CCRN-Pediatric CCRN (Pediatric) - Direct Care Eligibility Pathway Exam Questions and Answers

SIRS leads towidespread vasodilation and increased capillary permeability, which causesfluid shifting, hypotension, and potential multi-organ dysfunction. This systemic response is part of the pathophysiology ofsepsis and MODS.

“SIRS involves a cytokine-mediated vasodilatory response with increased capillary permeability, leading to third-spacing, hypoperfusion, and potential organ dysfunction.”

(Referenced from CCRN Pediatric – Direct Care: Multisystem, Inflammatory Cascade in Sepsis)

Chest physiotherapy (CPT)isnot recommended in asthmabecause it can lead tobronchospasm and increased airway resistance. Unlike conditions with excessive mucus production (e.g., cystic fibrosis), asthma management focuses onairway relaxation and inflammation reduction, not mechanical clearance.

“Chest physiotherapy is contraindicated in asthma due to the risk of increasing bronchospasm. Treatment should focus on bronchodilators and anti-inflammatory medications.”

(Referenced from CCRN Pediatric – Direct Care: Pulmonary, Asthma Management in Ventilated Patients)

Peaked T waveson ECG are a hallmark ofhyperkalemia, which is a life-threatening electrolyte imbalance commonly seen inhemolytic uremic syndrome (HUS)due to acute kidney injury. This requiresimmediate interventionto prevent cardiac arrhythmias.

“In patients with HUS, hyperkalemia is a critical electrolyte disturbance. Peaked T waves are a warning sign of impending cardiac complications and demand emergent treatment.”

(Referenced from CCRN Pediatric – Direct Care: Renal, Hemolytic Uremic Syndrome and Electrolyte Emergencies)

In aventricular septal defect (VSD), blood shunts from theleft to the right ventricledue to higher systemic pressure. This leads toincreased pulmonary blood flow(left-to-right shunt), which can cause pulmonary overcirculation and heart failure if untreated.

“VSDs result in a left-to-right shunt that increases pulmonary circulation. This may cause pulmonary congestion, increased work of breathing, and failure to thrive in infants.”

(Referenced from CCRN Pediatric – Direct Care: Cardiovascular Congenital Defects)

The correct approach in end-of-life and ethical situations is to useopen-ended, family-centered communicationthat exploresvalues, hopes, and goals. This response promotesshared decision-making, validates emotional experience, and begins an appropriate dialogue about care direction.

“Ask families open-ended questions to explore goals and values, especially in cases of poor neurologic prognosis. It guides ethical, supportive decision-making.”

(Referenced from CCRN Pediatric – Professional Caring and Ethical Practice: End-of-Life Care, Family Communication)

The ABG shows aprimary metabolic alkalosis(elevated HCO₃⁻ and high pH). In alkalosis,hydrogen ions shift out of cells, andpotassium shifts into cells, leading tohypokalemia. This intracellular shift reducesserum potassiumlevels.

“Metabolic alkalosis results in intracellular potassium shifting, causing serum hypokalemia, which may lead to arrhythmias or muscle weakness.”

(Referenced from CCRN Pediatric – Direct Care: Endocrine, Acid-Base Balance and Electrolyte Implications)

AGCS score of 6indicatessevere neurologic impairmentand correlates strongly with poor outcomes in pediatric head trauma. It reflectsdeep unconsciousness and minimal responsiveness.

“A GCS < 8 indicates severe head injury and is associated with higher morbidity and mortality in pediatric trauma. Prognosis worsens as the score decreases.”

(Referenced from CCRN Pediatric – Direct Care: Neurologic Trauma and Intracranial Monitoring)

Prolonged aortic cross-clampingcan impairrenal perfusion, especially during cardiac surgery.Decreased urine outputpostoperatively may be a sign ofacute kidney injury (AKI)secondary to hypoperfusion during the clamping phase.

“Renal hypoperfusion during prolonged aortic cross-clamping may manifest postoperatively as oliguria or anuria, indicating renal compromise.”

(Referenced from CCRN Pediatric – Direct Care: Cardiovascular, Postoperative Transplant Complications)

Central venous catheter placementcan lead toiatrogenic pneumothorax, particularly on the side of the subclavian or internal jugular access. Signs of sudden desaturation, hypotension, and tachycardia suggesttension pneumothorax, which requiresemergent chest tube insertion.

