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Question 1. Which of the following congenital heart defects is most likely to present with a harsh systolic ejection murmur and a single S2? A) Tetralogy of Fallot B) Ventricular septal defect C) Atrial septal defect D) Patent ductus arteriosus Answer: A Explanation: Tetralogy of Fallot classically presents with a harsh systolic ejection murmur due to right ventricular outflow obstruction and a single second heart sound because the pulmonary component is soft or absent. Question 2. In a child with a large patent ductus arteriosus (PDA) who is developing heart failure, the first pharmacologic agent of choice is: A) Indomethacin B) Furosemide C) Propranolol D) Digoxin Answer: B Explanation: Loop diuretics such as furosemide are used initially to reduce volume overload and pulmonary congestion in PDA-related heart failure. Question 3. A 4-year-old post-operative cardiac patient exhibits a mean arterial pressure (MAP) of 45 mm Hg, central venous pressure (CVP) of 2 mm Hg, and urine output of 0.3 mL/kg/hr. The most likely diagnosis is: A) Low cardiac output syndrome B) Cardiac tamponade C) Hyperdynamic circulation D) Acute kidney injury unrelated to perfusion Answer: A
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Explanation: Low MAP, low CVP, and oliguria indicate inadequate cardiac output despite low filling pressures, characteristic of low cardiac output syndrome. Question 4. Which hemodynamic parameter is the most direct indicator of preload in a mechanically ventilated pediatric patient? A) MAP B) CVP C) Cardiac index D) Systemic vascular resistance Answer: B Explanation: Central venous pressure reflects right-sided filling pressures and is used as a surrogate for preload. Question 5. Milrinone provides hemodynamic support by: A) Alpha-adrenergic vasoconstriction B) Beta-adrenergic stimulation C) Phosphodiesterase-III inhibition D) Calcium channel blockade Answer: C Explanation: Milrinone inhibits phosphodiesterase-III, increasing intracellular cAMP, leading to positive inotropy and vasodilation. Question 6. A child with septic shock is receiving epinephrine infusion at 0.2 μg/kg/min. Which physiologic effect is primarily responsible for the increase in cardiac output? A) Alpha-1 mediated vasoconstriction B) Beta-1 mediated increase in heart rate and contractility C) Beta-2 mediated bronchodilation D) Dopamine-mediated renal vasodilation
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D) Inhaled racemic epinephrine Answer: D Explanation: Inhaled racemic epinephrine rapidly reduces airway edema and improves stridor in moderate croup. Question 10. A pediatric patient on BiPAP develops a sudden “high-pressure” alarm. The most likely cause is: A) Disconnection of the circuit B) Patient’s cough causing auto-PEEP C) Decreased inspiratory time setting D) Blocked exhalation valve Answer: D Explanation: A blocked exhalation valve prevents pressure release, triggering a high-pressure alarm. Question 11. A 6-month-old presents with bronchiolitis and requires intubation. Which ventilator mode best supports their physiology? A) Pressure control ventilation (PCV) B) Volume-controlled ventilation (VCV) C) Synchronized intermittent mandatory ventilation (SIMV) D) High-frequency oscillatory ventilation (HFOV) Answer: A Explanation: PCV delivers a set pressure, limiting barotrauma in infants with compliant lungs, making it suitable for bronchiolitis. Question 12. Which blood gas interpretation indicates metabolic alkalosis with partial respiratory compensation? A) pH 7.48, PaCO₂ 30 mm Hg, HCO₃⁻ 28 mEq/L B) pH 7.30, PaCO₂ 55 mm Hg, HCO₃⁻ 24 mEq/L
