Pediatric Emergency Care: Recognizing and Managing Critical Conditions, Exams of Nursing

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Pediatric Advanced

Life Support (PALS)

Exam A and B

50 Questions and

answers

Record the best answer on the separate answer sheet. (CORRECT ANSWERS ARE HIGHLIGHED)

1. You are caring for patients in the emergency department. Which 2-year-old child requires immediate intervention? A. A child who is grunting B. A child with an SpO2 of 95% on room air C. A child with a systolic blood pressure of 92 mm Hg D. A child with a temperature of 37.4°C (99.3°F)
2. In which of the following situations may IO access be used? A. An extremity with signs of infection B. An extremity with signs of a crush injury C. An extremity with a previous unsuccessful IO attempt D. An extremity with slow a capillary refill time
3. A 2-week-old infant is being evaluated for irritability and poor feeding. His blood pressure is 55/40 mm Hg, and capillary refill time is 5 seconds. Which statement best describes your assessment of this infant’s blood pressure? A. It represents compensated shock. B. It is hypertensive. C. It is hypotensive. D. It is normal.
4. A 3-year-old child is having difficulty breathing. What finding would most likely lead you to suspect an upper airway obstruction in this child? A. Expiratory breath sounds B. Decreased expiratory effort C. Increased inspiratory effort with retractions D. Normal inspiratory sounds
5. A team member is unable to perform an assigned task because it is beyond the team member’s scope of practice. What action should the team member take? A. Ask for a new task or role B. Refuse to perform the task C. Do it anyway D. Seek expert consultation
6. You are the Team Leader during a pediatric resuscitation attempt. What action is an element of high-quality CPR? A. Providing a compression depth of one fourth the depth of the chest B. Providing a compression rate of 80 to 100/min

C. Allowing complete chest wall recoil after each compression D. Performing pulse checks every minute

7. An 8-year-old child is brought to the emergency department by his mother for difficulty breathing. He has a history of asthma and nut allergies. His mother tells you that he recently ate a cookie at a family picnic. What condition is most likely to be present in this child? A. Disordered control of breathing B. Hypovolemic shock C. Lung tissue disease D. Upper airway obstruction
8. An 8-year-old child is brought to the emergency department by ambulance after being involved in a motor vehicle collision. What finding would suggest that immediate intervention is needed? A. Decreased level of consciousness B. Systolic blood pressure of 106 mm Hg C. Temperature of 38.1°C (100.5°F) D. Warm, moist skin
9. A 6-year-old child is found unresponsive, not breathing, and without a pulse. One healthcare worker leaves to activate the emergency response system and get the resuscitation equipment. You and another healthcare provider immediately begin performing CPR. What compression-to- ventilation ratio do you use? A. 15: B. 30: C. 15: D. 30:
10. A 3-year-old child is in cardiac arrest, and high-quality CPR is in progress. You are the Team Leader. The first rhythm check reveals the rhythm shown here. Defibrillation is attempted with a shock dose of 2 J/kg. After shock administration, what should you say to your team members? A. “Check for a pulse.” B. “Give epinephrine 0.01 mg/kg.” C. “Let’s check the rhythm.” D. “Resume compressions.” Use this scenario to answer the next 2 questions: You are caring for a 5-year-old boy with a 4-day history of high fever and cough. He is having increasing lethargy, grunting, and sleepiness. Now he is difficult to arouse and is unresponsive to voice commands. His oxygen saturation is 72% on room air and 89% when on a nonrebreathing oxygen mask. He has shallow respirations with a respiratory rate of 38/min. Auscultation of the lungs reveals bilateral crackles.
11. What assessment finding is consistent with respiratory failure in this child? A. Cough B. Fever