“Following central line placement, sudden cardiorespiratory compromise should prompt evaluation for pneumothorax. Treatment is immediate decompression and chest tube placement.”

(Referenced from CCRN Pediatric – Direct Care: Pulmonary, Air Leak Syndromes and Ventilator Complications)

Establishingadmission and discharge criteriaensures that care decisions areconsistent, justifiable, and ethically grounded. These criteria guide clinicians inresource allocation, promotingfair accessand minimizing bias in treatment decisions.

“Admission/discharge policies support ethical care delivery by ensuring objective, equitable decision-making, especially in high-acuity environments like ICUs.”

(Referenced from CCRN Pediatric – Professional Caring and Ethical Practice: Ethical Resource Management and Clinical Guidelines)

Aplanned transition, includingunit orientation, helps reduce family anxiety, provides clear expectations, and improves continuity of care. After long ICU stays, families benefit from structured support as they adjust to alower-acuity environmentand new staff.

“ICU discharge can be distressing for families. Orienting them to the receiving unit fosters trust, continuity, and a smoother emotional and clinical transition.”

(Referenced from CCRN Pediatric – Professional Caring and Ethical Practice: Family Support and Transitional Care)

Dobutamine is abeta-1 agonistthat increases myocardial contractility. Its primary action isincreasing stroke volume and cardiac output, withminimal effect on systemic vascular resistance, making it ideal for patients with low-output states.

“Dobutamine enhances myocardial contractility and increases cardiac output without significantly increasing systemic vascular resistance, making it effective in heart failure with preserved perfusion.”

(Referenced from CCRN Pediatric – Direct Care: Cardiovascular Pharmacology and Hemodynamic Support)

Bronchiolitis causeslower airway obstruction, air trapping, andhypoventilation. On chest radiographs,hypoinflation(low lung volumes) and peribronchial thickening are common. The ABG showsrespiratory acidosis and hypoxemia, consistent withbronchiolar obstructionand hypoinflation.

“In bronchiolitis, hypoinflation and peribronchial thickening are typical CXR findings. ABG shows respiratory acidosis with hypoxemia in severe cases requiring ventilation.”

(Referenced from CCRN Pediatric – Direct Care: Pulmonary, Bronchiolitis and Ventilatory Support)

In esophageal atresia with tracheoesophageal fistula,secretions can accumulate in the blind-ending proximal pouch, riskingaspiration. Areplogle tube with low continuous suction (sump)is placed tokeep the pouch draineduntil surgical repair.

“Management of esophageal atresia includes placement of a sump in the upper pouch to prevent aspiration and respiratory compromise. This is standard preoperative care.”

(Referenced from CCRN Pediatric – Direct Care: Gastrointestinal, Congenital Abnormalities)

Thefrontal lobeis responsible forexecutive function, behavior, and personality. Tumors in this area often causebehavioral changes, mood instability, andseizures—particularlygeneralized seizureslike tonic-clonic.

“Frontal lobe tumors are commonly associated with personality and behavioral changes and are a common site for seizure onset in pediatric brain tumors.”

(Referenced from CCRN Pediatric – Direct Care: Neurological, Brain Tumors and Seizure Presentation)

Myeloablationprior to bone marrow transplantdestroys bone marrow cells, leading toprofound neutropenia and thrombocytopenia. As a result, patients are atextremely high risk for infection and bleeding, requiring close monitoring, isolation, and transfusion support.

“Pre-transplant conditioning regimens cause neutropenia and thrombocytopenia, making infection and bleeding the primary complications during marrow ablation.”

(Referenced from CCRN Pediatric – Direct Care: Hematology, Bone Marrow Transplantation and Myelosuppression)

Children withSMA Type Ihave profound muscle weakness, including respiratory muscles. RSV increases respiratory workload, and once non-invasive measures and suctioning fail,intubation and mechanical ventilationare indicated to reduce fatigue and support gas exchange.

“Patients with neuromuscular disorders such as SMA are at increased risk for respiratory failure during acute infections. Mechanical ventilation is required when oxygenation does not improve with non-invasive methods or when respiratory fatigue is evident.”

(Referenced from CCRN Pediatric – Direct Care: Pulmonary Disorders and Neuromuscular Disease)

O₂ saturations in the low 90s despite 50% FiO₂ signal worsening gas exchange. Non-invasive support may be inadequate in the setting of hypotonia and viral pneumonia.

