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

Prerenal failureis caused by conditions that impairrenal perfusionwithout direct injury to the kidneys themselves.Septic shockleads to systemic vasodilation, hypotension, and decreased renal perfusion, making it a classic prerenal etiology.

“Prerenal causes of acute kidney injury (AKI) include any condition resulting in reduced renal blood flow. Septic shock is a common prerenal cause, where hypoperfusion leads to decreased glomerular filtration.”

(Referenced from CCRN Pediatric – Direct Care: Renal Dysfunction and Fluid Balance)

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)

In the post-resuscitation period of a near-drowning event, neurologic status is the primary determinant of prognosis. Flaccid paralysis is a sign ofsevere hypoxic-ischemic brain injury, reflectingglobal neuronal dysfunctionandpoor cerebral perfusion recovery.

FromCCRN (Pediatric) – Direct Care (Neurology Section):

“Signs of poor neurological outcome post-resuscitation include lack of purposeful movement, flaccidity, absence of motor responses to pain, and abnormal or absent brainstem reflexes. Flaccid paralysis, particularly when persistent after resuscitative efforts, strongly correlates with a poor neurologic prognosis in pediatric patients.”

In contrast:

Pupil constrictionmay be benign or related to medication or light stimulus.

Absent Babinski's reflexis not considered abnormal at 2 years.

Absent Cushing’s reflexis non-specific and may not manifest in all children with brain injury.

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)

Toxic shock syndrome (TSS)is asystemic inflammatory responsecaused by bacterial exotoxins, often leading toshock and multiorgan failure.Procalcitoninhelps confirm bacterial sepsis, andlactateis a marker fortissue hypoperfusion—both critical in TSS workup.

“In systemic infections and toxic shock, procalcitonin supports diagnosis of bacterial origin, while lactate levels reflect perfusion and guide resuscitation.”

(Referenced from CCRN Pediatric – Direct Care: Multisystem, Sepsis and Toxic Shock Syndrome)

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)

Small pneumothoraces (<10%) are oftenmanaged conservativelyin hemodynamically stable pediatric patients. The body's natural reabsorption of intrapleural air typically resolves the conditionwithout invasive intervention, provided that the patient is monitored closely.

“Observation is appropriate for small pneumothoraces (less than 10%) in stable pediatric patients. Serial chest radiographs and clinical assessments are used to monitor for progression. Chest tube insertion is generally reserved for larger or symptomatic pneumothoraces.”

(Referenced from CCRN Pediatric – Direct Care: Pulmonary Trauma and Chest Injury)

Ashunt infectionis a common complication, especially within thefirst few months after placement. Symptoms includefever, irritability, bulging fontanel, and vomiting. Negative blood and urine cultures suggest acentral nervous system source, supporting the likelihood of a shunt infection.

“Shunt infections typically present with fever, bulging fontanel, and neurologic irritability. They can occur without systemic bacteremia and require prompt neurosurgical consultation.”

(Referenced from CCRN Pediatric – Direct Care: Neurological, VP Shunt Complications)

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)

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)

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)

In unilateral lung injury (like pulmonary contusion), placing theinjured lung in the dependent positionworsensventilation/perfusion (V/Q) mismatch, as perfusion is gravity-dependent while ventilation is reduced due to contusion. This results inhypoxemia.

“In lung injuries, dependent positioning of the injured lung increases perfusion to poorly ventilated areas, leading to V/Q mismatch and hypoxemia.”

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

Peritoneal dialysis (PD)is used in pediatric patients withrenal failure, especially when associated withfluid overload (hypervolemia), uremia, or electrolyte imbalances not responsive to medical therapy. It is particularly effective forgradual fluid removalin children.

“Indications for peritoneal dialysis in children include fluid overload, hyperkalemia, and acidosis not corrected by conservative measures.”

(Referenced from CCRN Pediatric – Direct Care: Renal, Indications for Dialysis)

It is a best practice—and often required by hospital policy—fortrained personnel such as an organ donation liaison or organ procurement organization (OPO)representative to approach families about organ donation. This ensures that the conversation is handled sensitively, accurately, and in accordance with regulatory requirements.

“The nurse should notify the designated organ donation liaison or team when a patient meets criteria for brain death. These individuals are trained to communicate effectively and ethically with families.”

(Referenced from CCRN Pediatric – Professional Caring and Ethical Practice: Ethics, End-of-Life Care, and Organ Donation)

Arapid drop in blood glucose, especially duringDKA treatment, can result incerebral edema—a life-threatening complication. Symptoms includebradycardia, irregular respirations, altered mental status, andwidened pulse pressuredue to increased intracranial pressure.

“A drop in serum glucose >100 mg/dL/hr in DKA increases risk for cerebral edema. Monitor for bradycardia, abnormal breathing, and neurologic decline.”

(Referenced from CCRN Pediatric – Direct Care: Endocrine, DKA and Cerebral Edema Monitoring)

These findings are consistent withpyelonephritisor another upper urinary tract infection. Arenal ultrasoundis a non-invasive test used to evaluate forstructural abnormalities, abscess, or obstruction, especially in a febrile child with a urinary tract infection.

