APRN ACCNS(P) - Final Test Review(Qns & Ans) - 2025, Exams of Nursing

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APRN ACCNS-P

Final Test Review

(Questions & Solutions)

1. Viral Myocarditis vs. Sepsis A 6-year-old previously healthy boy presents with 2 days of fever and new hepatomegaly. BP 90/50 mm Hg, HR 146, CRP 12 mg/dL, troponin I 1.2 ng/mL, BNP 2,400 pg/mL, lactate 1.9 mmol/L. Bedside echo: LVEF 38 %, no pericardial effusion. Best initial pharmacologic therapy? A. Ceftriaxone 75 mg/kg IV B. Milrinone 0.5 μg/kg/min IV C. Dopamine 7 μg/kg/min IV D. High-dose IVIG 2 g/kg Rationale: Depressed systolic function with low SVR favors inodilator milrinone; vasopressors raise afterload and worsen performance.

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2. Post–Fontan Plastic Bronchitis A 9-year-old with extracardiac Fontan completes bronchoscopy for refractory chylous casts. CVP 20 mm Hg, SpO₂ 88 % on RA. Which intervention targets the root pathophysiology? A. Inhaled hypertonic saline TID B. Lymphatic embolization via dynamic contrast MR lymphangiography C. High-frequency chest wall oscillation D. Nebulized t-PA 5 mg q6 h Rationale: Aberrant thoracic duct leak into airways is now treated definitively with interventional radiology–guided lymphatic embolization.

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3. Pulmonary Hypertension Crisis A 4-year-old with idiopathic PAH deteriorates in the PICU: PAP equals systemic BP on echo; CO₂ 55 mm Hg; sat 85 % despite FiO₂ 1.0.

6. Severe Status Asthmaticus – Vent Strategy Intubated 10-year-old, peak 45, plateau 24 cm H₂O, pH 7.17, PaCO₂ 82 mm Hg. Optimal mode change? A. Volume AC, VT 10 mL/kg, RR 22 B. Pressure-controlled ventilation with prolonged expiratory time (I:E 1:6) C. Add 10 cm H₂O PEEP D. APRV Rationale: Permissive hypercapnia with long exhalation minimizes dynamic air-trapping and barotrauma.

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7. CF Pulmonary Exacerbation – Synergy A 16-year-old CF patient, FEV₁ 38 %, colonized with MRSA & P. aeruginosa. Febrile 39 °C, infiltrates bilateral. Best empiric IV combo? A. Cefepime + vancomycin B. Piperacillin-tazobactam + linezolid C. Ceftazidime-avibactam + vancomycin + azithromycin D. Meropenem-vaborbactam + daptomycin Rationale: New β-lactam/β-lactamase pairs provide anti-pseudomonal coverage; vancomycin hits MRSA; azithromycin modulates inflammation.

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8. Apnea of Prematurity – Caffeine Toxicity A 32-week 1,500-g neonate on caffeine citrate develops HR 208, glucose 53 mg/dL, jitteriness. Serum caffeine 42 μg/mL (goal 20). First intervention? A. Intubate and ventilate B. Hold caffeine and give IV fluids 10 mL/kg D5 NS

C. Phenobarbital load D. Start propranolol Rationale: Supportive care and drug cessation suffice; severe toxicity rewinds with dilution and elimination (half-life 100 h preterm).

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9. Bronchiolitis – High-Flow vs. CPAP An RSV-positive 5-month-old (6 kg) with moderate retractions, SpO₂ 90 % on 2 L O₂ NC. Work of breathing rising. Evidence-based escalation? A. CPAP 8 cm H₂O B. Heated humidified high-flow nasal cannula 2 L/kg/min C. Trial of racemic epinephrine D. Intubation Rationale: HFNC improves alveolar ventilation, reduces intubation, and is first-line over CPAP in moderate bronchiolitis.