C. Oxygen saturation D. Respiratory rate

12. What medication would be most appropriate? A. A bronchodilator B. An antibiotic C. A corticosteroid D. A vasopressor
13. During a resuscitation attempt, the Team Leader asks you to administer an initial dose of epinephrine at 0.1 mg/kg to be given IO. How should you respond? A. “I can’t administer the drug at the dose you ordered.” B. “OK, but I will administer epinephrine 0.01 mg/kg.” C. “OK. I will administer epinephrine 0.1 mg/kg.” D. “I think the correct dose is 0.01 mg/kg. Should I give that dose instead?”
14. A 6-month-old infant is unresponsive. You begin checking for breathing at the same time you check for the infant’s pulse. What is the maximum time you should spend trying to simultaneously check for breathing and palpate the infant’s pulse before starting CPR? A. 10 seconds B. 15 seconds C. 30 seconds D. 60 seconds
15. A 10-year-old child is being evaluated for a headache. What is a normal finding for this 10- year-old child? A. Blood pressure of 60/50 mm Hg B. Heart rate of 88/min C. Respiratory rate of 8/min D. Temperature of 39.6°C (103.2°F)
16. A 6-year-old boy is being evaluated for difficulty breathing. What finding would suggest this child has respiratory distress? A. Audible inspiratory stridor B. Decreased respiratory effort C. Oxygen saturation of 95% D. Respiratory rate of 8/min Use this scenario to answer the next 2 questions: A 4-year-old child in cardiac arrest is brought to the emergency department by ambulance. High- quality CPR is being performed. The cardiac monitor displays the rhythm strip shown here. The estimated weight of the child is 20 kg.
17. What dosage range should you use for initial defibrillation? A. 0.5 to 2 J/kg

B. 4 to 6 J/kg C. 6 to 8 J/kg D. 2 to 4 J/kg

18. As the Team Leader, how many joules do you tell your team member to use to perform initial defibrillation? A. 10 J B. 40 J C. 100 J D. 140 J
19. You respond to an infant who is unresponsive, is not breathing, and does not have a pulse. You do not have a mobile device, and you shout for nearby help but no one arrives. What action should you take next? A. Begin CPR for 2 minutes before leaving to activate the emergency response system B. Begin CPR for 1 minute before leaving to activate the emergency response system C. Activate the emergency response system after giving CPR for 10 minutes D. Activate the emergency response system after giving CPR for 5 minutes
20. What ratio for compressions to breaths should be used for 1-rescuer infant CPR? A. Give 30 compressions to 2 breaths B. Give 5 compressions to 1 breath C. Give 20 compressions to 2 breaths D. Give 15 compressions to 2 breaths
21. A 3-year-old boy is brought to the emergency department by his mother. He is lethargic, with retractions and nasal flaring. He has a respiratory rate of 70/min, with warm extremities and brisk capillary refill. Which immediate life-threatening condition could this child’s condition most likely progress to if left untreated? A. Cardiogenic shock B. Hypovolemic shock C. Respiratory distress D. Respiratory failure
22. You are evaluating a 10-year-old child who is febrile and tachycardic. The child’s capillary refill time is 5 seconds. What parameter will determine if the child is in compensated shock? A. Blood pressure B. Chest movement C. Respiratory effort D. Respiratory rate
23. An 18-month-old has had vomiting and diarrhea for the past 2 days; the mother brings him to the emergency department because he is becoming more lethargic. What diagnostic test should you order first? A. 12 - lead ECG B. Arterial blood gases C. Blood glucose D. Serum potassium Use this scenario to answer the next 3 questions:

You are caring for a 3-month-old boy with a 2-day history of fever, vomiting, and diarrhea. His parents state that he has been sleeping much more. His heart rate is 190/min, temperature is 38.3°C (101°F), blood pressure is 59/29 mm Hg, respiratory rate is 70/min and shallow, and oxygen saturation is 94% on 100% oxygen. His capillary refill time is 4 to 5 seconds, and he has mottled, cool extremities. The infant weighs 6 kg.