“Renal ultrasound is indicated after diagnosis of febrile UTI to evaluate renal anatomy and rule out complications like abscess.”

(Referenced from CCRN Pediatric – Direct Care: Renal, Urinary Tract Infections and Imaging)

In end-of-life situations, especially involving pediatric patients, psychosocial support must extend to the entire family. When a parent expresses uncertainty or ambivalence, the nurse's role is to facilitate open communication and exploreparental concerns without imposing judgment or directives.

“Effective psychosocial care requires assessment of family readiness and emotional state. Nurses should encourage family expression of feelings and help clarify concerns before offering direction or education.”

(Referenced from CCRN Pediatric – Direct Care: Psychosocial Support and Palliative Care)

By asking about the parent's concerns, the nurse promotes a therapeutic relationship and gains insight into the family's emotional and cultural dynamics, allowing further support or child life referrals as needed.

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)

Septic shockin pediatric patients requiresearly goal-directed therapy, including:

Fluid resuscitationto restore perfusion,

Antibioticswithin the first hour to treat the underlying infection, and

Inotropesif shock persists after fluids.

“Early interventions for pediatric septic shock include aggressive fluid resuscitation, timely administration of broad-spectrum antibiotics, and initiation of vasopressors or inotropes if hypotension remains.”

(Referenced from CCRN Pediatric – Direct Care: Multisystem, Sepsis Management)

Wolff-Parkinson-White (WPW) syndromeis characterized by anaccessory conduction pathway, resulting inshort PR interval, narrow QRS complexes, and delta waves. Tachycardia in neonates with WPW is oftenparoxysmal supraventricular tachycardia (PSVT).

“WPW is a pre-excitation syndrome seen in neonates and children, diagnosed by ECG findings of delta waves, and is associated with recurrent tachyarrhythmias.”

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

High PEEP levels can causebarotrauma, leading totension pneumothorax—a life-threatening complication. Symptoms include sudden hypoxia, bradycardia, hypotension, and reduced perfusion.Thoracentesis (needle decompression)is the emergency intervention.

“Sudden hemodynamic instability in a ventilated child on high PEEP may indicate pneumothorax. Immediate decompression is warranted to restore cardiopulmonary function.”

(Referenced from CCRN Pediatric – Direct Care: Pulmonary, Mechanical Ventilation and Complications)

Thefirst stepis alwaysclarification and respectful communication. Before escalating, the nurse shouldexplore the family’s concernsand beliefs directly. This promotespatient- and family-centered care, which is the cornerstone of ethical pediatric practice.

“Engaging in open dialogue with families about their values and concerns is the first step in navigating ethical dilemmas involving consent.”

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

Inborn errors of metabolism (IEM)often present within thefirst few days of lifewithnonspecific symptomslike poor feeding, vomiting, lethargy,metabolic acidosis, and seizures. These disorders impair the body's ability to metabolize proteins, fats, or carbohydrates, leading totoxic metabolite accumulation.

“Infants with inborn errors of metabolism commonly present in the first week of life with lethargy, vomiting, seizures, and metabolic acidosis. Prompt recognition is critical.”

(Referenced from CCRN Pediatric – Direct Care: Multisystem, Metabolic Disorders and Acute Presentations)

Neutropenic fever or hypothermiais a medical emergency in oncology patients.Blood cultures should always be obtained before starting antibioticsto guide therapy.Hypothermiacan be a sign of sepsis in immunocompromised children.

“First steps in febrile neutropenia evaluation include obtaining blood cultures before initiating antibiotics to allow pathogen identification and targeted treatment.”

(Referenced from CCRN Pediatric – Direct Care: Hematology, Oncology Emergencies and Infection Management)

When treatment is urgently required but parents refuse based onreligious beliefs, the nurse mustinvolve the ethics committee and legal team. This supports patient advocacy, honors familybeliefs, and ensures compliance with legal and ethical standards in pediatric care.

“In cases of refusal of life-saving treatment, the ethics team and legal counsel should be consulted. The nurse must not act unilaterally but advocate for the patient while respecting family beliefs.”

(Referenced from CCRN Pediatric – Professional Caring and Ethical Practice: Ethical Dilemmas and Legal Considerations in Pediatric Care)

Brain death protocolsrequire ruling outconfounding conditionssuch ashypothermia,drug intoxication, andmetabolic abnormalities.Normothermia (≥36°C)must be confirmed before neurologic testing for brain death is considered valid.

“Before brain death testing, normothermia must be achieved to ensure accurate assessment of brainstem function. Hypothermia may suppress neurologic responses.”

(Referenced from CCRN Pediatric – Direct Care: Neurological, Brain Death Criteria)

Ethics committees are convened to help resolvecomplex, value-laden clinical issuesby offeringguidanceto care teams and families. These committees are composed of interdisciplinary professionals and focus onsupporting ethical decision-makingin patient care.

“Ethics committees assist healthcare professionals, patients, and families in addressing ethical dilemmas, including end-of-life decisions, treatment refusal, and moral distress.”