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C) pH 7.55, PaCO₂ 45 mm Hg, HCO₃⁻ 34 mEq/L D) pH 7.22, PaCO₂ 25 mm Hg, HCO₃⁻ 12 mEq/L Answer: C Explanation: Elevated pH with high bicarbonate indicates metabolic alkalosis; PaCO₂ is slightly elevated, reflecting respiratory compensation. Question 13. The most reliable clinical sign of increased intracranial pressure (ICP) in a sedated toddler is: A) Fixed, dilated pupils B) Hypertension with bradycardia (Cushing reflex) C) Seizure activity D) Decreased reflexes Answer: B Explanation: Cushing’s triad (hypertension, bradycardia, irregular respirations) is a classic sign of elevated ICP. Question 14. Hypertonic saline (3%) is administered to a child with increased ICP. The primary physiologic effect is: A) Decreasing cerebral metabolic demand B) Osmotic draw of water from brain tissue to intravascular space C) Direct vasoconstriction of cerebral vessels D) Inhibition of glutamate release Answer: B Explanation: Hypertonic saline creates an osmotic gradient that pulls water out of edematous brain cells, reducing ICP. Question 15. Which medication is the first-line treatment for status epilepticus in a pediatric patient? A) Phenytoin B) Phenobarbital
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D. Hepatitis B infection Answer: B Explanation: Reye’s syndrome is a rare but fatal hepatic encephalopathy linked to aspirin ingestion during viral infections, especially influenza or varicella. Question 19. In the management of pediatric diabetic ketoacidosis (DKA), the initial fluid of choice is: A) 0.9% Normal saline B) 0.45% Half-normal saline C) Lactated Ringer’s solution D) Dextrose-containing solution Answer: A Explanation: Isotonic normal saline is used first to restore intravascular volume before addressing hyperglycemia. Question 20. Which intervention most effectively reduces the risk of cerebral edema during DKA treatment? A) Rapid infusion of bicarbonate B) Administration of insulin at 0.5 U/kg/hr C) Reducing serum glucose by >100 mg/dL per hour D) Maintaining serum sodium >135 mEq/L Answer: D Explanation: Preserving or raising serum sodium (by using isotonic fluids) mitigates the osmotic shift that can precipitate cerebral edema. Question 21. A child with sickle cell disease presents with a vaso-occlusive crisis. The most appropriate nursing intervention is: A) Immediate blood transfusion B) Administration of high-dose opioids only after fluids
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C) Warm compresses to the painful area D) Adequate hydration and analgesia Answer: D Explanation: Hydration improves blood viscosity, and timely analgesia (often opioids) reduces pain and prevents further sickling. Question 22. Disseminated intravascular coagulation (DIC) is characterized by all of the following EXCEPT: A) Elevated D-dimer B) Prolonged PT and aPTT C) Thrombocytosis D) Low fibrinogen Answer: C Explanation: DIC typically causes thrombocytopenia, not thrombocytosis. Question 23. In immune thrombocytopenic purpura (ITP), the first-line therapy for a severely bleeding child is: A) Platelet transfusion B) Intravenous immunoglobulin (IVIG) C) High-dose steroids D) Splenectomy Answer: B Explanation: IVIG rapidly raises platelet counts and is preferred over transfusion, which is often ineffective due to ongoing immune destruction. Question 24. Tumor lysis syndrome most commonly leads to which electrolyte abnormality? A) Hypercalcemia B) Hyperphosphatemia
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D) Barium enema Answer: B Explanation: An upper GI series quickly demonstrates abnormal duodenal positioning and corkscrew appearance indicative of volvulus. Question 28. Necrotizing enterocolitis (NEC) most commonly occurs in which patient population? A) Full-term infants > 2 months old B) Preterm infants < 32 weeks gestation C) Children with cystic fibrosis D) Adolescents with Crohn disease Answer: B Explanation: NEC predominantly affects very low-birth-weight, preterm neonates. Question 29. A 5-year-old with acute kidney injury (AKI) has a serum potassium of 6.8 mEq/L and ECG shows peaked T waves. The fastest method to lower potassium is: A) Oral sodium polystyrene sulfonate B) Intravenous calcium gluconate C) Intravenous insulin with glucose D) Hemodialysis Answer: B Explanation: Calcium gluconate stabilizes myocardial membranes, providing immediate protection, though it does not remove potassium. Question 30. Peritoneal dialysis in a pediatric patient is contraindicated when: A) The child is hemodynamically stable B) There is intra-abdominal infection C) Serum creatinine is <2 mg/dL
