CCRN (Pediatric) – Pediatric Critical
Care Nursing Comprehensive
Examination
INSTRUCTIONS:
Read each question carefully. Select the best answer. Answers are highlighted
in bold with rationales provided.
1. A 6-month-old with respiratory syncytial virus (RSV) bronchiolitis is on
high-flow nasal cannula (HFNC) at 12 L/min, FiO2 0.5. The infant develops
worsening retractions, nasal flaring, and SpO2 drops to 85%. Blood gas shows
pH 7.28, PaCO2 65, PaO2 55. What is the most appropriate next step?
• A) Increase HFNC to 15 L/min and FiO2 to 0.6
• B) Transition to non-invasive positive pressure ventilation (NIPPV)
• C) Urgent intubation and mechanical ventilation
• D) Administer albuterol nebulizer
Answer: C
Rationale: This infant has acute hypercapnic respiratory failure (PaCO2 65, pH
7.28) with hypoxemia despite HFNC. Non-invasive ventilation may be attempted,
but worsening work of breathing and acidosis indicate impending respiratory
failure. Urgent intubation is indicated to prevent further deterioration.
2. A 4-year-old with status asthmaticus is receiving continuous albuterol,
ipratropium, and IV magnesium. The child is tachypneic, using accessory
muscles, and has a silent chest. The most appropriate next intervention is:
• A) Increase albuterol to double the rate
• B) Administer IV epinephrine
, • C) Prepare for intubation and mechanical ventilation
• D) Obtain a stat chest x-ray
Answer: C
Rationale: Silent chest in asthma indicates severely diminished airflow and
impending respiratory arrest. Despite maximal medical therapy, the child is in
near-failure. Immediate preparation for intubation is necessary. Do not delay;
this is a life-threatening situation.
3. A ventilated 2-year-old with pneumonia has a tidal volume of 8 mL/kg,
plateau pressure 32 cm H2O, and PEEP 8. Which change is most likely to
reduce the risk of ventilator-induced lung injury (VILI)?
• A) Increase tidal volume to 10 mL/kg
• B) Decrease PEEP to 5 cm H2O
• C) Switch to pressure control mode
• D) Reduce tidal volume to 6 mL/kg and monitor plateau pressure
Answer: D
Rationale: Lung-protective ventilation in pediatrics aims for tidal volume 4-6
mL/kg (or 3-6 mL/kg in ARDS) and plateau pressure <28-30 cm H2O. This
patient's plateau pressure is high; reducing tidal volume lowers plateau pressure
and reduces VILI (volutrauma, barotrauma).
4. A 3-month-old with pertussis is intubated and has severe pulmonary
hypertension. The nurse notes an acute increase in peak inspiratory pressure
(PIP) and drop in SpO2. The most likely cause is:
• A) Pneumothorax
• B) Mucus plug
• C) Kinked endotracheal tube
• D) Inadvertent extubation
Answer: B
Rationale: Patients with pertussis have thick, tenacious secretions. A mucus
,plug is common and causes sudden increased PIP, decreased tidal volume, and
desaturation. Immediate suctioning is required. Pneumothorax is also possible but
less likely without sudden hemodynamic change.
5. A 7-year-old with acute respiratory distress syndrome (ARDS) is proned.
Which finding indicates the need to return to supine position?
• A) PaO2/FiO2 ratio increases from 120 to 180
• B) Endotracheal tube cuff pressure is 25 cm H2O
• C) New facial edema and pressure injury on the forehead
• D) Secretions drain from the nares
Answer: C
Rationale: Prone positioning improves oxygenation but carries risks of pressure
injuries, facial edema, and accidental extubation. New facial pressure
injury requires repositioning to prevent skin breakdown. Prone should be cycled
(e.g., 16 hours prone, 8 supine).
6. A 10-month-old with tracheostomy is on a home ventilator. The low
pressure alarm sounds. The nurse assesses the child, who is in respiratory
distress. What is the priority action?
• A) Increase the pressure limit on the ventilator
• B) Manually ventilate with a self-inflating bag and 100% oxygen
• C) Suction the tracheostomy tube
• D) Replace the tracheostomy tube
Answer: B
Rationale: Low pressure alarm suggests a disconnection or large
leak. Immediately disconnect the ventilator and manually ventilate with a bag
that bypasses the leak, while another person checks connections and cuff. Do not
waste time troubleshooting before securing the airway.
, 7. A 5-year-old with smoke inhalation injury has carbonaceous sputum,
hoarseness, and facial burns. The most concerning finding requiring
immediate airway management is:
• A) Heart rate 120 bpm
• B) Stridor at rest
• C) Cough with black sputum
• D) Oxygen saturation 91% on face mask
Answer: B
Rationale: Stridor at rest indicates upper airway obstruction from laryngeal
edema, a medical emergency. This child requires immediate intubation (or
tracheostomy) before complete airway collapse. Hoarseness and carbonaceous
sputum are warning signs, but stridor is the red flag.
8. A 12-year-old with cystic fibrosis and pneumothorax has a chest tube to
water seal. The nurse notes continuous bubbling in the water seal chamber.
What is the most likely cause?
• A) Large air leak from the lung parenchyma
• B) Normal finding immediately after placement
• C) Kink in the tubing
• D) Clamp on the chest tube
Answer: A
Rationale: Continuous bubbling indicates a persistent air leak (bronchopleural
fistula). Intermittent bubbling with cough or expiration is normal, but continuous
suggests ongoing leak. Notify the provider; may require suction, pleurodesis, or
surgical repair.
9. A 2-week-old full-term neonate presents with respiratory distress, cyanosis,
and decreased breath sounds on the left. A chest x-ray shows a hyperlucent
left hemithorax with mediastinal shift to the right. The most likely diagnosis
is:
Care Nursing Comprehensive
Examination
INSTRUCTIONS:
Read each question carefully. Select the best answer. Answers are highlighted
in bold with rationales provided.