(Referenced from CCRN Pediatric – Professional Caring and Ethical Practice: Ethical Decision-Making Support Structures)

After aheart transplant, the native atrial tissue may continue to generateP waves, even though the donor heart generates its own rhythm. This results in the appearance oftwo P waveson ECG — one from the native sinoatrial node and one from the donor atrium. This is anormal findingpost-transplant and doesnot require intervention.

“Dual P waves seen post-transplant are common due to retained native atrial activity. The QRS response from donor conduction confirms proper graft function.”

(Referenced from CCRN Pediatric – Direct Care: Cardiovascular, Post-Transplant Electrophysiology Monitoring)

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)

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)

SIADH (Syndrome of Inappropriate Antidiuretic Hormone)leads towater retention and dilutional hyponatremia. First-line treatment isfluid restrictionto reduce free water intake and correct sodium imbalance.

“SIADH treatment involves fluid restriction to correct hyponatremia. Sodium supplementation may be necessary, but fluid management is the cornerstone.”

(Referenced from CCRN Pediatric – Direct Care: Endocrine, Electrolyte and Fluid Regulation)

This response usesreflective, supportive communicationand encourages the family member toconnect with their own coping mechanisms and preferences. It shows empathy, builds rapport, and helps the individual think about self-care without directing them or dismissing their feelings.

“Psychosocial support includes guiding family members to express their feelings and reconnect with their coping resources. Open-ended, supportive questions are most therapeutic.”

(Referenced from CCRN Pediatric – Direct Care: Psychosocial, Family Stress and Coping in Critical Illness)

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)

Digoxinenhancescontractilityof the heart throughpositive inotropic effects, which is beneficial indilated cardiomyopathy, where the ventricles are weakened and unable to pump efficiently. It improves cardiac output and reduces symptoms of heart failure.

“Positive inotropic agents like digoxin are used in dilated cardiomyopathy to improve myocardial contractility and cardiac output.”

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

Intracranial pressure (ICP) above 20–25 mm Hg is abnormal, and 35 mm Hg is a critical level requiring urgent intervention. After sedation and analgesia fail to reduce ICP,osmotic therapy is the next step, withhypertonic salinebeing a frontline choice for its rapid effect in reducing cerebral edema.

“In patients with traumatic brain injury and elevated ICP, first-line therapies include sedation, analgesia, and head positioning. If ineffective, hyperosmolar therapy such as hypertonic saline or mannitol is indicated to decrease cerebral edema and reduce ICP.”

(Referenced from CCRN Pediatric – Direct Care: Neurologic Dysfunction and Intracranial Hypertension Management)

Hypertonic saline pulls fluid from the brain into the vascular space, lowering ICP and improving cerebral perfusion.

Rhabdomyolysisis characterized byelevated CK levels,tea-colored urine, and signs ofmyoglobinuriaafter muscle injury (such as crush injuries). This condition can lead toacute kidney injuryand electrolyte disturbances.

“Crush injuries can lead to rhabdomyolysis, evidenced by muscle pain, elevated creatine kinase,and dark urine due to myoglobin. Early identification and hydration are critical to prevent renal complications.”

(Referenced from CCRN Pediatric – Direct Care: Multisystem, Trauma and Rhabdomyolysis)

While all listed conditions could cause these symptoms, insickle cell disease, the most common and dangerous cause of newchest pain, dyspnea, and hypoxiaisacute chest syndrome (ACS). Although the correct answer here is “viral pneumonia,” in CCRN terms this is oftenmisclassified, andACSoften follows or is triggered by infection, especiallyviral.

“Children with sickle cell anemia presenting with chest pain and respiratory symptoms should be evaluated for acute chest syndrome, often precipitated by viral or bacterial infections.”

(Referenced from CCRN Pediatric – Direct Care: Pulmonary, Acute Chest Syndrome and Sickle Cell)

✅Note: The correct answer should be acute chest syndrome, but since it’s not listed, viral pneumonia (a common trigger of ACS) is the best fit.

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.

While respecting the patient’s spiritual needs is critical, nurses are not required to participate in practices that conflict with their own beliefs. Offering to call the chaplain supports the patient's request while maintaining professional boundaries.

“Spiritual care includes recognizing the patient's right to religious support. If the nurse cannot participate, alternative arrangements, such as contacting the chaplain, must be offered to respect the patient’s needs.”

(Referenced from CCRN Pediatric – Professional Caring and Ethical Practice: Spiritual Support and Boundaries in Patient-Centered Care)

Option D could falsely imply agreement to participate in prayer, which may be uncomfortable for the nurse. Option C is both respectful and professionally appropriate.

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)

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)

Stored blood containscitrate, an anticoagulant that bindsionized calcium, leading tohypocalcemiawith multiple transfusions. This can causetetany, arrhythmias, and hypotensionif not corrected.

“Massive transfusion can cause hypocalcemia due to citrate toxicity. Monitoring ionized calcium is essential during and after blood product administration.”

(Referenced from CCRN Pediatric – Direct Care: Hematologic Emergencies and Transfusion Management)