Immediate access to the deceased patient supportsgrief processingandfamily-centered care. Presence at the bedside allows the family to begin saying goodbye and mayreduce psychological traumaassociated with sudden loss.

“Grief support includes prompt access to the deceased loved one. Delaying this can intensify distress and negatively affect family outcomes.”

(Referenced from CCRN Pediatric – Direct Care: Psychosocial, End-of-Life and Bereavement Support)

Earlynutritional support,mobilization, and maintainingskin integritywith gentle cleansing are proven strategies to preventsurgical site infections (SSIs). Nutrients supportwound healing, while early mobility reduces the risk of complications likepneumonia and impaired circulation.

“Postoperative infection prevention includes early enteral feeding, routine hygiene with non-irritating agents, and ambulation. These reduce bacterial overgrowth, maintain perfusion, and support immune function.”

(Referenced from CCRN Pediatric – Direct Care: Integumentary, Postoperative Infection Prevention)

Blunt abdominal trauma, such as from a bicycle fall, can result inhollow viscus injury(e.g., bowel perforation). Classic signs includenausea, vomiting, fever, and decreased bowel sounds, often developing12–24 hours post-injurydue to peritonitis.

“After blunt abdominal trauma, particularly with handlebars or falls, visceral perforation must be suspected when symptoms like fever, ileus, and abdominal pain develop. Surgical evaluation is urgent.”

(Referenced from CCRN Pediatric – Direct Care: Gastrointestinal, Trauma and Acute Abdomen)

Even with a good initial response,delayed respiratory complications, such asacute respiratory distress syndrome (ARDS)orpulmonary edema, can develop within 24–48 hours after submersion. All pediatric near-drowning cases should bemonitored in an ICU settingfor at least 24 hours.

“Post-submersion patients are at high risk for delayed onset ARDS. Observation in a monitored setting is essential regardless of initial neurologic status.”

(Referenced from CCRN Pediatric – Direct Care: Pulmonary, Submersion Injuries and Post-Resuscitation Care)

Education must beindividualizedbased on theparent’s learning style and comprehension.Combiningdemonstration, return demonstration, written materials, and verbal teaching—as preferred by the family—ensures the greatestretention and competence.Ongoing evaluationof skills is essential before discharge.

“Use of preferred teaching methods, with return demonstration and skill validation, ensures family readiness for complex care like tracheostomy management.”

(Referenced from CCRN Pediatric – Professional Caring and Ethical Practice: Family-Centered Teaching and Discharge Readiness)

A sudden drop in oxygen saturation withdiminished breath sounds bilaterallysuggests a possibleET tube issue, pneumothorax, or mucus plug. Achest x-rayis the most appropriate immediate step toidentify the cause, and anABGcan assess ventilation status.

“Sudden desaturation in an intubated patient warrants immediate imaging and gas exchange assessment to identify pneumothorax, malpositioned tube, or obstruction.”

(Referenced from CCRN Pediatric – Direct Care: Pulmonary, Emergency Airway Complications)

Atelectasisis common postoperatively, especially after spinal surgery due toimmobility, poor inspiratory effort, andsedation. Thedecreased breath sounds, fever, and low FVC (<15 mL/kg)strongly support this diagnosis.

“Postoperative patients, particularly those with thoracoabdominal or spinal surgery, are at high risk for atelectasis. Low FVC, diminished breath sounds, and hypoxemia are hallmark signs.”

(Referenced from CCRN Pediatric – Direct Care: Pulmonary, Postoperative Respiratory Complications)

Neonatal Respiratory Distress Syndrome (RDS) is primarily caused by surfactant deficiency, which results in alveolar collapse and increased permeability of the alveolar-capillary membrane. This leads to pulmonary edema, impaired gas exchange, and hypoxemia.

“The hallmark of RDS is increased permeability of the alveolar-capillary membrane, which allows fluid to leak into alveoli, contributing to atelectasis and reduced oxygenation. Surfactant deficiency is the initiating factor.”

(Referenced from CCRN Pediatric – Direct Care: Pulmonary, Neonatal RDS Pathophysiology)

Increased surfactant production would be protective, not pathological. Pulmonary vascular hypertension can occur secondarily but is not the initiating pathophysiology.

When communication and relationships become strained, themost appropriate first action is to initiate a care conference. This collaborative approach provides a forum for the family and healthcare team to align goals, express concerns, andrebuild trustthrough structured, clear communication.

“Care conferences serve as a critical strategy to address and resolve family-staff conflict, particularly in long-term ICU stays where emotional fatigue and communication breakdowns are common.”

(Referenced from CCRN Pediatric – Professional Caring and Ethical Practice: Family-Centered Communication and Collaboration)

Since it has only been 15 minutes since PO medication was administered (which may take 30–60 minutes for full effect), it is appropriate tosupport the patient with non-pharmacologic strategies(e.g., repositioning, distraction, relaxation techniques) while allowing the medication time to work.

“Non-pharmacologic interventions should be implemented early and concurrently with medications. For mild or dull pain shortly after analgesic administration, repositioning or distraction can improve comfort.”

(Referenced from CCRN Pediatric – Direct Care: Psychosocial, Comfort and Pain Management Strategies)

Hypertrophic cardiomyopathy (HCM)causesleft ventricular outflow tract obstruction, impairing cardiac output. The low blood pressure, tachycardia, and hypoxemia are classic signs ofventricular dysfunction—specificallydiastolic dysfunctiondue to a thickened, stiff left ventricle.

“HCM may lead to ventricular dysfunction due to impaired relaxation and outflow obstruction, especially during increased demand. Symptoms include hypotension, tachycardia, and hypoxia.”

(Referenced from CCRN Pediatric – Direct Care: Cardiovascular, Cardiomyopathies and Shock States)

The patient is stable withsupraventricular tachycardia (SVT). Initial treatment in stable pediatric SVT involvesvagal maneuversto increase vagal tone and potentially terminate the arrhythmia. Having the childblow through a straw or simulate blowing a hornis a safe and effective method in a cooperative child.

“In stable pediatric patients with SVT, vagal maneuvers are the first-line intervention. Activities such as forced exhalation (blowing through a straw) may revert the rhythm.”

(Referenced from CCRN Pediatric – Direct Care: Cardiovascular, Pediatric Tachyarrhythmias Management)

Effective communication is a pillar of ethical and professional nursing practice. In complex care situations,coordination and unified messagingare vital to support family understanding and reduce distress.

“When families express confusion or frustration due to inconsistent communication, it is the nurse’s responsibility to advocate for a coordinated approach by facilitating interdisciplinary collaboration and clarity of plan.”

(Referenced from CCRN Pediatric – Professional Caring and Ethical Practice: Communication and Advocacy)

Arranging a team meeting promotes collaboration, consistency, and ensures that the family receives accurate, unified information.

Hemolytic uremic syndrome (HUS)is commonly preceded by a diarrheal illness, often caused byE. coli O157:H7. Classic triad:microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury—often with petechiae, hypertension, and decreased urine output.

“HUS presents in children as a post-infectious complication, typically following bloody diarrhea. It manifests with renal failure, anemia, thrombocytopenia, and neurologic or hypertensive symptoms.”

(Referenced from CCRN Pediatric – Direct Care: Renal Dysfunction and Hematologic Disorders)

Febrile seizuresare the mostcommon cause of seizures in infants and young children, typically between 6 months and 5 years. They often occur with arapid rise in body temperature, even inthe absence of intracranial infection or metabolic disturbances.

“In infants, febrile seizures are the most likely cause of new-onset seizures. Tonic-clonic activity confined to extremities is typical. Evaluation focuses on identifying the febrile source.”

(Referenced from CCRN Pediatric – Direct Care: Neurological, Pediatric Seizure Disorders)

Lead poisoning and structural brain anomalies are less common and usually not the first consideration in an acute setting with fever.

Naloxone has ashorter half-lifethan many opioids. After the initial reversal, the opioid's effects canresurge, leading torespiratory depressionand sedation. This is calledre-sedationoropioid re-narcotization. Re-dosing or initiating analoxone infusionmay be required.

“Recurrent sedation or respiratory depression after naloxone administration suggests opioid duration outlasting naloxone’s half-life. Repeat dosing or continuous infusion may be necessary.”

(Referenced from CCRN Pediatric – Direct Care: Multisystem, Opioid Toxicity and Naloxone Pharmacology)

Fresh frozen plasma (FFP)containsall coagulation factorsand is used in the treatment ofDIC, where widespread clotting consumes clotting factors and leads to bleeding. FFP replenishesmultiple depleted clotting factors, thereby stabilizing coagulation.

“FFP provides all clotting factors and is indicated in DIC to replace consumed factors and improve hemostasis. It is essential in active bleeding with prolonged PT, PTT, or low fibrinogen.”

(Referenced from CCRN Pediatric – Direct Care: Hematology, Coagulopathies and Transfusion Management)

Early in career development,identifying a mentor or role modelprovides foundational support for leadership growth. This allows the nurse to observe effective leadership behaviors, gain guidance, anddevelop long-term goals through structured exposure.

“Mentorship is essential in leadership development. New nurses with administrative goals should be encouraged to identify and learn from respected leaders to develop the skills and behaviors required for advanced roles.”

(Referenced from CCRN Pediatric – Professional Caring and Ethical Practice: Leadership Development and Mentorship)

In neonates and infants, hypoglycemia is oftensymptomatically silentor presents withnonspecific signs, includinghypothermia, lethargy, and apnea. These can quickly progress to seizures or coma if not corrected.

“Hypoglycemia in infants may manifest as apnea, poor feeding, jitteriness, or hypothermia. Immediate intervention is required to prevent neurological injury.”

(Referenced from CCRN Pediatric – Direct Care: Endocrine Function and Metabolic Monitoring)

Arising blood pressure with bradycardia(Cushing’s triad) suggestsincreased intracranial pressureand impendingherniation. This is themost critical and time-sensitivesign of neurologic deterioration.

“Signs of increased ICP and impending herniation include bradycardia, hypertension, and irregular respiration. These warrant immediate intervention to prevent irreversible brain injury.”

(Referenced from CCRN Pediatric – Direct Care: Neurological Trauma and Intracranial Hypertension)

Expressions ofhopelessness, fatigue, and unbearable painare red flags forsuicidal ideation, particularly in pediatric patients. Immediate action is needed toassess suicide riskto ensure patient safety.

“In pediatric patients, behavioral cues such as excessive sleep, hopelessness, and verbal expressions of despair should trigger immediate suicide screening and risk assessment protocols.”

(Referenced from CCRN Pediatric – Direct Care: Psychosocial and Emotional Assessment in Critically Ill Children)

This is apriority safety concernand must be addressed before any further medical assessments or reviews.

This infant displays signs ofearly septic shock, includingtachycardia,fever,normal cap refill, andlow CVP. In thehyperdynamic early phase of septic shock, patients may initially havewarm, flushed skinandbounding pulses, with preserved perfusion before progressing to a decompensated state.

“Septic shock may present with increased HR, fever, and warm extremities in its compensated phase. CVP may be low due to vasodilation and capillary leakage.”

(Referenced from CCRN Pediatric – Direct Care: Cardiovascular, Types of Shock and Sepsis Pathophysiology)

Pediatric ICU delirium is a common but underdiagnosed condition in critically ill children, especially those on prolonged ventilation. Hallmarks includedisorientation, sleep disturbance, agitation, and altered attention.

“Delirium should be suspected in pediatric ICU patients showing new or worsening behavioral symptoms, altered sleep-wake cycles, and fluctuating mental status. Prolonged sedation and critical illness are risk factors.”

(Referenced from CCRN Pediatric – Direct Care: Neurologic Dysfunction and ICU Delirium)

ThePlan-Do-Study-Act (PDSA)cycle is the most widely acceptedquality improvement methodologyin healthcare. It's iterative and promotes continuous improvement:

Plan: Identify a goal and create an intervention

Do: Implement the intervention on a small scale

Study: Analyze the data and assess the outcome

Act: Adopt, adjust, or abandon the intervention based on the findings

“PDSA methodology supports quality improvement in healthcare, especially in infection prevention initiatives such as reducing CLABSIs.”

(Referenced from CCRN Pediatric – Professional Caring & Ethical Practice: Evidence-Based Practice and Quality Improvement)

The described symptoms indicateanticholinergic toxicity, which is classically associated with tricyclic antidepressant (TCA) overdose.Amitriptyline, a TCA, causesanticholinergic symptoms: tachycardia, dilated pupils, dry mucosa, urinary retention, altered mental status, and PVCs on ECG.

“TCA toxicity presents with anticholinergic signs—dry mouth, mydriasis, tachycardia, neurologic changes, and cardiac conduction abnormalities. Amitriptyline overdose is life-threatening and requires immediate supportive care and cardiac monitoring.”

(Referenced from CCRN Pediatric – Direct Care: Neurological Emergencies and Toxicology)