CCRN Pediatric - Critical Care Nursing Pediatric Exam Review
The CCRN Pediatric Exam is a certification exam created by the American Association of Critical-Care Nurses Certification Corporation that is very similar to the CCRN Adult exam except that the CCRN Pediatric Exam is used to determine whether or not an individual has the knowledge necessary to be an effective critical care nurse for child patients rather than adult patients. The CCRN Pediatric Exam does not register an individual as a registered nurse and is usually not required for an individual to work in a pediatric critical care unit. However, it is an indication that an individual has an advanced knowledge of critical care procedures related to the care of children and allows the individual to use the CCRN letters after his or her licensing credentials. The CCRN Pediatric Exam consists of 150 multiple-choice questions, 125 of which are scored and 25 that are not scored, that covers information related to the following areas:
- Cardiovascular (19%)
- Endocrine (5%)
- Gastrointestinal (5%)
- Hematology and Immunology (6%)
- Multisystem (9%)
- Neurology (10%)
- Pulmonary (22%)
- Renal (4%)
- Advocacy and Moral Agency (2%)
- Caring Practices (4%)
- Collaboration (4%)
- Clinical Inquiry (2%)
- Facilitation of Learning (4%)
- Handling Diversity (2%)
- Systems Thinking (2%)
Individuals taking any CCRN exam will have three hours to complete the exam. The CCRN Pediatric Exam is scored in the same manner as the CCRN Adult exam and the individual will receive a final grade of pass or fail depending upon whether or not the individual answers enough questions correctly to reach the passing threshold. The number of correct responses required to pass the exam is usually approximately 70% or 88 questions, but varies depending upon exactly which exam questions an individual receives. For an individual to be eligible to take the CCRN Pediatric Exam, the individual must be a registered nurse without any restrictions on his or her license of any kind. The candidate must also have worked in a critical care environment handling childcare for at least 1,750 hours of which 875 hours must have been completed in the year prior to the candidate's application. Potential candidates can register for the CCRN Pediatric Exam on the AACN Certification Corporation website and can choose to take the CCRN test either in a computerized form administered by AMP or a written form administered by the NTI. The registration fee for the CCRN Pediatric Exam is $220 for AACN members and $325 for nonmembers.
Free CCRN Practice Test Questions
1. A 15-month-old immunized child is admitted with viral croup. She is treated with a single dose of nebulized racemic epinephrine and dexamethasone in the emergency department. Initial assessment upon transfer to the critical care unit 2 hours later reveals an alert toddler with moderate inspiratory stridor at rest and moderate suprasternal and intercostal retractions. Respiratory rate is 32 breaths/min; heart rate is 140 beats/min; and pulse oximetry reveals an oxygen saturation of 98% on room air. Appropriate management of this patient consists of:
A. nebulized albuterol.
B. cool mist and observation.
D. additional nebulized racemic epinephrine.
2. A 3-year-old boy is evaluated after an accidental submersion injury. A family member reports leaving the bathroom while he was in the bathtub and returning "just a little while later" to find him submerged. When they pulled him out, he was blue and unresponsive. A family member performed cardiopulmonary resuscitation for 1-2 minutes, at which point the child began breathing spontaneously. Upon arrival to the hospital 45 minutes after the initial event, the child is appropriate but appears tired with a heart rate of 140 beats/min, respiratory rate of 36 breaths/min, oxygen saturation of 95% on room air, and blood pressure of 90/50 mm Hg. Appropriate management of this patient consists of:
A. supplemental oxygen administration, chest x-ray, intravenous line placement, and
close inpatient monitoring.
B. observation in the emergency department for 1-2 hours with discharge home unless the patient's status worsens.
C. endotracheal intubation with invasive intracranial pressure monitoring in the critical care unit.
D. early administration of intravenous antibiotics.
3. A 7-month-old boy with unrepaired tetralogy of Fallot is in the intensive care unit with an accidental partial-thickness scald burn. Due to an error, he does not receive two scheduled doses of pain medication and is crying uncontrollably because of the pain. The critical care nurse notes that he suddenly develops worsening agitation, cyanosis, and tachypnea. His usual prominent murmur is no longer audible on auscultation. In this situation, the nurse expects that the initial treatment is most likely to be:
A. nebulized albuterol administration.
B. placement of the infant in the knee-chest position to increase systemic vascular resistance.
C. emergent needle decompression of a probable tension pneumothorax.
D. transthoracic cardiac pacing.
4. A 16-year-old patient in the critical care unit has an external ventriculostomy placed for acute hydrocephalus secondary to a brain tumor. Over the course of a 4-hour period, he becomes progressively more lethargic and complains of severe headache despite pain medication; the nurse notes that his pupils are symmetric in size but sluggishly reactive. The nurse finds the bedside ventriculostomy drainage bag unexpectedly full. On the basis of this information, the critical care nurse suspects that the most likely explanation for the patient's deterioration is:
A. ventriculostomy catheter-related meningitis.
B. clogging of the ventriculostomy catheter leading to inadequate cerebrospinal fluid drainage.
C. excessive drainage of cerebrospinal fluid by the ventriculostomy drain.
D. progression in size of the patient's brain tumor.
5. A 5-year-old previously healthy boy is admitted to the intensive care unit with a 12-hour history of fever, severe headache, and vomiting. Physical examination reveals a febrile, lethargic child with tachycardia, neck stiffness, and poor peripheral perfusion. Soon after arrival in the intensive care unit, he develops a purple nonblanching rash on his lower extremities. The most likely etiology for his illness is:
A. Henoch-Schonlein purpura.
B. Streptococcus pneumoniae.
C. acute lymphocytic leukemia.
D. Neisseria meningitidis.
Answers and Explanations
Croup is characterized by larygneal inflammation and edema in association with a viral upper respiratory infection. Clinically, patients usually present with symptoms of upper respiratory infection, a hoarse voice, and a "barky" or "brassy" cough. Depending on the degree of upper airway inflammation, inspiratory stridor and retractions may also be present. Symptoms are classically worse at night and with patient agitation. Patients with mild symptoms without respiratory distress are treated with corticosteroids (e.g., dexamethasone) administered orally or intramuscularly. More serious cases (e.g., respiratory distress, stridor at rest) are treated with nebulized racemic epinephrine, corticosteroids, and potentially inhaled heliox. Intubation and mechanical ventilation for respiratory failure are rarely required with viral croup.
The patient described in the question is in moderate respiratory distress and, thus, should continue with the corticosteroids and the nebulized racemic epinephrine. Respiratory failure does not appear imminent given that the patient is maintaining oxygenation, adequate respiratory effort, and normal mental status. Intubation is, therefore, not indicated at this point, although the patient's respiratory status requires close monitoring for any deterioration. Beta-agonist bronchodilators, such as albuterol, do not generally improve the upper airway edema associated with croup.
The child described in the question is being evaluated shortly after a significant submersion injury, which required cardiopulmonary resuscitation at the scene of the event. Patients who did not require significant resuscitation after a submersion injury and are asymptomatic 6 hours after the event are appropriate for discharge. Any patient who is symptomatic (e.g., hypoxia, tachypnea, respiratory distress, altered mental status) should be treated and monitored in the inpatient setting.
This patient is maintaining his airway but demonstrates tachypnea and mild hypoxia. Mental status is adequate but requires close monitoring. Appropriate management of this patient consists of intravenous placement for support of hydration, supplemental oxygen administration, and monitoring for signs of respiratory deterioration. Prophylactic antibiotics are not generally indicated in the initial management of a submersion injury. Patients may require intravascular volume replacement, mechanical ventilation, and intracranial hypertension management. The longterm prognosis with a submersion injury is primarily determined by the degree of cerebral hypoxic injury. Patients who continue to need cardiopulmonary resuscitation on arrival to the hospital have markedly decreased rates of neurologic recovery and survival.
Tetralogy of Fallot is characterized by ventricular septal defect, pulmonic stenosis, overriding aorta, and right ventricular hypertrophy. This patient's rapid change in status is consistent with a "Tet spell" or a hypercyanotic episode. Tet spells may occur spontaneously or in association with agitation, hypotension, or crying. The inciting event of a Tet spell is worsening of the right ventricular outflow tract obstruction, which causes increased right-to-left shunting through the ventricular septal defect. This leads to decreased pulmonary blood flow and hypoxia, which increases pulmonary vascular resistance, creating a cycle of worsening hypoxia and impaired pulmonary blood flow. During an acute Tet spell, the patient's usual pulmonic stenosis murmur is absent or markedly decreased.
Treatment is aimed at decreasing systemic venous return and increasing systemic vascular resistance (to reverse the right-to-left shunting). This is accomplished by placing the child in the knee-chest position and attempting to calm the child. If this fails to abort the hypercyanotic episode, oxygen, intravenous fluids, morphine, phenylephrine, or sedation may be required. If persistent, a Tet spell may progress to syncope, seizure, cerebrovascular accident, or death.
Ventriculostomy devices allow for continuous intracranial pressure (ICP) monitoring and cerebrospinal fluid (CSF) drainage to an external collection device. They are less commonly used for the administration of medications or dye. The ventriculostomy catheter is placed in one of the patient's lateral ventricles and then connected externally to a collection bag. The position of the collection bag relative to the patient's head determines the rate of CSF drainage. Monitoring the patient's scalp incision, the amount and color of CSF drainage, and careful attention to the proper positioning of the collection device are paramount to preventing ventriculostomy-related complications. Over drainage or under drainage of CSF can lead to tentorial herniation. The description of a drainage bag that is unexpectedly full in this case suggests excessive CSF drainage. Infection is not uncommon in patients with ventriculostomy catheters. Although catheter-related meningitis may present similarly to impending herniation, CSF volume would not normally be increased.
The development of a petechial or purpuric rash in the setting of a febrile illness is concerning for meningococcal disease. Acute infection caused by Neisseria meningitidis (a gramnegative encapsulated diplococcus) generally progresses rapidly and is characterized by either meningitis, septicemia, or a combination of both. Treatment consists of fluid resuscitation, prompt antibiotic administration, blood pressure support as indicated, and close hemodynamic, respiratory, and neurologic monitoring.
Henoch-Schonlein purpura (HSP) is a systemic vasculitis characterized by arthritis, extremity edema, abdominal pain, and a purpuric rash, which is classically present from the waist down. Meningitis and rapid clinical deterioration are not associated with HSP. Although Streptococcus pneumoniae can cause critical illness with a petechial or purpuric rash, the clinical scenario in this case is more often associated with N. meningitidis. Patients with acute lymphocytic leukemia are at increased risk for invasive, severe, infectious illness and can have petechial rashes secondary to thrombocytopenia. Given the clinical scenario in this case, meningococcal disease is the most likely explanation.
Last Updated: 04/18/2018