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10. ALI After Drowning A 3-year-old pulled from pool 8 min submersion: PaO₂/FiO₂ 80 on FiO₂ 0.9, PEEP 10. Lung ultrasound: diffuse B lines. Adjunct that lowers mortality? A. Surfactant lavage B. Early neuromuscular blockade with cisatracurium infusion C. Steroid bolus D. Sildenafil Rationale: ACURASYS pediatric data extrapolate that early paralysis facilitates lung-protective synchrony in severe ARDS.

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Rationale: CRASH-2 pediatric data show survival when TXA given early, regardless of lab coagulopathy.

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14. SIADH vs. CSW After TBI A 10-year-old severe TBI day 4: Na⁺ 126, urine Na⁺ 160 mmol/L, UO 4 mL/kg/hr, CVP 4 cm H₂O. Diagnosis? A. SIADH B. Cerebral salt wasting C. Diabetes insipidus D. Hypervolemic hyponatremia Rationale: Hypovolemia with high urine sodium and polyuria signals CSW (treat with 3 % saline ± fludrocortisone).

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15. Intracranial Hypertension – Hyperosmolar Agent ICP monitor 28 mm Hg, CPP 58 mm Hg in 14-year-old with malignant edema. Serum Na⁺ 148, osmol 305. Drug of choice? A. Hypertonic saline 23.4 % 0.5 mL/kg IV push B. 3 % saline 6.5 mL/kg over 20 min C. 20 % mannitol 0.25 g/kg D. Furosemide 1 mg/kg Rationale: Moderate 3 % bolus safely raises Na⁺ target 155 to draw water; mannitol less useful when osmol trending high.

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16. Guillain-Barré – Vent Prediction A 13-year-old with rapidly ascending paralysis: VC 12 mL/kg (baseline 55). Which criterion mandates elective intubation? A. Inability to lift head

B. VC < 15 mL/kg C. Weak gag reflex only D. HR variability Rationale: Critical threshold VC < 15 mL/kg portends imminent respiratory failure.

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17. Autoimmune Encephalitis – First-Line Immunotherapy An 8-year-old with anti-NMDA-R antibodies, orolingual dyskinesias, seizures. After tumor ruled out, initial treatment? A. Prednisone 2 mg/kg/day PO B. Cyclophosphamide 750 mg/m² IV C. High-dose IV methylprednisolone 30 mg/kg/day ×5 + IVIG 2 g/kg D. Rituximab 375 mg/m² IV Rationale: Steroids plus IVIG constitute first-line; monoclonals reserved for refractory cases.

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18. Neonatal HSV – Acyclovir Dosing A term neonate with seizures; CSF PCR positive HSV-2. Weight 3.4 kg, Cr 0.5 mg/dL. Correct IV acyclovir regimen? A. 20 mg/kg Q12 h B. 20 mg/kg Q8 h C. 60 mg/kg/day continuous D. 10 mg/kg Q8 h Rationale: CNS disease requires 60 mg/kg/day divided Q8 h (20 mg/kg each), monitored for nephrotoxicity.

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Rationale: Overlap prevents rebound ketosis due to lag in SQ absorption.

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22. Thyroid Storm – Pediatric Dosing A 10-year-old with Graves’ develops storm: HR 180, BP 145/55, fever 40 °C. Best pharmacologic sequence? A. Propylthiouracil → propranolol → iodine B. Propranolol 0.5 mg/kg IV → methimazole 1 mg/kg PO → Lugol 1 h later C. Hydrocortisone → iodine → PTU D. Methimazole only Rationale: Beta-blockade controls adrenergic surge, then thionamide blocks synthesis, iodine blunts release after organification inhibited.

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23. Adrenal Crisis – CAH Newborn with ambiguous genitalia, Na⁺ 118, K⁺ 7.2, glucose 38 mg/dL, hypotensive. Initial steroid? A. Prednisone PO B. Hydrocortisone 100 mg/m² IV bolus C. Dexamethasone 0.6 mg/kg IV D. Fludrocortisone 0.1 mg Rationale: Stress-dose hydrocortisone provides glucocorticoid & some mineralocorticoid; dex lacks salt-retaining effect.