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D) Urine output is >1 mL/kg/hr Answer: B Explanation: Peritonitis or any intra-abdominal infection precludes peritoneal dialysis due to risk of worsening infection. Question 31. The pediatric surviving sepsis bundle recommends which of the following within the first hour? A) Administration of broad-spectrum antibiotics B) Initiation of vasopressors only after 3 hours C) Fluid bolus of 10 mL/kg of isotonic crystalloid D) Both A and C Answer: D Explanation: Early antibiotics and a 20 mL/kg fluid bolus (often given as two 10 mL/kg boluses) are core components of the first-hour bundle. Question 32. A child who ingested acetaminophen 2 hours ago is asymptomatic. Which lab test is most useful to determine need for N-acetylcysteine (NAC) therapy? A) Serum acetaminophen level B) Liver function tests (AST/ALT) C) Prothrombin time D) Serum creatinine Answer: A Explanation: The Rumack-Mattox nomogram uses serum acetaminophen concentration and time since ingestion to guide NAC administration. Question 33. In lead poisoning, the most sensitive indicator of exposure in children is: A) Blood lead level >5 μg/dL B) Elevated serum ferritin
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C) Unpredictability of condition D) Length of stay Answer: C Explanation: Unpredictable or rapidly changing clinical situations increase the complexity of care, requiring higher nursing competency in assessment and decision-making. Question 37. A family requests that no blood products be given to their child due to religious beliefs. The nurse’s ethical responsibility is to: A) Override the family’s wishes to preserve life B) Document the refusal and notify the ethics committee C) Provide a bloodless alternative if medically feasible D) Both B and C Answer: D Explanation: Respect for cultural/religious values is essential; the nurse must document the refusal, involve the ethics committee, and explore acceptable alternatives. Question 38. In family-centered care, the “rooming-in” concept primarily aims to: A) Reduce hospital costs B) Decrease infection rates C) Promote parental participation in care D) Increase nursing workload Answer: C Explanation: Rooming-in allows parents to stay with the child, fostering involvement in care decisions and emotional support. Question 39. A 10-year-old undergoing chemotherapy develops febrile neutropenia (ANC < 500). The immediate nursing priority is:
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A) Start broad-spectrum antibiotics within 1 hour B) Obtain a complete blood count (CBC) only C) Delay treatment until culture results return D) Administer granulocyte colony-stimulating factor (G-CSF) only Answer: A Explanation: Prompt empiric antibiotics are critical to reduce mortality in febrile neutropenia. Question 40. When caring for a child with a speech delay, the nurse should: A) Speak only in medical terminology B) Use simple, concrete language and allow extra processing time C) Avoid eye contact to reduce overstimulation D) Restrict the child’s interaction with peers Answer: B Explanation: Simple language and patience support communication for children with speech delays. Question 41. A pediatric patient’s medication order lists “Infuse dopamine at 5 μg/kg/min.” The nurse calculates the infusion rate as 0.5 mL/hr. Which factor is most likely missing from the calculation? A) Concentration of dopamine solution B) Patient’s weight in kilograms C) Duration of infusion D) Drop factor of the IV set Answer: A Explanation: Infusion rate depends on the concentration (e.g., mg/mL) of the dopamine preparation; without it the rate cannot be determined. Question 42. Which of the following best describes the “Coping” competency in the Synergy Model?