24. What assessment finding indicates that the infant has hypotensive shock? A. Blood pressure B. Capillary refill time C. Heart rate D. Tachypnea
25. On the basis of this infant’s presentation, what type of shock does this infant have? A. Cardiogenic B. Distributive C. Hypovolemic D. Obstructive
26. You have decided that this infant needs fluid resuscitation. How much fluid should you administer? A. 10 mL/kg lactated Ringer’s B. 15 mL/kg 5% dextrose in 0.45% normal saline C. 20 mL/kg normal saline D. 20 mL/kg 0.45% normal saline
27. What abnormality helps identify children with acute respiratory distress caused by lung tissue disease? A. Crackles B. Prolonged inspiratory time C. Stridor D. Wheezes Use this scenario to answer the next 2 questions: You are caring for a 9-month-old girl who has increased work of breathing, a fever, and a cough. On assessment, you find an alert infant with stridor and retractions. The infant’s SpO2 is 94%. On auscultation, the lungs are clear bilaterally.
28. What is the most likely cause of this infant’s respiratory distress? A. Disordered control of breathing B. Lower airway obstruction C. Parenchymal lung disease D. Upper airway obstruction Page 7
29. What medication should you administer first? A. Albuterol, nebulized B. Ceftriaxone, IV

C. Dexamethasone, PO/IM D. Epinephrine, nebulized

30. What condition is characterized by a prolonged expiratory phase and wheezing? A. Disordered control of breathing B. Hypovolemic shock C. Lower airway obstruction D. Upper airway obstruction
31. A 5-year-old child is brought to the emergency department by ambulance after being involved in a motor vehicle collision. You are using the primary assessment to evaluate the child. When assessing the child’s neurologic status, you note that he has spontaneous eye opening, is fully oriented, and is able to follow commands. How would you document this child’s AVPU (Alert, Voice, Painful, Unresponsive) Pediatric Response Scale finding? A. Alert B. Voice C. Painful D. Unresponsive
32. A 4-year-old child is brought to the emergency department for seizures. The seizures stopped a few minutes ago, but the child continues to have slow and irregular respirations. What condition is most consistent with your assessment? A. Disordered control of breathing B. Lower airway obstruction C. Lung tissue disease D. Upper airway obstruction
33. You are evaluating a 1-year-old child for respiratory distress. His heart rate is 168/min, and his respiratory rate has decreased from 65/min to 30/min. He now appears more lethargic and continues to have severe subcostal retractions. On the basis of your assessment, what is the most likely reason for this change in the child’s condition? A. The child has a neurologic problem rather than a respiratory problem. B. The child has signs of respiratory failure. C. The child likely has an arrhythmia rather than a respiratory problem. D. The child’s status is improving.
34. A 7-year-old child in cardiac arrest is brought to the emergency department by ambulance. No palpable pulses are detected. The child’s ECG is shown here. How would you characterize this child’s rhythm? A. Pulseless electrical activity B. Sinus bradycardia C. Ventricular escape rhythm D. Ventricular tachycardia Use this scenario to answer the next 2 questions:

After rectal administration of diazepam, an 8-year-old boy with a history of seizures is now unresponsive to painful stimulation. His respirations are shallow, at a rate of 10/min. His oxygen saturation is 94% on 2 L/min of nasal cannula oxygen. On examination, the child is snoring with poor chest rise and poor air entry bilaterally.

35. What action should you take next? A. Administer naloxone B. Perform endotracheal intubation C. Increase nasal cannula flow D. Reposition the patient and insert an oral airway
36. If the patient continues to snore and exhibit poor chest rise and poor air entry bilaterally after your initial intervention, what next step is most appropriate? A. Increase nasal cannula flow B. Provide bag-mask ventilation C. Administer nebulized epinephrine D. Perform nasal suctioning
37. You are performing the airway component of the primary assessment. What finding would lead you to conclude that the child has an upper airway obstruction? A. Dry, nonproductive cough B. Inspiratory stridor C. Subcostal retractions D. Wheezing
38. In management of post–cardiac arrest patients, extra care should be taken to avoid reperfusion injury. What should the ideal oxygen saturation range most likely be? A. 90% to 98% B. 94% to 99% C. 94% to 100% D. 98% to 100% Use this scenario to answer the next 4 questions: You are caring for a 12-year-old girl with acute lymphoblastic leukemia. She is responsive, but she does not feel well and appears to be flushed. Her temperature is 39°C (102.2°F), heart rate is 118/min, respiratory rate is 36/min, blood pressure is 100/40 mm Hg, and oxygen saturation is 96% on room air. Your assessment reveals mild increase in work of breathing and bounding pulses. The child is receiving 100% oxygen by nonrebreathing mask.
39. Laboratory studies document lactic acidosis. On the basis of the patient’s clinical assessment and history, what type of shock does this patient most likely have? A. Cardiogenic B. Distributive, neurogenic C. Distributive, septic D. Obstructive
40. What assessment finding is most important in your determination of the severity of the patient’s condition?