1. A 6-month-old with respiratory syncytial virus (RSV) bronchiolitis is on
high-flow nasal cannula (HFNC) at 12 L/min, FiO2 0.5. The infant develops
worsening retractions, nasal flaring, and SpO2 drops to 85%. Blood gas shows
pH 7.28, PaCO2 65, PaO2 55. What is the most appropriate next step?
• A) Increase HFNC to 15 L/min and FiO2 to 0.6
• B) Transition to non-invasive positive pressure ventilation (NIPPV)
• C) Urgent intubation and mechanical ventilation
• D) Administer albuterol nebulizer
Answer: C
Rationale: This infant has acute hypercapnic respiratory failure (PaCO2 65, pH
7.28) with hypoxemia despite HFNC. Non-invasive ventilation may be attempted,
but worsening work of breathing and acidosis indicate impending respiratory
failure. Urgent intubation is indicated to prevent further deterioration.
2. A 4-year-old with status asthmaticus is receiving continuous albuterol,
ipratropium, and IV magnesium. The child is tachypneic, using accessory
muscles, and has a silent chest. The most appropriate next intervention is:
• A) Increase albuterol to double the rate
• B) Administer IV epinephrine
, • C) Prepare for intubation and mechanical ventilation
• D) Obtain a stat chest x-ray
Answer: C
Rationale: Silent chest in asthma indicates severely diminished airflow and
impending respiratory arrest. Despite maximal medical therapy, the child is in
near-failure. Immediate preparation for intubation is necessary. Do not delay;
this is a life-threatening situation.
3. A ventilated 2-year-old with pneumonia has a tidal volume of 8 mL/kg,
plateau pressure 32 cm H2O, and PEEP 8. Which change is most likely to
reduce the risk of ventilator-induced lung injury (VILI)?
• A) Increase tidal volume to 10 mL/kg
• B) Decrease PEEP to 5 cm H2O
• C) Switch to pressure control mode
• D) Reduce tidal volume to 6 mL/kg and monitor plateau pressure
Answer: D
Rationale: Lung-protective ventilation in pediatrics aims for tidal volume 4-6
mL/kg (or 3-6 mL/kg in ARDS) and plateau pressure <28-30 cm H2O. This
patient's plateau pressure is high; reducing tidal volume lowers plateau pressure
and reduces VILI (volutrauma, barotrauma).
4. A 3-month-old with pertussis is intubated and has severe pulmonary
hypertension. The nurse notes an acute increase in peak inspiratory pressure
(PIP) and drop in SpO2. The most likely cause is:
• A) Pneumothorax
• B) Mucus plug
• C) Kinked endotracheal tube
• D) Inadvertent extubation
Answer: B
Rationale: Patients with pertussis have thick, tenacious secretions. A mucus
,plug is common and causes sudden increased PIP, decreased tidal volume, and
desaturation. Immediate suctioning is required. Pneumothorax is also possible but
less likely without sudden hemodynamic change.
5. A 7-year-old with acute respiratory distress syndrome (ARDS) is proned.
Which finding indicates the need to return to supine position?
• A) PaO2/FiO2 ratio increases from 120 to 180
• B) Endotracheal tube cuff pressure is 25 cm H2O
• C) New facial edema and pressure injury on the forehead
• D) Secretions drain from the nares
Answer: C
Rationale: Prone positioning improves oxygenation but carries risks of pressure
injuries, facial edema, and accidental extubation. New facial pressure
injury requires repositioning to prevent skin breakdown. Prone should be cycled
(e.g., 16 hours prone, 8 supine).
6. A 10-month-old with tracheostomy is on a home ventilator. The low
pressure alarm sounds. The nurse assesses the child, who is in respiratory
distress. What is the priority action?
• A) Increase the pressure limit on the ventilator
• B) Manually ventilate with a self-inflating bag and 100% oxygen
• C) Suction the tracheostomy tube
• D) Replace the tracheostomy tube
Answer: B
Rationale: Low pressure alarm suggests a disconnection or large
leak. Immediately disconnect the ventilator and manually ventilate with a bag
that bypasses the leak, while another person checks connections and cuff. Do not
waste time troubleshooting before securing the airway.
, 7. A 5-year-old with smoke inhalation injury has carbonaceous sputum,
hoarseness, and facial burns. The most concerning finding requiring
immediate airway management is:
• A) Heart rate 120 bpm
• B) Stridor at rest
• C) Cough with black sputum
• D) Oxygen saturation 91% on face mask
Answer: B
Rationale: Stridor at rest indicates upper airway obstruction from laryngeal
edema, a medical emergency. This child requires immediate intubation (or
tracheostomy) before complete airway collapse. Hoarseness and carbonaceous
sputum are warning signs, but stridor is the red flag.
8. A 12-year-old with cystic fibrosis and pneumothorax has a chest tube to
water seal. The nurse notes continuous bubbling in the water seal chamber.
What is the most likely cause?
• A) Large air leak from the lung parenchyma
• B) Normal finding immediately after placement
• C) Kink in the tubing
• D) Clamp on the chest tube
Answer: A
Rationale: Continuous bubbling indicates a persistent air leak (bronchopleural
fistula). Intermittent bubbling with cough or expiration is normal, but continuous
suggests ongoing leak. Notify the provider; may require suction, pleurodesis, or
surgical repair.
9. A 2-week-old full-term neonate presents with respiratory distress, cyanosis,
and decreased breath sounds on the left. A chest x-ray shows a hyperlucent
left hemithorax with mediastinal shift to the right. The most likely diagnosis
is:
