, vulnerability, stability, complexity, resource availability, participation in care, participation in decision making, and predictability. Each is scored on a continuum, so a child can be highly complex yet resilient. Naming them turns a vague sense that a family is struggling into a specific need you can staff and plan for.

Clinical judgment, advocacy and moral agency, caring practices, collaboration, systems thinking, response to diversity, facilitation of learning, and clinical inquiry. Clinical judgment forms the 80% clinical section of the exam, and the other seven make up the Professional Caring and Ethical Practice section.

Acting on behalf of a child and family and resolving ethical conflict, especially when the patient cannot speak for themselves. Examples include escalating when a family's stated goals are not reflected in the plan, requesting an ethics consult, and voicing moral distress through a formal channel. It means representing the patient's interests, not the team's convenience.

AACN supports offering family members the option to be present during resuscitation and invasive procedures, with a trained staff member assigned to support them. Presence helps families understand that everything was done and can ease grieving. The role of the support person is what makes it safe, so a facilitator must be available before offering.

Use a qualified professional interpreter for consent, teaching, and goals-of-care talks. Never use a child, sibling, or other family member: they may filter bad news, lack clinical vocabulary, and carry lasting burden. Speak to the family and watch their faces, not the interpreter, and confirm understanding afterward.

Use teach-back: ask the caregiver to explain the plan or demonstrate the skill in their own words, and re-teach whatever is missing. Asking whether they have questions only measures politeness. For the child, tailor the explanation to developmental stage, using play or simple concrete language for younger children.

Use structured assertion. State the concern, state why you are uncomfortable, and say that this is a safety issue, then use the two-challenge rule: if your first assertion is ignored, state it a second time and, if still unaddressed, move up the chain of command. Structured language keeps the concern about the patient rather than the personalities.

Recognizing that the patient sits inside a system and using its resources on their behalf: activating rapid response, arranging transfer to a higher level of care, involving palliative care or child life, and coordinating discharge and community follow-up. Family-activated escalation pathways exist because caregivers often notice deterioration first.

Questioning and evaluating practice, and changing it through research and evidence-based improvement rather than continuing what is customary. In practice this is auditing outcomes, joining unit quality improvement work, applying practice alerts, and challenging a routine that has no current evidence behind it.