A. Blood pressure B. Heart rate C. Oxygen saturation D. Respiratory rate

41. What is the most appropriate amount to administer for the first normal saline fluid bolus? A. 5 to 10 mL/kg B. 10 to 20 mL/kg C. 20 to 30 mL/kg D. 30 to 40 mL/kg
42. In addition to oxygen administration and appropriate fluid resuscitation, what additional early intervention should you provide to this patient? A. Bronchodilator administration B. Antibiotic administration C. Corticosteroid administration D. Glucose administration
43. A 10-year-old child is brought to the emergency department for fever and cough. You obtain an oxygen saturation on the child. What oxygen saturation would indicate that immediate intervention is needed? A. 88% on 4 L/min of nasal oxygen B. 95% on room air C. 96% on room air D. 97% on 50% oxygen Use this scenario to answer the next 2 questions: An unresponsive 14-year-old girl is pale and cool to the touch. Her blood pressure is 70/45 mm Hg, heart rate is 190/min, and respiratory rate is 12/min. The SpO2 is not detectable. Capillary refill time is 5 seconds. An IV is in place. The cardiac monitor displays the rhythm shown here.
44. What rhythm is seen on the patient’s cardiac monitor? A. Normal sinus rhythm B. Sinus tachycardia C. Supraventricular tachycardia D. Ventricular tachycardia
45. If pharmacological interventions are unavailable or delayed, what intervention is indicated? A. Defibrillation B. 20 mL/kg bolus isotonic crystalloid C. High-quality CPR D. Synchronized cardioversion

46. The parents of a 7-year-old child who is undergoing chemotherapy report that the child has been febrile and has not been feeling well, with recent onset of lethargy. Assessment reveals that the child is difficult to arouse, and her skin color is pale. The child’s heart rate is 160/min, respiratory rate is 38/min, blood pressure is 76/45 mm Hg, capillary refill time is 5 to 6 seconds, and temperature is 39.4°C (103°F). IV access has been established, and blood cultures have been obtained. What is the most appropriate intervention? A. Administer 10 to 20 mL/kg of isotonic crystalloid over 5 to 10 minutes B. Administer 20 to 30 mL/kg of isotonic crystalloid over 30 minutes C. Administer 5 to 10 mL/kg of packed red blood cells D. Obtain a chest x-ray Use this scenario to answer the next 2 questions: An unresponsive 9-year-old boy was given a dose of rectal valium by his caretaker for a prolonged seizure. His blood pressure is 80/40 mm Hg, heart rate is 45/min, respiratory rate is 6/min, and SpO2 is 60% on room air. He is unresponsive and cyanotic. The cardiac monitor displays the rhythm shown here.
47. What rhythm is most consistent with this patient’s presentation and ECG findings? A. Normal sinus rhythm B. Second-degree heart block (Mobitz type II) C. Sinus bradycardia D. Pulseless electrical activity
48. What action do you take next? A. Administer epinephrine IV B. Perform transcutaneous pacing C. Provide bag-mask ventilation with 100% oxygen D. Perform endotracheal intubation
49. A 3-year-old child is brought to the emergency department by his mother. What is a normal finding for a 3- year-old child? A. Blood pressure of 55/30 mm Hg B. Heart rate of 220/min C. Oxygen saturation of 90% D. Respiratory rate of 24/min
50. A 6-month-old infant is being evaluated for bradycardia. What is the most likely cause of bradycardia? A. Hypovolemia B. Hypoxia C. Drug toxicity D. Hyperglycemia