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24. HUS – Dialysis Threshold A 5-year-old post-E. coli O157:H7 colitis: BUN 96, Cr 4.1, K⁺ 5.9, Hb 6.9, platelets 28 K, urine output 0.2 mL/kg/h. Next?

A. Transfuse packed cells only B. Initiate CRRT C. Start eculizumab D. Observe; HUS self-resolves Rationale: Worsening azotemia, hyperkalemia and oliguria require renal replacement; eculizumab reserved for atypical complement- mediated HUS.

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25. AKI Nephrotoxin Avoidance PICU sedation plan for 9-year-old with septic AKI stage 2. Which agent is safest? A. Ketorolac B. Dexmedetomidine infusion C. Gentamicin D. IV contrast CT Rationale: α₂-agonist lacks nephrotoxicity; NSAIDs, aminoglycosides, contrast increase AKI risk.

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26. Onco-Crit Care – Tumor Lysis Prophylaxis A 12-year-old with 250,000 WBC B-ALL starts induction. Baseline Cr 0.6, uric acid 7.8 mg/dL. Guideline-driven prophylaxis? A. Allopurinol PO only B. Rasburicase 0.2 mg/kg once C. Rasburicase 0.15 mg/kg IV then allopurinol D. Dialysis catheter placement pre-emptively Rationale: High-risk cytoreduction needs urate oxidase plus xanthine oxidase inhibition.

Rationale: Severe presentation, multiple epi doses, comorbid asthma raise biphasic risk; extended monitoring recommended.

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30. Vaccine-Preventable Meningitis Gaps A 17-month-old incompletely vaccinated develops purpura fulminans N. meningitidis serogroup B. Which schedule gap enabled illness? A. DTaP B. MenB series (given ≥10 yrs only) C. PCV D. Hib Rationale: Routine infant schedule lacks MenB; outbreaks lead to off- label considerations but not yet universal.

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31. Burns – Resuscitation Formula A 20-kg child with 25 % TBSA partial-thickness burn. Parkland guides first- 24 - h fluid? A. 2 mL/kg/% = 1 L LR B. 4 mL/kg/% = 2 L LR; half in first 8 h C. 6 mL/kg/% = 3 L NS D. Maintain maintenance only Rationale: Pediatric Parkland 4 mL/kg/% yields 2 L plus D5 maintenance for glucose.

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32. Pressure Injuries – Prevention Bundle Which evidence-based measure most reduces ICU stage II+ pressure injuries in ventilated infants?

A. Turn Q4 h B. Use of foam head-positioning devices with moisture-wicking cover C. Low-air-loss mattress only D. Daily chlorhexidine bath Rationale: Cranial devices distribute occipital pressure; neonates highest risk.

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33. Stevens–Johnson – Medication Offenders In an 11-year-old with new SJS/TEN, which antibiotic is most commonly implicated and should be documented allergy? A. Amoxicillin B. Sulfonamide (trimethoprim-sulfamethoxazole) C. Azithromycin D. Clindamycin Rationale: Sulfa antibiotics top the pediatric SJS trigger list.

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34. ECMO Anticoagulation Monitoring On VV ECMO, an infant’s ACT 240 s (target 180–220), anti-Xa 0.4 IU/mL (target 0.3–0.7). Platelets 90 K, O₂ator clot noted. Adjustment? A. Decrease heparin B. Maintain heparin; add direct-thrombin inhibitor bivalirudin? C. Give protamine D. Switch to aspirin only Rationale: Clot despite therapeutic heparin suggests heparin-resistant state; DTI addition improves circuit patency.

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A) >10 mmHg B) >15 mmHg C) >20 mmHg D) >30 mmHg ANS : C) >20 mmHg Rationale: ICP above 20 mmHg in children generally indicates raised intracranial hypertension needing treatment to prevent secondary brain injury.

