CCRN-Pediatric AACN CCRN (Pediatric) - Direct Care Eligibility Pathway Exam Free Practice Exam Questions (2025 Updated)

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)

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)

The first step in any evidence-based practice (EBP) or quality improvement (QI) process is toclearly define the clinical problem or question. Before outcomes or interventions are addressed, the council mustdetermine the exact issue to be studied.

“In quality improvement and evidence-based practice, step one is always problem identification. A well-defined problem leads to targeted and effective research.”

(Referenced from CCRN Pediatric – Professional Caring and Ethical Practice: Evidence-Based Practice and QI Models)

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)

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)

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)

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)

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)

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)

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)

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)

Encephalopathy refers to aglobal brain dysfunctioncaused by various factors such asmetabolic imbalances, toxins, hypoxia, or infections. In many cases,no definitive causative agent is identified, and treatment focuses onsupportive care and managing underlying triggers.

“Pediatric encephalopathy is often multifactorial, and in many cases no specific causative agent is isolated. Families should be counseled accordingly.”

(Referenced from CCRN Pediatric – Direct Care: Neurological, Encephalopathy and Parental Education)

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)

The most effective and collaborative approach is toengage the familyin a respectful conversation about visitation behavior, including settingclear behavioral expectations. This promotes therapeutic communication and family involvement without escalating conflict.

“When visitor behavior interferes with care or other patients’ well-being, nurses should initiate a discussion that includes setting expectations and collaboratively developing a behavior plan.”

(Referenced from CCRN Pediatric – Professional Caring and Ethical Practice: Family-Centered Care and Conflict Resolution)

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)

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)

Classic CSF findings inbacterial meningitis:

Low glucose(<40 mg/dL) – due to bacterial consumption

High protein(>100 mg/dL) – from inflammation and blood-brain barrier disruption

High WBCs, particularlypolymorphonuclear cells(>1000/microliter) – indicating a strong immune response

These values are not consistent with viral meningitis or autoimmune disorders like Guillain-Barré.

“In bacterial meningitis, CSF typically reveals hypoglycorrhachia, elevated protein, and a predominance of neutrophilic leukocytosis.”

(Referenced from CCRN Pediatric – Direct Care: Neurological, Meningitis Diagnosis and Management)

The first step in quality improvement or post-event evaluation—such as after a disaster drill—is tosystematically identify all problems or deviationsfrom expected protocols. Only once the problems are fully defined canroot causes be analyzedand process improvement initiated.

“After-action reviews following drills or emergencies should begin with problem identification. Comprehensive review and categorization of issues precede root cause analysis and protocol modification.”

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