PALS Precourse Test

PALS Pre-course Test 1. Parents of a 1-year-old female phoned EMS when they picked up their daughter from the babysitter. Paramedics perform an initial impression revealing an obtunded infant with irregular breathing, bruises over the abdomen, abdominal distension, and cyanosis. Assisted bag-mask ventilation with 100% oxygen is initiated. On primary assessment heart rate is 36/min, peripheral pulses cannot be palpated, and central pulses are barely palpable. Cardiac monitor shows sinus bradycardia. Chest compressions are started at 15:2. In the ED the infant is intubated and ventilated, and IV access is established. The heart rate is now up to 150/min, but there are weak central pulses and no distal pulses. Systolic BP is 74. Of the following, which would be most useful in management of this infant? A. B. C. D. Synchronized cardioversion Epinephrine 0.01 mg/kg (0.1 mL/kg of 1:10,000 dilution) IV Rapid bolus of 20 mL/kg of isotonic crystalloid Atropine 0.02 mg/kg IV - C 2. You enter a room to perform an initial impression of a previously stable 10-year-old male and find him unresponsive and apneic. A code is called and bag-mask ventilation is performed with 100% oxygen. The cardiac monitor shows a wide-complex tachycardia. The boy has no detectable pulses so compressions and ventilations are provided. As soon as the defibrillator arrives you deliver an unsynchronized shock with 2 J/kg. The rhythm check after 2 minutes of CPR reveals VF. You then deliver a shock of 4 J/kg and resume immediate CPR beginning with compressions. A team member has established IO access, so you give a dose of epi, 0.01 mg/kg (0.1 mL/kg of 1:10,000 dilution) IO after second shock. At the next rhythm check, persistent VF is present. You administer another 4 J/kg shock and resume CPR. Based on the PALS Pulseless Arrest Algorithm, what is the next drug and dose to administer when CPR is restarted? A. Magnesium sulfate 25-50 mg/kg IO B. Atropine 0.02 mg/kg IO C. Epinephrine 0.1 mg/kg of 1:10,000 dilution IO D. Amiodarone 5 mg/kg IO - D 3. Which of the following statements about calcium is true? A. Calcium chloride 10% has the same bioavailability of elemental calcium as calcium gluconate in critically ill children B. The recommended dose is 1-2 mg/kg of calcium chloride. C. Indications for administration of calcium include hypercalcemia, hypokalemia, and hypomagnesemia. D. Routine administration of calcium is not indicated during cardiac arrest. - D 4. Initial impression of a 9-year-old male with increased work of breathing reveals the boy to be agitated and leaning forward on the bed with obvious respiratory distress. You administer 100% oxygen by nonrebreathing mask. The patient is speaking in short phrases and tells you that he has asthma but does not carry an inhaler. He has nasal flaring, severe suprasternal and intercostal retractions, and decreased air movement with prolonged expiratory time and wheezing. His SpO2 is 96% (on nonrebreathing mask). What is the next medical therapy to provide to this patient? A. Adenosine 0.1 mg/kg B. Amiodarone 5 mg/kg IV/IO C. Albuterol by nebulization D. Procainamide 15 mg/kg IV/IO - C 5. You are called to help resuscitate an infant with severe symptomatic bradycardia associated with respiratory distress. The bradycardia persists despite establishment of an effective airway, oxygenation, and ventilation. There is no heart block present. Which of the following is the first drug you should administer? A. Dopamine B. Adenosine C. Atropine D. Epinephrine - D 6. An infant with a history of vomiting and diarrhea arrives by ambulance. During your primary assessment the infant responds only to painful stimulation. The upper airway is patent, the repiratory rate is 40/min with good bilateral breath sounds, and 100% oxygen is being administered. The infant has cool extremities, weak pulses, and a cap refill of more than 5 seconds. The infant's BP is 85/65 mm Hg and glucose concentration is 30 mg/dL (1.65 mmol/L). Which of the following is the most appropriate treatment to provide for this infant? A. Establish IV or IO access, administer 20 mL/kg isotonic crystalloid over 10 to 20 minutes, and simultaneously administer D25W 2 to 4 mL/kg in a separate infusion. B. Establish IV or IO access and administer 20 mL/kg D50 .45% sodium chloride bolus over 15 minutes. C. Establish IV or IO access and administer 20 mL/kg Lactated Ringer's solution over 60 minutes. D. Perform endotracheal intubation and administer epinephrine 0.1 mg/kg 1:1,000 via the endotracheal tube. - A 7. Which of the following statements about endotracheal drug administration is true? A. Endotracheal doses of resuscitation drugs in children have been well established and are supported by evidence from clinical trials. B. Endotracheal drug administration is the least desirable route of administration because of this route results in unpredictable drug levels and effects. C. Endotracheal drug administration is the preferred route of drug administration dring resuscitation because is results in predictable drug levels and drug effects. D. Intravenous drug doses for resuscitation drugs should be used whther you give the drugs by the IV, IO, or the endotracheal route. - B 8. Which of the following statements most accurately reflects the PALS recommendations for the use of magnesium sulfate in the treatment of cardiac arrest? A. Routine use of magnesium sulfate is indicated for shock-refractory monomorphic VT. B. Magnesium sulfate is indicated for torsades de pointes and VF/ pulseless VT associated with suspected hypomagnesemia. C. Magnesium sulfate is indicated for VF refractory to repeated shocks and amiodarone or lidocaine. D. Magnesium sulfate is contraindicated in VT associated with an abnormal QT interval during the preceding sinus rhythm. - B 9. Initial impression of a 2-year-old female reveals her to be alert with mild breathing difficulty during inspiration and pale skin color. On primary assessment, she makes high-pitched inspiratory sounds (mild stridor) when agitated; otherwise, her breathing is quiet. Her SpO2 is 92% in room air, and she has mild inspiratory intercostal retractions. Lung auscultation reveals transmitted upper airway sounds with adequate distal breath sounds bilaterally. Which of the following is the most appropriate initial therapeutic intervention for this child? A. Administer an IV dose of dexamethasone B. Perform immediate endotracheal intubation C. Administer humidified supplementary oxygen as tolerated and continue evaluation D. Nebulize 2.5 mg of albuterol - C 10. Which of the following statements about the effects of epinephrine during attempted resuscitation is true? A. Epinephrine decreases the peripheral vascular resistance and reduces myocardial afterload so that ventricular contractions are more effective B. Epinephrine is contraindicated in ventricular fibrillation because it increases myocardial irritability. C. Epinephrine improves coronary artery perfusion pressure and stimulates spontaneous contractions when asystole is present. D. Epinephrine decreases myocardial oxygen consumption. - C 11. Which of the following most reliably delivers a high (90% or greater) concentration of inspired oxygen in a toddler or older child? A. Face tent with 15 L/min oxygen flow B. Simple oxygen mask with 15 L/min oxygen flow C. Nasal cannula with 4 L/min oxygen flow D. Nonrebreathing face mask with 12 L/min oxygen flow - D 12. A 3-year-old unresponsive, apneic child is brought to the emergency department. The cardiac monitor shows V Fib. EMS personnel report that the child became unresponsive as they arrived at the hospital. The child is receiving CPR, including bag-mask ventilation with 100% O2 and chest compressions at a rate of at least 100/min. Compressions and ventilations are being coordinated at a ratio of 15:2. You conform that apnea is present and that ventilation is producing bilateral breath sounds and chest expansion while a colleague confirms absent pulses. Cardiac monitor shows the above rhythm. A biphasic manual defibrillator is present. You quickly use the crown-heel length of the child on a length based, color-coded resuscitation tape to estimate the approximate weight as 15kg. Which of the following therapies is most appropriate for this child at this time? A. Establish IV/IO access and administer lidocaine 1 mg/kg IV/IO B. Establish IV/IO access and administer epinephrine 0.01 mg/kg (0.1 mL/kg of 1:10,000 dilution) IV/IO C. Attempt defibrillation at 30 J, then resume CPR beginning with compressions. D. Establish IV/IO access and administer amiodarone 5 mg/kg IV/IO. - C 13. A 3-year-old boy presents with multiple system trauma. The child was an unrestrained passenger in a motor vehicle crash. On primary assessment he is unresponsive to voice or painful stimulation. His respiratory rate is less than 6/min, heart rate is 170/min, systolic blood pressure is 60 mm Hg, cap refill is 5 seconds, and SpO2 is 75% in room air. Which of the following most accurately summarizes the first interventions you should take to support this child? A. Establish immediate vascular access, administer 20 mL/kg isotonic crystalloid, and reassess the patient; if the child's systemic perfusion does not improve, administer 10 to 20 mL/kg packed red blood cells. B. Provide 100% oxygen by simple mask and perform a head-to-toe survey to identify the extent of all injuries; begin an epinephrine infusion and titrate to maintain a systolic blood pressure of at least 76 mm Hg C. Open the airway (jaw-thrust technique) while stabilizing the cervical spine, administer positive-pressure ventilation with 100% oxygen, and establish immediate IV/IO access. D. Provide 100% oxygen by simple mask, stabilize the cervical spine, establish vascular access, and provide maintenance IV fluids. - C 14. Initial impression of a 10-month-old male in the emergency department reveals a lethargic pale infant with slow respirations. You begin assisted ventilation with a bag-mask device using 100% oxygen. On primary assessment heart rate is 38/min, central pulses are weak, but distal pulses cannot be palpated. Blood pressure is 60/40, and cap refill is 4 seconds. During your assessment, as colleague places the child on a cardiac monitor and you observe the rhythm above (sinus bradycardia, 40 bpm). The rhythm remains unchanged despite ventilation with 100% oxygen. What are your next management steps? A. Administer adenosine 0.1 mg/kg rapid IV/IO and prepare for synchronized cardioversion. B. Start chest compressions and give epinephrine 0.1 mg/kg (0.1 mg/kg of 1:1,000) IV/IO C. Start chest compressions and give epinephrine 0.01 mg/kg (0.1 mL/kg of 1:10,000) IV/IO D. Administer 20 mL/kg isotonic crystalloid and epinephrine 0.1 mg/kg (0.1 mL/kg of 1:10,000) IV/IO - C 15. A 1-year-old male is brought to the emergency department for evaluation of poor feeding, fussiness, and sweating. On initial impression he is lethargic but arousable and has labored breathing and a dusky color. Primary assessment reveals a respiratory rate of 68/min, heart rate 300/min that does not very with activity or sleep, blood pressure 70/45 mm Hg, weak brachial pulses and absent radial pulses, cap refill 6 seconds, SpO2 85% in room air, and good bilateral breath sounds. You administer high-flow oxygen and place the child on a cardiac monitor. You see the above rhythm (SVT) with little beat-to-beat variability of the heart rate. Secondary assessment reveals no history of congenital heart disease. IV access has been established. Which of the following therapies is most appropriate for this infant? A. Adenosine 0.1 mg/kg IV rapidly; if adenosine is not immediately available, perform synchronized cardioversion. B. Make an appointment with a pediatric cardiologist for later in the week. C. Establish IV access and administer a flid bolus of 20 mL/kg isotonic crystalloid. D. Perform immediate defibrillation without waiting for IV access - A 16. You are preparing to use a manual defibrillator and paddles in the pediatric setting. When would it be most appropriate to use the smaller "pediatric" sized paddles for shock delivery? A. If the patient weighs less than approximately 10 kg or is less than 1 year of age. B. Whenever you can compress the victim's chest using only the heel of one hand C. To attempt synchronized cardioversion but not defibrillation D. If the patient weighs less than approximately 25 kg, or is less than 8 years of age. - A 17. Initial impression of a 10-year-old male shows him to be unresponsive. You shout for help, check breathing or only gasping. After finding that he is pulseless, you begin CPR. A colleague arrives and places the child on a cardiac monitor, revealing the above rhythm (V Tach). The two of you attempt defibrillation at 2 J/kg and give 2 minutes of CPR. The rhythm persists at the second rhythm check, at which point you attempt defibrillation using 4 J/kg. A third colleague establishes IO access and administers one dose of epinephrine 0.01 mg/kg (0.1 mL/kg of 1:10,0000) during the compressions following the second shock. If VF or pulseless VT persists after 2 minutes of CPR, what is the next drug/dose to administer? A. Adenosine 0.1 mg/kg IV B. Amiodarone 5 mg/kg IV C. Epinephrine 0.1 mg/kg (0.1 mL/kg of 1:1,000) IV D. Atropine 0.02 mg/kg IV - B 18. You are supervising another healthcare provider who is inserting an intraosseous (IO) needle into an infant's tibia. Which of the following signs should you tell the provider is the best indication of successful insertion of a needle into the bone marrow cavity? A. You are unable to aspirate any blood through the needle. B. Pulsatile blood flow will be present in the needle hub. C. Once inserted, the shaft of the needle moves easily in all directions within the bone. D. Fluids can be administered freely without local soft tissue swelling. - D 19. You are evaluating an irritable 6-year-old girl with mottled color. On primary assessment she is febrile ( temperature 104 F) and her extremities are cold (despite a warm ambient temperature in the room) with cap refill of 5 seconds. Distal pulses are absent and central pulses are weak. Heart rate is 180/min, respiratory rate is 45/min, and blood pressure is 98/56. Which of the following most accurately describes the categorization of this chil's condition using the terminology taught in the PALS Provider Course? A. Hypotensive shock associated with inadequate tissue perfusion. B. Compensated shock associated with tachycardia and inadequate tissue perfusion. C. Hypotensive shock associated with inadequate tissue perfusion and significant hypotension. D. Compensated shock requiring no intervention. - B 20. You are caring for a 3-year-old with vomiting and diarrhea. You have established IV access. When you place an orogastric tube, the child begins gagging and continues to gag after the tube is placed. The child's color has deteriorated; pulses are palpable but faint and the child is now lethargic. The heart rate is variable (range 44/min to 62/min). You begin bag-mask ventilation with 100% oxygen. When the heart rate does not improve, you begin chest compressions. The cardiac monitor shows the above rhythm (Sinus Bradycardia at 50 bpm). Which of the following would be the most appropriate therapy to consider next. A. Cardiology consult for transcutaneous pacing. B. Epinephrine 0.1 mg/kg (0.1 mL/kg of 1:1,000) IV C. Atropine 0.02 mg/kg IV D. Attempt synchronized cardioversion at 0.5 J/kg - C 21. An 18-month-old child presents with a 1-week history of cough and runny nose. Your initial impression is a toddler responsive only to painful stimulation with slow respirations and diffuse cyanosis. You begin a primary assessment and find that the child's respiratory rate has fallen from 65/min to 10/min, severe inspiratory intercostal retractions are present, heart rate is 160/min, SpO2 is 65% in room air, and cap refill is less than 2 seconds. Which of the following is the most appropriate immediate treatment for this toddler? A. Administer 100% oxygen by face mask, obtain an arterial blood gas, and establish vascular access. B. Administer 100% oxygen by face mask, establish vascular access, and obtain a STAT chest x-ray. C. Establish vascular access and administer a 20 mL/kg bolus of isotonic crystalloid. D. Open the airway and provide positive-pressure ventilation using 100% oxygen and a bag-mask device. - D 22. You are transporting a 6-year-old endotracheally intubated patient who is receiving positivepressure mechanical ventilation. The child begins to move his head and suddenly becomes cyanotic and bradycardic. SpO2 is 65% with good pulse signal. You remove the child from the mechanical ventilator circuit and provide manual ventilation with a bag via the endotracheal tube. During manual ventilation with 100% oxygen, the child's color and heart rate improve slightly and his blood pressure remains adequate. Breath sounds and chest expansion are present and adequate on the right side, but they are consistently diminished on the left side. The trachea is not deviated, and the neck veins are not distended. A suction catheter passes easily beyond the tip of the endotracheal tube. Which of the following is the most likely cause of this child's acute deterioration? A. Tracheal tube displacement into the right main bronchus B. Tension pneumothorax on the right side C. Tracheal tube obstruction D. Equipment failure. - A 23. A child becomes unresponsive in the emergency department and is not breathing. You provide ventilation with 100% oxygen. You are uncertain if a faint pulse is present with the above rhythm (asystole). What is your next action? A. Order transcutaneous pacing. B. Start high quality CPR, beginning with compressions. C. Start an IV and give atropine 0.01 mg/kg IV D. Start an IV and give epinephrine 0.01 mg/kg IV (0.1 mL/kg of 1:10,000) - B 24. You have just assisted with the elective endotracheal intubation of a child with respiratory failure and a perfusing rhythm. Which of the following provides the most reliable, prompt assessment of correct endotracheal tube placement in this child? A. Absence of audible breath sounds over the abdomen during positive-pressure ventilation. B. Auscultation of breath sounds over the lateral chest bilaterally plus presence of mist in the endotracheal tube. C. Clinical assessment of adequate bilateral breath sounds and chest expansion plus presence of exhaled CO2 in a colormetric detection device after delivery of 6 positivepressure ventilations. D. Confirmation of appropriate oxygen and carbon dioxide tensions on arterial blood gas analysis. - C 25. An 8-year-old child was struck by a car. He arrives in the emergency department alert, anxious, and in respiratory distress. His cervical spine is immobilized, and he is receiving a 10 L/min flow of 100% oxygen by nonrebreathing face mask. PRimary assessment reveals respiratory rate 60/min, heart rate 150/min, systolic blood pressure 70, and SpO2 84% on supplementary oxygen. Breath sounds are absent over the right chest, and the trachea is deviated to the left. He has weak central pulses and absent distal pulses. Which of the following is the most appropriate immediate intervention for this child? A. Provide bag-mask ventilation and call for a STAT chest x-ray B. Perform needle decompression of the right chest and assist ventilation with a bag and mask if necessary. C. Establish IV access and administer a 20 mL/kg normal saline fluid bolus D. Perform endotracheal intubation and call for a STAT chest x-ray - B 26. A 7-year-old boy is found unresponsive, apneic, and pulseless. CPR is ongoing. The child is intubated and vascular access is established. The ECG monitor reveals an organized rhythm, but a pulse check reveals no palpable pulses. Effective ventilations and compressions are resumed, and an initial IV dose of epinephrine is administered. Which of the following therapies should you perform next? A. Administer synchronized cardioversion at 1 J/kg B. Administer epinephrine 0.1 mg/kg IV (0.1 mL/kg of 1:1,000) C. Attempt defibrillation at 4 J/kg D. Attempt to identify and treat reversible causes (using the H's and T's as a memory aid) -D 27. A 4-year-old male is in pulseless arrest in the pediatric intensive care unit. A code is in progress. As the on-call physician you quickly review his chart and find that his baseline corrected QT interval on a 12-lead ECG is prolonged. A glance at the monitor shows recurrect episodes of the above rhythm. The boy has received one dose of epi, but continues to demonstrate the rhythm illustrated above (Torsades de Pointes). If this rhythm persists at the next rhythm check, which medication would be the most appropriate to administer at this time? A. Lidocaine 1 mg/kg IV B. Adenosine 0.1 mg/kg IV C. Epinephrine 0.1 mg/kg (1:1000) D. Magnesium sulfate 25 to 50 mg/kg IV - D 28. A pale and obtunded 3-year-old child with a history of diarrhea is brought to the hospital. Primary assessment reveals respiratory rate of 45/min with good breath sounds bilaterally. Heart rate is 150/min, blood pressure is 90/64, and SpO2 is 96% room air. Cap refill is 5 seconds and peripheral pulses are weak. After placing the child on a nonrebreathing face mask (10 L/min) with 100% O2 and obtaining vascular access, which of the following is the most appropriate immediate treatment for this child? A. Begin a maintenance crystalloid infusion B. Administer a bolus of 20 mL/kg isotonic crystalloid C. Obtain a chest x-ray D. Administer a dopamine infusion at 2 to 5 mcg/kg per minute. - B 29. An 8-month-old male is brought to the ED for evaluation of severe diarrhea and dehydration. In the ED the child becomes unresponsive and pulseless. You should for help and start CPR. Another provider arrives, and you begin a compression-to-ventilation ratio of 15:2. The cardiac monitor shows the above rhythm. The infant is intubated and ventilated with 100% O2. An IO line is rapidly established and a dose of epi is given. Of the following choices for management, which would be most appropriate to give next? A. Normal saline 20 mL/kg IV rapidly B. Amiodarone 5 mg/kg IO C. Defibrillation 2 J/kg D. High dose epinephrine 1:1,000, 0.1 mg/kg - A 30. You are participating in the elective intubation of a 4-year-old child with respiratory failure. You must select the appropriate sized uncuffed endotracheal tube. You do not have a Brazlow tape to use to estimate correct endotracheal tube size. Which of the following is the most appropriate uncuffed endotracheal tube for an average 4-year-old. A. 4-mm tube B. 6-mm tube C. 5-mm tube D. 3-mm tube - C