4. A 3-year-old patient post status epilepticus is on continuous EEG monitoring. The EEG indicates non-convulsive status epilepticus. What is the best next step? A) Discontinue all anticonvulsants B) Increase anticonvulsant therapy C) Initiate surgical evaluation for epilepsy D) Observe without intervention ANS : B) Increase anticonvulsant therapy Rationale: Non-convulsive status epilepticus requires aggressive management with anticonvulsants to prevent ongoing neuronal injury.
5. A neonate with hypoxic-ischemic encephalopathy is started on therapeutic hypothermia. What core temperature target and duration are recommended? A) 32°C for 24 hours B) 33.5°C for 72 hours C) 35°C for 48 hours D) 36.5°C for 24 hours ANS : B) 33.5°C for 72 hours Rationale: Therapeutic hypothermia at 33.5°C for 72 hours improves

neurological outcomes in neonatal encephalopathy by reducing metabolic demand and inflammation.

6. In pediatric patients with hydrocephalus due to aqueductal stenosis, what is the preferred surgical treatment? A) Ventriculoperitoneal shunt placement B) Endoscopic third ventriculostomy (ETV) C) External ventricular drain D) Craniotomy with lesion excision ANS : B) Endoscopic third ventriculostomy (ETV) Rationale: ETV bypasses obstruction in aqueductal stenosis and is preferred to avoid shunt complications when anatomy is favorable.
7. A 12-year-old with a known CNS tumor develops increased ICP and deteriorating consciousness. What is the priority acute management? A) Administer mannitol and hyperventilation B) Immediate radiation therapy C) Start chemotherapy D) Observe and reassess in 12 hours ANS : A) Administer mannitol and hyperventilation Rationale: Osmotic diuretics and controlled hyperventilation rapidly reduce ICP while planning definitive treatment.
8. Which clinical feature is most indicative of early brainstem involvement in pediatric CNS infection? A) Fever and neck stiffness B) Bradycardia and irregular respirations C) Seizures D) Peripheral neuropathy

D) Brainstem ischemia ANS : B) Obstructive hydrocephalus due to hindbrain herniation Rationale: Arnold-Chiari II malformation causes hindbrain herniation obstructing CSF flow, leading to hydrocephalus.

12. During pediatric spinal cord injury assessment, which clinical finding indicates sacral sparing? A) Complete loss of motor function below injury B) Preservation of perianal sensation and voluntary anal contraction C) Loss of diaphragm function D) Flaccid paralysis ANS : B) Preservation of perianal sensation and voluntary anal contraction Rationale: Sacral sparing suggests incomplete spinal cord injury, associated with better prognosis.
13. Which neuroimaging modality is considered the gold standard in evaluating pediatric CNS vascular malformations? A) CT scan with contrast B) MRI with angiography (MRA) C) Ultrasound D) PET scan ANS : B) MRI with angiography (MRA) Rationale: MRA provides detailed vascular anatomy without ionizing radiation, essential for vascular malformation characterization.
14. A pediatric patient exhibits progressive weakness and areflexia after a recent viral illness. CSF reveals albuminocytologic dissociation. What is the most probable diagnosis?

A) Multiple sclerosis B) Guillain-Barré syndrome C) Myasthenia gravis D) Acute transverse myelitis ANS : B) Guillain-Barré syndrome Rationale: Albuminocytologic dissociation and ascending weakness post- infection are typical for Guillain-Barré syndrome.

15. What is the most appropriate monitoring parameter to guide therapy in a child with suspected cerebral perfusion compromise? A) Systolic blood pressure alone B) ICP measurement and cerebral perfusion pressure (CPP) C) Heart rate variability D) Serum lactate levels ANS : B) ICP measurement and cerebral perfusion pressure (CPP) Rationale: CPP, calculated as mean arterial pressure minus ICP, guides management to maintain adequate brain perfusion.
16. Which metabolic abnormality should be aggressively corrected in a child with acute CNS insult to minimize secondary brain injury? A) Hypoglycemia B) Hyperkalemia C) Hyponatremia D) Hypercalcemia ANS : A) Hypoglycemia Rationale: Hypoglycemia worsens neuronal injury and must be rapidly corrected during CNS crises.
17. During acute management of pediatric CNS infections, dexamethasone administration is recommended primarily to: