A 14-month-old with unrepaired tetralogy of Fallot wakes from a nap crying inconsolably on the step-down unit. The child becomes deeply cyanotic, breathes rapidly and deeply, and the previously loud systolic murmur becomes much softer. SpO2 is 62%. Which action should the nurse take FIRST?

Hold the child in a knee-to-chest position and calmly comfort the child

Obtain an arterial blood gas to measure the degree of metabolic acidosis

Place the child supine and apply 100% oxygen by non-rebreather mask

Prepare a 20 mL/kg isotonic bolus and call for intraosseous access

A 7-month-old with pulmonary hypertension after repair of total anomalous pulmonary venous return is receiving inhaled nitric oxide at 20 ppm through the ventilator. The infant needs a CT scan. Which plan should the nurse ensure for transport?

Continue nitric oxide without interruption using a transport delivery system

Use room air on the transport bag to avoid oxygen toxicity during the trip

Stop nitric oxide for the trip and increase FiO2 to 1.0 on the transport bag

Wean nitric oxide to 5 ppm before leaving and resume it after the scan

A 14-year-old with severe anorexia nervosa (weight 61% of expected) started continuous nasogastric feedings 36 hours ago. The adolescent now reports leg weakness and has new ankle edema. Phosphorus is 1.7 mg/dL (2.9 on admission), potassium 3.1 mEq/L, magnesium 1.5 mg/dL. HR is 52 with occasional ectopy. Which action is most appropriate?

Hold the feeding advance and anticipate IV phosphate, potassium and magnesium

Advance the feeding rate to meet full caloric goals and add a multivitamin

Give furosemide for the ankle edema and recheck labs in the morning

Stop all nutrition for 48 hours until the electrolytes return to normal

A 15-year-old with a history of generalized anxiety disorder is on day 2 in the PICU after a femur fracture and a pulmonary contusion. The adolescent suddenly becomes restless, says "something is wrong," and pulls at the nasal cannula. HR is 132, RR 34 and SpO2 86% on 2 L/min. The parent says, "This is one of her panic attacks." Which action should the nurse take FIRST?

Assess breathing, increase the oxygen, and notify the provider at once

Give the ordered lorazepam for anxiety and coach slow, deep breathing

Ask the parent to step out so the adolescent has less stimulation

Reassure the adolescent that panic passes and recheck vitals in 1 hour

A 9-year-old with leukemia is eligible for a research study that adds an extra bone marrow sample with no direct benefit to him. His parents have signed consent, but he says clearly, "No, I don't want another needle." Which action by the nurse is MOST appropriate?

Tell the research team the child has declined and his refusal should be honored

Give extra procedural sedation so the sample can be obtained without his distress

Ask the parents to persuade him, since their consent overrides his wishes in law

Proceed with the sample because the parents have legally consented for the study

A 3-kg neonate is 12 hours out from a Norwood procedure with a modified Blalock-Taussig shunt for hypoplastic left heart syndrome. The infant is sedated and ventilated on FiO2 0.50. The following data were obtained. Finding Value SpO2 96% HR / BP 175 / 52/24 pH / PaCO2 / PaO2 7.28 / 34 / 72 mmHg Lactate 4.5 mmol/L Cerebral NIRS 42% Urine output 0.6 mL/kg/hr Which action should the nurse anticipate?

Lower the FiO2 and avoid hyperventilation to raise pulmonary resistance

Increase the FiO2 to 1.0 to raise the systemic oxygen content further

Give a 20 mL/kg bolus to raise BP while keeping oxygen settings unchanged

Increase the ventilator rate to lower the PaCO2 and correct the acidosis

A 7-month-old former 25-week preterm infant with bronchopulmonary dysplasia is admitted for poor weight gain. The infant takes furosemide and chlorothiazide daily and is on 0.5 L/min nasal cannula. The following results were obtained. Test Result pH / PaCO2 7.48 / 58 mmHg HCO3 42 mEq/L Sodium 131 mEq/L Potassium 2.9 mEq/L Chloride 82 mEq/L Which intervention should the nurse anticipate?

Potassium chloride supplementation and review of the diuretic regimen

Sodium bicarbonate to treat the high PaCO2 and protect the kidneys

Fluid restriction to correct the low sodium and reduce lung water

Increasing support to bring the PaCO2 into the normal range quickly

A newborn with gastroschisis arrives in the PICU from the delivery hospital. The exposed bowel is loosely wrapped in dry gauze, and the infant's temperature is 35.8 C (96.4 F). Which action is most appropriate?

Place the bowel in a sterile bowel bag and support it to prevent kinking

Wrap the bowel tightly with an elastic bandage for protection

Gently push the exposed bowel back into the abdomen to reduce heat and fluid loss

Leave the dry gauze in place and position the infant prone

A 15-year-old with type 1 diabetes is admitted for the third episode of DKA in 6 months. The adolescent admits skipping insulin doses at school and with friends. Which approach by the nurse is most likely to improve adherence?

Talk privately with the teen about barriers and plan routines together

Review the dangers of DKA again until the teen can repeat them correctly

Have the parents give and supervise every insulin dose at home and school

Tell the teen that another admission will lead to a psychiatric referral

A nurse is asked to witness a mother's signature on the surgical consent for her infant's gastrostomy tube placement. When the nurse asks what she understands, the mother says, "They're going to fix his stomach so he won't need any more surgery." Which action should the nurse take?

Hold the signature and ask the surgeon to explain the procedure to her again

Explain the risks and benefits of the procedure herself and then witness it

Witness the signature because the surgeon already discussed the procedure

Witness it now and write a note in the chart that she seemed to be confused

Pediatric CCRN Exam

Free Pediatric CCRN Practice Questions

10 sample questions for the Pediatric CCRN Exam, with the correct answer and an explanation for each. No account needed. Try each one before you open the answer.

Sections covered on the exam: Foundations of Pediatric Critical Care, Endocrine, Hematology and Immunology, Gastrointestinal, Renal, Genitourinary and Integumentary, Musculoskeletal and Neurological, Cardiovascular, Professional Caring and Ethical Practice.

Question 1 · Foundations of Pediatric Critical Care
A 14-month-old with unrepaired tetralogy of Fallot wakes from a nap crying inconsolably on the step-down unit. The child becomes deeply cyanotic, breathes rapidly and deeply, and the previously loud systolic murmur becomes much softer. SpO2 is 62%. Which action should the nurse take FIRST?
- A.Hold the child in a knee-to-chest position and calmly comfort the child
- B.Obtain an arterial blood gas to measure the degree of metabolic acidosis
- C.Place the child supine and apply 100% oxygen by non-rebreather mask
- D.Prepare a 20 mL/kg isotonic bolus and call for intraosseous access
Show answer and explanation
Answer: A. Hold the child in a knee-to-chest position and calmly comfort the child
A softening murmur with deep cyanosis during crying signals a hypercyanotic spell: less blood crosses the narrowed right ventricular outflow tract. The knee-to-chest position raises systemic vascular resistance and pushes more blood to the lungs, and calming the child lowers oxygen demand, so this comes first. Oxygen, morphine, fluids and phenylephrine follow if positioning fails, while drawing labs delays treatment and agitates the child.
Question 2 · Foundations of Pediatric Critical Care
A 7-month-old with pulmonary hypertension after repair of total anomalous pulmonary venous return is receiving inhaled nitric oxide at 20 ppm through the ventilator. The infant needs a CT scan. Which plan should the nurse ensure for transport?
- A.Continue nitric oxide without interruption using a transport delivery system
- B.Use room air on the transport bag to avoid oxygen toxicity during the trip
- C.Stop nitric oxide for the trip and increase FiO2 to 1.0 on the transport bag
- D.Wean nitric oxide to 5 ppm before leaving and resume it after the scan
Show answer and explanation
Answer: A. Continue nitric oxide without interruption using a transport delivery system
Abrupt interruption of inhaled nitric oxide can cause severe rebound pulmonary vasoconstriction and a pulmonary hypertensive crisis, so delivery must continue during manual ventilation and transport. Weaning is done gradually and only when the infant is stable, not to make travel easier. Extra oxygen alone does not prevent rebound.
Question 3 · Gastrointestinal
A 14-year-old with severe anorexia nervosa (weight 61% of expected) started continuous nasogastric feedings 36 hours ago. The adolescent now reports leg weakness and has new ankle edema. Phosphorus is 1.7 mg/dL (2.9 on admission), potassium 3.1 mEq/L, magnesium 1.5 mg/dL. HR is 52 with occasional ectopy. Which action is most appropriate?
- A.Hold the feeding advance and anticipate IV phosphate, potassium and magnesium
- B.Advance the feeding rate to meet full caloric goals and add a multivitamin
- C.Give furosemide for the ankle edema and recheck labs in the morning
- D.Stop all nutrition for 48 hours until the electrolytes return to normal
Show answer and explanation
Answer: A. Hold the feeding advance and anticipate IV phosphate, potassium and magnesium
A sharp fall in phosphorus with weakness, edema and arrhythmia after feeding begins is refeeding syndrome, driven by insulin-mediated intracellular shifts. Feeds are held at the current rate or slowed while phosphate, potassium and magnesium are replaced, with cardiac monitoring and thiamine. Stopping nutrition entirely prolongs starvation, and a diuretic would worsen the electrolyte losses.
Question 4 · Foundations of Pediatric Critical Care
A 15-year-old with a history of generalized anxiety disorder is on day 2 in the PICU after a femur fracture and a pulmonary contusion. The adolescent suddenly becomes restless, says "something is wrong," and pulls at the nasal cannula. HR is 132, RR 34 and SpO2 86% on 2 L/min. The parent says, "This is one of her panic attacks." Which action should the nurse take FIRST?
- A.Give the ordered lorazepam for anxiety and coach slow, deep breathing
- B.Assess breathing, increase the oxygen, and notify the provider at once
- C.Ask the parent to step out so the adolescent has less stimulation
- D.Reassure the adolescent that panic passes and recheck vitals in 1 hour
Show answer and explanation
Answer: B. Assess breathing, increase the oxygen, and notify the provider at once
Restlessness and a sense that something is wrong, with tachycardia, tachypnea and an SpO2 of 86%, must be treated as a physiologic problem before the behavior is labeled anxiety. After a long-bone fracture and a pulmonary contusion, a worsening contusion, pulmonary embolism or fat embolism syndrome are real possibilities. The nurse supports oxygenation, assesses breathing and calls the provider. A benzodiazepine could depress breathing and hide hypoxemia, and reassurance or removing the parent delays recognition.
Question 5 · Professional Caring and Ethical Practice
A 9-year-old with leukemia is eligible for a research study that adds an extra bone marrow sample with no direct benefit to him. His parents have signed consent, but he says clearly, "No, I don't want another needle." Which action by the nurse is MOST appropriate?
- A.Give extra procedural sedation so the sample can be obtained without his distress
- B.Ask the parents to persuade him, since their consent overrides his wishes in law
- C.Tell the research team the child has declined and his refusal should be honored
- D.Proceed with the sample because the parents have legally consented for the study
Show answer and explanation
Answer: C. Tell the research team the child has declined and his refusal should be honored
For research that offers no direct benefit, a child's dissent should generally be respected even when parents consent; children of about 7 years and older are asked for assent. The nurse advocates by informing the investigators. Using sedation or parental pressure to overcome a clear refusal violates the ethical protections for child research participants.
Question 6 · Foundations of Pediatric Critical Care
A 3-kg neonate is 12 hours out from a Norwood procedure with a modified Blalock-Taussig shunt for hypoplastic left heart syndrome. The infant is sedated and ventilated on FiO2 0.50. The following data were obtained.
Finding Value
SpO2 96%
HR / BP 175 / 52/24
pH / PaCO2 / PaO2 7.28 / 34 / 72 mmHg
Lactate 4.5 mmol/L
Cerebral NIRS 42%
Urine output 0.6 mL/kg/hr
Which action should the nurse anticipate?
- A.Increase the FiO2 to 1.0 to raise the systemic oxygen content further
- B.Give a 20 mL/kg bolus to raise BP while keeping oxygen settings unchanged
- C.Lower the FiO2 and avoid hyperventilation to raise pulmonary resistance
- D.Increase the ventilator rate to lower the PaCO2 and correct the acidosis
Show answer and explanation
Answer: C. Lower the FiO2 and avoid hyperventilation to raise pulmonary resistance
In single-ventricle circulation, an SpO2 well above the usual 75 to 85% target with a low diastolic BP, lactic acidosis and low NIRS suggests too much flow to the lungs (Qp:Qs well above 1) at the expense of the body. Lowering FiO2 and allowing a normal to slightly higher PaCO2 raises pulmonary vascular resistance and redirects flow systemically. More oxygen or hyperventilation would worsen the steal.
Question 7 · Foundations of Pediatric Critical Care
A 7-month-old former 25-week preterm infant with bronchopulmonary dysplasia is admitted for poor weight gain. The infant takes furosemide and chlorothiazide daily and is on 0.5 L/min nasal cannula. The following results were obtained.
Test Result
pH / PaCO2 7.48 / 58 mmHg
HCO3 42 mEq/L
Sodium 131 mEq/L
Potassium 2.9 mEq/L
Chloride 82 mEq/L
Which intervention should the nurse anticipate?
- A.Potassium chloride supplementation and review of the diuretic regimen
- B.Sodium bicarbonate to treat the high PaCO2 and protect the kidneys
- C.Fluid restriction to correct the low sodium and reduce lung water
- D.Increasing support to bring the PaCO2 into the normal range quickly
Show answer and explanation
Answer: A. Potassium chloride supplementation and review of the diuretic regimen
The high pH with a markedly elevated bicarbonate and low chloride and potassium shows a hypochloremic, hypokalemic metabolic alkalosis from chronic diuretics, with the high PaCO2 partly compensating. Replacing chloride and potassium (often as potassium chloride) and adjusting diuretics corrects the alkalosis, which otherwise depresses ventilatory drive. Forcing the PaCO2 down would worsen the alkalemia.
Question 8 · Gastrointestinal
A newborn with gastroschisis arrives in the PICU from the delivery hospital. The exposed bowel is loosely wrapped in dry gauze, and the infant's temperature is 35.8 C (96.4 F). Which action is most appropriate?
- A.Wrap the bowel tightly with an elastic bandage for protection
- B.Place the bowel in a sterile bowel bag and support it to prevent kinking
- C.Gently push the exposed bowel back into the abdomen to reduce heat and fluid loss
- D.Leave the dry gauze in place and position the infant prone
Show answer and explanation
Answer: B. Place the bowel in a sterile bowel bag and support it to prevent kinking
Exposed bowel loses heat and fluid quickly and can become ischemic if the mesentery kinks. A sterile bowel bag or clear plastic wrap reduces evaporative loss and allows inspection, with the infant side-lying and the bowel supported, plus warming, gastric decompression and generous isotonic fluids. Manual reduction is a surgical decision, and dry gauze adheres to the bowel.
Question 9 · Foundations of Pediatric Critical Care
A 15-year-old with type 1 diabetes is admitted for the third episode of DKA in 6 months. The adolescent admits skipping insulin doses at school and with friends. Which approach by the nurse is most likely to improve adherence?
- A.Review the dangers of DKA again until the teen can repeat them correctly
- B.Have the parents give and supervise every insulin dose at home and school
- C.Tell the teen that another admission will lead to a psychiatric referral
- D.Talk privately with the teen about barriers and plan routines together
Show answer and explanation
Answer: D. Talk privately with the teen about barriers and plan routines together
Adolescents often skip treatment because of peer pressure, a wish to fit in, depression or a need for control, not lack of knowledge. A confidential conversation that explores barriers and involves the teen in practical problem-solving supports autonomy and engagement, with screening for depression and appropriate parental involvement. Threats or repeated lectures tend to increase resistance.
Question 10 · Professional Caring and Ethical Practice
A nurse is asked to witness a mother's signature on the surgical consent for her infant's gastrostomy tube placement. When the nurse asks what she understands, the mother says, "They're going to fix his stomach so he won't need any more surgery." Which action should the nurse take?
- A.Hold the signature and ask the surgeon to explain the procedure to her again
- B.Explain the risks and benefits of the procedure herself and then witness it
- C.Witness the signature because the surgeon already discussed the procedure
- D.Witness it now and write a note in the chart that she seemed to be confused
Show answer and explanation
Answer: A. Hold the signature and ask the surgeon to explain the procedure to her again
The nurse's role in consent is to witness the signature and confirm that the parent has the information she needs; when a misunderstanding is evident, the nurse advocates by asking the surgeon to clarify before signing. The duty to provide informed consent belongs to the provider performing the procedure. Witnessing a consent the nurse knows is not informed is inappropriate.

Finding	Value
SpO2	96%
HR / BP	175 / 52/24
pH / PaCO2 / PaO2	7.28 / 34 / 72 mmHg
Lactate	4.5 mmol/L
Cerebral NIRS	42%
Urine output	0.6 mL/kg/hr

Test	Result
pH / PaCO2	7.48 / 58 mmHg
HCO3	42 mEq/L
Sodium	131 mEq/L
Potassium	2.9 mEq/L
Chloride	82 mEq/L

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