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Question 45. A 3-year-old presents with a “boot-shaped” heart on chest X-ray. The most likely diagnosis is: A) Tetralogy of Fallot B) Transposition of the great arteries (TGA) C) Truncus arteriosus D) Pulmonary atresia Answer: A Explanation: The classic boot-shaped silhouette reflects right ventricular hypertrophy in Tetralogy of Fallot. Question 46. Which of the following is the best indicator of tissue perfusion in a shocked pediatric patient? A) Central venous oxygen saturation (ScvO₂) B) Heart rate C) Respiratory rate D) Blood pressure Answer: A Explanation: ScvO₂ reflects the balance between oxygen delivery and consumption, providing a direct measure of perfusion adequacy. Question 47. A child with severe asthma receives repeated albuterol doses and develops tachycardia, tremor, and hypokalemia. The most appropriate nursing intervention is: A) Discontinue albuterol immediately B) Administer a potassium-rich diet or supplement C) Initiate magnesium sulfate infusion D) Switch to a β-blocker Answer: B Explanation: β₂-agonists drive potassium intracellularly; supplementation helps prevent arrhythmias while therapy continues.
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Question 48. The most common cause of upper airway obstruction in a toddler during winter months is: A) Foreign body aspiration B) Croup (laryngotracheobronchitis) C) Epiglottitis D) Bacterial tracheitis Answer: B Explanation: Viral croup peaks in winter and causes subglottic edema leading to inspiratory stridor. Question 49. When interpreting a pediatric arterial blood gas, a pH of 7.30, PaCO₂ 30 mm Hg, and HCO₃⁻ 18 mEq/L indicates: A) Primary respiratory acidosis with metabolic compensation B) Primary metabolic acidosis with respiratory compensation C) Mixed respiratory and metabolic alkalosis D) Normal acid-base status Answer: B Explanation: Low HCO₃⁻ indicates metabolic acidosis; the low PaCO₂ reflects compensatory hyperventilation. Question 50. A child with a traumatic brain injury is placed in a head-of-bed elevation of 30 degrees. This positioning primarily serves to: A) Increase cerebral perfusion pressure (CPP) B) Decrease intracranial pressure (ICP) by improving venous drainage C) Prevent aspiration D) Reduce spinal cord compression Answer: B Explanation: Elevating the head facilitates venous outflow from the brain, lowering ICP.
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Question 54. In pediatric DKA, the recommended target for serum bicarbonate before initiating insulin is: A) >22 mEq/L B) >18 mEq/L C) >15 mEq/L D) No specific target; start insulin immediately after fluids Answer: D Explanation: After initial fluid resuscitation, insulin is started promptly; waiting for bicarbonate correction is not recommended. Question 55. Which of the following best describes the “Family Partnership” component of the Synergy Model? A) Nurse’s ability to anticipate patient needs B) Family’s active involvement in care planning and decision-making C) Hospital’s policy on visitation hours D) Availability of child life services Answer: B Explanation: Family partnership emphasizes collaborative care where families contribute to planning and evaluating care. Question 56. A child with leukemia develops tumor lysis syndrome after chemotherapy. Which medication should be administered prophylactically to reduce uric acid levels? A) Allopurinol B) Rasburicase C) Febuxostat D) Probenecid Answer: B
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Explanation: Rasburicase enzymatically degrades uric acid to allantoin, rapidly lowering serum uric acid in TLS. Question 57. In a pediatric patient with a suspected foreign body airway obstruction, the first maneuver for a conscious child >1 year old is: A) Heimlich maneuver (abdominal thrusts) B) Back blows only C) Chest compressions D) Finger sweep without visualization Answer: A Explanation: The Heimlich maneuver is the recommended initial technique for conscious children over one year with complete airway obstruction. Question 58. A 2-year-old with bronchiolitis is placed on high-flow nasal cannula (HFNC). The primary physiologic benefit of HFNC is: A) Decreased work of breathing through low-level positive airway pressure B) Direct bronchodilation C) Increased alveolar surfactant production D) Immediate removal of secretions Answer: A Explanation: HFNC provides modest positive airway pressure and humidified oxygen, reducing inspiratory effort. Question 59. Which of the following is an early sign of septic shock in a pediatric patient? A) Warm extremities with bounding pulses B) Cool, clammy skin with delayed capillary refill C) Hypertension D) Bradycardia Answer: A
