200-Item Acute Care Examination

200-Item Acute Care Examination

1. A neonate presents with seizures at age 1 week. In the newborn period, he was noted to be hypotonic, with low-set ears and a cleft palate. Which of the following diagnoses is highest on the differential list?

a. Angelman syndrome.

b. Alagille syndrome.

c. DiGeorge syndrome.

d. Treacher Collins syndrome.

View Answer

Answer: C

DiGeorge syndrome results in absence or hypoplasia of the parathyroid gland which can lead to hypocalcemia resulting in seizures. Dysmorphic facial features characteristic of DiGeorge syndrome include low-set ears, micrognathia, and hypertelorism. Cleft palate is present 70% to 80% of the time in this syndrome. Hypotonia is common in infancy in those with the syndrome.

2. A 3-year-old is in the pediatric acute care unit after having a subclavian central line placed in the operating room. He is stable on 2-L nasal cannula and playful until a few minutes later when he starts crying and his SaO2 decreases to 85%. He is notably tachypneic and tachycardic and his breath sounds are unequal. What is the most likely explanation for this acute change in the patient’s condition?

a. Bronchospasm.

b. Pneumothorax.

c. Postoperative pain.

d. Foreign body aspiration.

View Answer

Answer: B

Pneumothorax is a known potential complication of central line placement. Unequal breath sounds with impaired oxygenation are hallmark signs. Foreign body aspiration could have a similar presentation but is less likely in a supervised environment.

3. An 8-year-old with cystic fibrosis (CF) is being treated for Pseudomonas aeruginosa infection in the respiratory tract. Serum tobramycin levels have been below the therapeutic range, despite being on appropriate dosing for her age (7.5 mg/kg/24 hours). What is the rationale and next best step in this child’s plan?

a. Tobramycin can cause nephrotoxicity and ototoxicity, so the dose should remain the same, despite low serum levels.

b. Patients with CF metabolize antibiotics rapidly; therefore, it is safe to increase the dose until desired therapeutic blood levels are achieved.

c. Patients with CF metabolize many antibiotics rapidly; therefore, it is safe to increase her dose to 10 mg/kg/24 hours.

d. Tobramycin can cause renal failure if the levels remain elevated, so the child should remain on the same dose.

View Answer

Answer: C

The recommended range for dosing of tobramycin in patients with CF is 7.5 to 10 mg/kg/24 hours. The risk of toxic side effects is real, but the dose should be increased to try to achieve therapeutic target, but not above the upper limit to minimize risk of toxicity.

4. When evaluating a toddler suspected of a foreign body aspiration, obtaining an inspiratory/expiratory chest radiograph is used to determine presence of which of the following?

a. Pleural effusion.

b. Object on the horizontal plane.

c. Lung deflation on exhalation.

d. Bilateral hyperinflation.

View Answer

Answer: C

Obtaining an inspiratory/expiratory chest radiograph assists in evaluating lung deflation on exhalation and presence of unilateral air trapping. Pleural effusions are generally not associated with foreign body aspiration. Objects most commonly position themselves on the vertical plane. Bilateral hyperinflation is common in asthma/status asthmaticus.

5. A 4-month-old infant was found gasping for breath in his crib. He was supported with positive-pressure bag-mask ventilation and transported to the hospital by the local emergency medical services. On arrival to the hospital, the child was lethargic, tachypneic, tachycardic, and wheezing. He was noted to have pink, frothy sputum when suctioned. The most likely reason for this presentation is:

a. Pneumonia.

b. Meningitis.

c. Reactive airway disease.

d. Pulmonary edema.

View Answer

Answer: D

The clinical presentation of a child with suspected pulmonary edema can include tachypnea, dyspnea, tachycardia, hypoxia, and wheezing. Cough with frothy sputum (often pink), diaphoresis, orthopnea, and paroxysmal nocturnal dyspnea with increased work of breathing are other clinical findings. On auscultation, crackles may be heard along with a third heart tone or gallop, which is indicative of cardiogenic pulmonary edema.

6. A child in cardiogenic shock is being treated with dobutamine. What is the mechanism of action of this medication?

a. Increasing contractility and promoting peripheral vasodilation.

b. Increasing contractility and increasing peripheral vasoconstriction.

c. Increasing heart rate and increasing renal perfusion.

d. Decreasing heart rate and decreasing systemic vascular resistance.

View Answer

Answer: A

Dobutamine is used to treat cardiogenic shock and works by increasing contractility and promoting peripheral vasodilation. It will also increase renal perfusion and urine output.

7. A teenager presents with cardiac tamponade following involvement in a motor vehicle crash at high speed. Clinical findings will include:

a. Hypotension, distended jugular veins, and distant heart sounds.

b. Hypertension, distant heart sounds, and widened pulse pressure.

c. Distended jugular veins, hypertension, and bradycardia.

d. Hypotension, widened pulse pressure, and bradycardia.

View Answer

Answer: A

Cardiac tamponade occurs as a result of several mechanisms including trauma. Clinical presentation includes Beck triad: hypotension—from low cardiac output; distended neck (jugular) veins—from heart compression; and muffled (distant) heart sounds—from fluid in pericardial space. Patients often have pulsus paradoxus with a narrow pulse pressure, altered neurologic status, audible pericardial rub, and shock with tachycardia and tachypnea.

8. A teenager with confirmed HIV infection presents with a persistent nonproductive cough for the past 3 weeks. The patient has been routinely taking his antiviral therapy, but states that school has been so busy that he sometimes forgets to take some of his medications. He appears stable but has a respiratory rate of 32 breaths/minute and a pulse oximeter reading of 88% on room air. Breath sounds are clear. A chest radiograph demonstrates “diffuse haziness in both lung fields but no focal consolidation.” Which diagnosis is highest on the differential list?

a. Streptococcus pneumoniae pneumonia.

b. Viral respiratory tract infection.

c. Pneumocystis jirovecii.

d. Tuberculosis.

View Answer

Answer: C

Bacterial pneumonia, while overall much more common than Pneumocystis, usually has a focal finding on chest radiograph and typically causes fever. Viral infections are usually associated with other symptoms such as rhinorrhea and cough. Tuberculosis is a reasonable concern, but usually does not cause persistent tachypnea or oxygen desaturations. Hilar adenopathy on chest radiograph would make the diagnosis more likely. Pneumocystis jirovecii is likely as it is common in immunocompromised patients, and without prophylaxis, it would be highest on the differential diagnosis.

9. The most common pathogens causing meningitis in infants between the ages of 1 and 3 months include which of the following?

a. Haemophilus influenzae type b, Streptococcus pneumoniae, Neisseria meningitidis.

b. Listeria monocytogenes, Streptococcus pneumoniae, Neisseria meningitidis.

c. Haemophilus influenzae type b, Chlamydia trachomatis, Escherichia coli.

d. Escherichia coli, Listeria monocytogenes, Chlamydia trachomatis.

View Answer

Answer: A

There are a variety of organisms that are responsible for causing meningitis in the newborn period, but these organisms change at 1 month of age and then again between 3 months and 2 years of age. Recognizing the potential etiology assists in providing appropriate treatment. The organisms that typically cause meningitis in infants beyond the neonatal period are Haemophilus influenzae type b, Streptococcus pneumoniae, Neisseria meningitidis, late-onset group B streptococcus and Bordetella pertussis.

10. The first, most important consideration in the management of a young child with suspected sepsis is:

a. Intravenous access.

b. Airway and oxygenation.

c. Obtaining laboratory results and blood culture.

d. Cardiopulmonary monitoring.

View Answer

Answer: B

Oxygen administration, respiratory support with intubation, and mechanical ventilation as needed are the first consideration for a child who presents with septic shock. Early establishment of vascular access, fluid resuscitation up to and over 60 mL/kg within 15 minutes, correction of hypoglycemia and hypocalcemia, and prompt antibiotic administration follow soon after.

11. A toddler with a diagnosis of spinal muscle atrophy (SMA) type I has been hospitalized multiple times for respiratory failure requiring mechanical ventilation. She is currently on bilevel positive airway pressure (BiPAP) at night time at home. Decisions for determining the next steps in care are based on which of the following statements?

a. Children with SMA type I have poor prognosis and there is no specific therapy or cure.

b. With targeted therapy, children with SMA type I can live into adolescence, so aggressive therapy is indicated.

c. Children with SMA type I may need support walking later in their life, but are expected to live a normal lifespan.

d. Optimal nutrition and intravenous immunoglobulin treatment can assist in managing respiratory symptoms.

View Answer

Answer: A

There are three specific types of SMA, with the first one (type I) typically diagnosed early in infancy with symptoms of hypotonia with generalized weakness, poor head control, lack of meeting milestones, paradoxical breathing, and areflexia. Once genetic testing indicates SMA type I, parents can be counseled that prognosis is poor and that there is no specific therapy or cure. Management is directed at aggressive treatment of symptoms, but palliative care is also often appropriate. SMA type II is usually diagnosed later in infancy with typically normal development until 6 months of age, with variable life expectancy, but often through adolescence. SMA type III may not be diagnosed until adulthood and these patients may live a normal life expectancy with more involvement in lower extremities, often requiring wheelchair for ambulation.

12. Which one of the following strategies is used to reduce the risk of a post-lumbar puncture (LP) headache in a 19-year-old girl who is suspected of having pseudotumor cerebri?

a. Using the smallest needle possible.

b. Using the largest needle possible.

c. Performing the LP while the patient is in the seated position instead of the lateral recumbent position.

d. Having the patient lie on the left side during the procedure.

View Answer

Answer: A

Typically, young children do not experience LP headaches, but by using the smallest needle possible for an LP, the patient will have less risk of postprocedure headache due to leaking of CSF outside of the spinal column. A larger needle increases the risk of fluid leakage. The position of the patient during the procedure does not change the risk of a postprocedure headache.

13. An acutely ill 5-year-old is admitted to the pediatric intensive care unit with a fever of 39.0°C orally. On physical examination she has a palpable spleen tip 5 cm below the left costal margin. In addition to physical examination findings, which laboratory findings are highly suspicious for hemophagocytic lymphohistiocytosis (HLH)?

a. Hemoglobin of 9.5 g/dL and platelets of 90 × 103 cells/mL.

b. A ferritin of 10,000 ng/mL and an elevated soluble CD25 (i.e., soluble IL-2 receptor).

c. Fasting triglycerides of 200 mg/dL.

d. An erythrocyte sedimentation rate (ESR) of 80 mm/hour.

View Answer

Answer: B

In HLH, serum ferritin is often quite elevated, and fibrinogen is often notably low (leading to a clinical coagulopathy when coupled with low platelets). Low hemoglobin and platelet count are part of the HLH-2004 diagnostic criteria, but these values are mild compared to those usually seen in HLH. Although ESR can be a marker for inflammation, it is generally nonspecific and not a part of the HLH-2004 criteria.

14. A 15-year-old boy develops urticaria, chills, hypotension, and hypoxia 5 minutes after initiation of a packed red blood cell transfusion. Initial management should include which of the following?

a. Obtain urine sample for urinalysis.

b. Administer 20 mL/kg of isotonic fluid bolus.

c. Administer epinephrine intramuscular injection.

d. Obtain blood culture if concerned for bacterial contamination leading to sepsis.

View Answer

Answer: C

Anaphylaxis should be treated with IM or IV epinephrine, even with mild symptoms such as pruritus, urticaria, and angioedema. Delay in administration of epinephrine has been associated with poor outcomes and additional doses may be required.

15. A 2-year-old with a large liver mass and an elevated α-fetoprotein level is being admitted for evaluation. What is the most likely diagnosis?

a. Wilms tumor.

b. Hepatocellular carcinoma.

c. Hepatoblastoma.

d. Neuroblastoma.

View Answer

Answer: C

Hepatoblastoma is the most common liver mass in children. An elevated α-fetoprotein is present in 90% of children who are diagnosed with this form of cancer. A Wilms tumor is a renal mass, not liver. Hepatocellular carcinoma is rare in young children and is usually associated with a long-standing chronic metabolic liver disease. Neuroblastoma is not a liver tumor and is most commonly of adrenal origin.

16. In a child undergoing initial treatment for a mediastinal mass, what laboratory results are most concerning?

a. Elevated potassium, uric acid, BUN, creatinine, and decreased phosphorus and calcium.

b. Decreased potassium, uric acid, BUN, creatinine, and increased phosphorus and calcium.

c. Decreased potassium, uric acid, BUN, creatinine, phosphorous, and elevated calcium.

d. Elevated potassium, uric acid, BUN, creatinine, phosphorous, and decreased calcium.

View Answer

Answer: D

Elevated potassium, phosphorous, and uric acid levels are indicative of tumor lysis syndrome, a side effect of chemotherapy when tumor cells are broken down. Elevated BUN and creatinine with low calcium can indicate renal failure which occurs as a result of tumor lysis syndrome.

17. A child with a history of treated community-acquired pneumonia remains febrile and tachypneic. Further radiologic evaluation confirms the presence of parapneumonic effusion and a chest tube is placed. The initial pleural fluid sample is exudative and purulent. Only 20 mL is obtained as compared to a moderate-sized effusion on chest ultrasound. What is the most likely complication if this effusion remains inadequately drained?

a. Bronchopleural fistula.

b. Pericardial effusion.

c. Empyema.

d. Bronchiectasis.

View Answer

Answer: C

Inadequately treated exudative parapneumonic effusion can be a risk for the formation of an empyema, requiring surgical debridement and prolonged antibiotic therapy.

18. A 2-week-old infant with a persistent cough has a positive pertussis polymerase chain reaction (PCR) and bacterial culture. What is the best antimicrobial treatment for this patient?

a. Oral erythromycin for 14 days.

b. Oral azithromycin for 5 to 7 days.

c. Intravenous ceftriaxone.

d. Oral clarithromycin for 14 days.

View Answer

Answer: B

Macrolides are the treatment for pertussis. Erythromycin and clarithromycin are not recommended in the neonatal period due to the risk of infantile hypertrophic pyloric stenosis. Azithromycin has equal efficacy. Bactrim is a preferred second-line agent, but duration of treatment is 14 days. Intravenous ceftriaxone is not recommended for treating pertussis.

19. What is considered the most sensitive radiologic study when evaluating an adolescent with a malignancy who suddenly develops onset of dyspnea, hypoxia, and sense of doom?

a. Spiral CT.

b. Echocardiogram.

c. Spirometry.

d. Ventilation/perfusion scan.

View Answer

Answer: A

A spiral CT is rapid, requiring the least amount of transport time, and is highly sensitive and specific for pulmonary embolus which needs to be considered in any patient who has an acute onset of hypoxia and dyspnea.

20. A 10-year-old presents with severe hypertension of unknown etiology. The child is clinically stable, but has a blood pressure (BP) of 240/108 mmHg and is complaining of a bad headache. Which of the following is the most important goal of management?

a. Treat the headache with analgesics which will assist in bringing the BP to normal levels.

b. Administer intravenous antihypertensives very quickly to bring BP to safe level as soon as possible.

c. Slowly decrease the BP to avoid hypoperfusion and end-organ failure.

d. Use fluid therapies and restriction to bring the BP to a normal level within 6 to 12 hours.

View Answer

Answer: C

The goal of therapy for a child with acute hypertension is to slowly bring the BP down to avoid hypoperfusion and end-organ failure. In the first 6 to 12 hours, BP should not be decreased by more than 25% to 33%.

21. An 8-year-old presents with complaints of chest pain and fever which began following upper respiratory tract infection symptoms 2 weeks ago. The child has a low-grade fever and is not taking fluids well. A friction rub is audible on examination of the chest. Which of the following is the most likely diagnosis?

a. Pericarditis.

b. Myocarditis.

c. Upper respiratory infection.

d. Postpericardiotomy syndrome.

View Answer

Answer: A

Pericarditis occurs when the layers of the pericardium become inflamed as a result of many different etiologies, including bacterial and viral infectious processes, metabolic disorders, medication reactions, and Kawasaki disease, among others. The symptoms of acute pericarditis include chest pain and fever. A pericardial friction rub is often noted on auscultation.

22. A 4-week-old presents with fever of 102°F, jaundice, and nasal congestion. The infant is exclusively breast-fed and growing well. Liver function results include alanine transaminase 179 IU/L, aspartate aminotransferase 152 IU/L, and total bilirubin 7 mg/dL. What is the initial management?

a. Order an abdominal ultrasound.

b. Serum studies for hepatitis A/B/C, Epstein-Barr virus, and cytomegalovirus.

c. Reassure parents and repeat testing in 2 weeks.

d. Complete sepsis evaluation and repeat liver function tests and test for bilirubin level.

View Answer

Answer: D

An infant less than 2 months of age with fever requires a septic workup, and in this case, there is also the need to distinguish between direct and indirect hyperbilirubinemia to assist in management. Transaminases may be transiently elevated due to infection, so further evaluation is indicated.

23. A 10-year-old, weighing 48 kg, presents with partial and deep thickness burns after being involved in a house fire. If the estimated total body surface area (TBSA) involved is 21%, what would be the fluid resuscitation for the first 8 hours according to the Parkland formula?

a. Lactated Ringer @ 252 mL/hour.

b. Normal saline @ 100 mL/hour.

c. D5 ½ normal saline @ 230 mL/hour.

d. Lactated Ringers @ 130 mL/hour.

View Answer

Answer: A

In children with burns >15% TBSA, formulas such as the Parkland formula are used to calculate fluid administration. The Parkland formula recommends 4 mL/kg multiplied by percentage of TBSA burned; half is replaced in the first 8 hours and the rest over the following 16 hours. Example: 4 mL × 48 × 21 = 4,032 mL; half of that = 2,016 mL divided by 8 hours = 252 mL/hour for the first 8 hours. Isotonic crystalloid solutions, such as Lactated Ringers, are recommended for initial fluid resuscitation.

24. A 16-year-old girl is brought to your facility 1 hour after ingestion of 20 extra-strength acetaminophen capsules. After establishing neurologic and respiratory stability, what system needs to be evaluated and how?

a. Renal by obtaining renal function tests.

b. Cardiovascular by obtaining a 12-lead ECG.

c. Hepatic by obtaining liver function tests.

d. Gastrointestinal by aspirating stomach contents with nasogastric tube.

View Answer

Answer: C

The risks of both accidental and intentional ingestion of acetaminophen include hepatic failure with potential for the need for liver transplant. It is important to identify the time of acetaminophen ingestion to allow more accurate evaluation of hepatotoxicity risks with serum drug levels. Obtaining serial liver function tests should continue with support from the poison control center and identification of when to stop obtaining laboratory tests based on results and clinical status.

25. A 15-month-old fell from the kitchen counter after climbing to find cookies. She hit her head on the ceramic floor and was “dazed” for a few minutes at that time. She cried and then was very sleepy and has a large visible hematoma in the parietal area with palpable suspicion of skull fracture. Her parents note that she is not walking as steadily as before and has been extremely irritable since the incident which occurred 2 hours ago. According to Pediatric Emergency Care Applied Research Network (PECARN) guidelines, what is the initial management of this child?

a. Complete a thorough neurologic evaluation and obtain a head CT or MRI.

b. Observe the child overnight in the hospital, no imaging is needed.

c. Discharge the child to home with instructions for the parents to bring her back if she has more severe symptoms.

d. Complete a neurologic evaluation and obtain an electroencephalogram and a skull X-ray.

View Answer

Answer: A

According to the PECARN algorithm, a child who has any alteration in neurologic status and a potential skull fracture would warrant a head CT with first management. An MRI may be more preferable as it does not require the exposure to radiation unlike a CT. Neurologic evaluation is extremely important with access to neurosurgical care as well.

26. Before the infant with pyloric stenosis can go for surgical repair, it is important to:

a. Correct metabolic acidosis with normal saline boluses.

b. Correct metabolic alkalosis with appropriate intravenous fluids.

c. Confirm diagnosis with upper gastrointestinal series.

d. Establish central line access for postoperative total parenteral nutrition.

View Answer

Answer: B

Due to the persistent vomiting and loss of gastric acid, infants with pyloric stenosis will develop a hypochloremic, hypokalemic metabolic alkalosis. The infant must have fluid and electrolyte balance restored and stabilized prior to surgical repair. Soon after the surgical procedure the infant will be able to feed normally again.

27. A 3-week-old infant presents to the emergency department with jaundice. Laboratory evaluation reveals a total bilirubin of 14 mg/dL and conjugated bilirubin of 10 mg/dL. Explanation of these findings to the family includes which of the following?

a. An elevated conjugated bilirubin is an expected result for infants with physiologic jaundice.

b. Laboratory studies are abnormal in an infant at this age, so a pediatric gastroenterologist will need to be consulted immediately.

c. These results could be from breast-feeding, so they should be repeated in 1 week.

d. The infant can be managed at home with exposure to direct sunlight and a Biliblanket.

View Answer

Answer: B

A high total bilirubin with presence of conjugated or direct bilirubin likely indicates cholestatic liver disease. These results are not physiologic jaundice of the newborn which has an associated elevated unconjugated bilirubin level. Evaluation by a pediatric gastroenterologist is most important as this child could have biliary atresia, with the best prognosis associated with timely diagnosis and treatment. The interventions of placing the infant in direct sunlight and maintaining hydration with regular bowel movements aid in the resolution of unconjugated hyperbilirubinemia, not conjugated hyperbilirubinemia. It is unlikely that repeating the laboratory studies will reveal different results.

28. A 7-year-old has a laparoscopic appendectomy for acute appendicitis. Prior to surgery the child received a dose of cefoxitin. As the surgical nurse practitioner, which of the following antibiotic courses should be considered?

a. A total of 3 days of intravenous (IV) antibiotics.

b. A total of 3 days of IV antibiotics and 4 additional days of oral antibiotics once discharged.

c. No further antibiotic dosing.

d. An additional 24 hours of oral antibiotic therapy.

View Answer

Answer: C

No additional antibiotic therapy is needed for a child following appendectomy for appendicitis which did not include perforation. For a perforated appendix, a longer duration of IV antibiotics is indicated and is based on the child’s response to therapy.

29. Which of the following is an acquired condition that may require the placement of a tracheostomy in a child that has been intubated for several weeks for respiratory failure?

a. Ventilator dependency.

b. Craniofacial anomalies.

c. Vascular ring.

d. Cervical hemangioma.

View Answer

Answer: A

There are several reasons for the placement of a tracheostomy tube, including the need for continued ventilation outside the hospital setting. For a child who has been on a ventilator for a long period of time and is not able to be successfully weaned, the tracheostomy is an acquired indication for either temporary or permanent respiratory support.

30. A high Mallampati score (class 3 or 4) is associated with:

a. More difficult intubation.

b. Patent airway.

c. Brain death.

d. Diffuse axonal injury.

View Answer

Answer: A

The Mallampati score is an assessment of the airway of a patient usually completed by an anesthesia provider prior to intubation. The patient is assessed by opening the mouth for direct visualization of the airway. A score of class 3 or 4 or higher is associated with a more difficult airway and intubation.

31. A 9-year-old presents to the emergency department with severe left eye pain and edema, and low-grade fever. Based on the history and physical examination you obtain, you suspect orbital cellulitis. Which of the following interventions would you perform first?

a. Establish IV access, give IV antibiotics, then obtain laboratory tests (e.g., blood culture, complete blood count).

b. Consult an ENT and ophthalmologist.

c. Obtain CT of the orbits and parasinuses.

d. Perform LP, then administer IV antibiotics.

View Answer

Answer: C

Obtaining a CT of the orbits and paranasal sinuses, with and without contrast, should be done first to differentiate the orbital cellulitis. While early treatment with IV antibiotics improves patient outcomes, it is important to obtain blood cultures prior to initiation of antibiotics. A lumbar puncture should be performed in patients who are exhibiting meningeal signs or if central nervous system dysfunction is suspected. Although an otolaryngologist and ophthalmologist may need to be consulted for further examination and treatment, this is not the first priority.

32. A teenager with cystic fibrosis is being considered for a lung transplant. She has a history of skin cancer which was effectively treated at age 7, hepatitis A liver disease which has resolved, and she currently has a body mass index (BMI) of 19.45. Which of the following applies to this scenario?

a. Hepatitis A, B, or C with liver disease pose contraindications for lung transplant.

b. She is not a candidate for a transplant as she is morbidly obese.

c. Certain types of chemotherapy preclude children from having lung transplants, regardless of how recently it was administered.

d. These problems do not pose definite contraindications to the lung transplant.

View Answer

Answer: D

Absolute contraindications to lung transplantation include malignancy within past 2 years, immunodeficiency syndrome, hepatitis B or C with liver disease, severe neuromuscular disease, multiorgan system dysfunction. Relative contraindications include pleurodesis, renal insufficiency, markedly abnormal BMI, chronic airway infection with specified organisms, severe scoliosis, active collagen disease, mechanical ventilation, among others. Careful evaluation is most important in any situation.

33. An athlete who experienced a loss of consciousness while playing football had a QTc measured at 0.45 m/second. What is the appropriate response?

a. Further evaluation is needed, and he should not engage in sports until cleared by a cardiologist.

b. This is a normal value, so he should have a head CT obtained and evaluated for concussion.

c. Even though this is a normal QTc value, the athlete should avoid sports until an echocardiogram can be obtained.

d. This abnormal value is probably caused by dehydration, so the athlete should consider taking salt tablets and increasing hydration during play.

View Answer

Answer: A

A normal QTc value is 0.44 m/second or less. Prolonged QT syndrome can be inherited or acquired, so the rationale for the prolonged value must be evaluated prior to the athlete returning to any sports activities. A cardiac consult should be obtained before any decisions of management or return to play is determined. If not inherited, the most likely causes of a prolonged QT interval include certain medications, intracranial processes, hypocalcemia, and hypokalemia; hence electrolyte assessment is also important in this case.

34. Peaked T waves found on a pediatric EKG are typically caused by which of the following electrolyte abnormality?

a. Hypocalcemia.

b. Hypophosphatemia.

c. Hyperkalemia.

d. Hypoglycemia.

View Answer

Answer: C

Hyperkalemia typically causes peaked T waves on EKG and is the most common presentation of this abnormality in children. If a child has an elevated potassium level, an EKG can support the reliability of the laboratory result. In all cases, however, the electrolytes should be repeated.

35. What is the purpose of obtaining an echocardiogram prior to and often during chemotherapy for a child with an oncologic diagnosis?

a. Identification of cardiac function often affected by chemotherapy agents.

b. Identification of structural abnormalities often caused by chemotherapy agents.

c. Evaluation of chest pain caused by ischemia related to chemotherapy agents.

d. Evaluation of abnormal electrolyte values when chemotherapy is given intravenously.

View Answer

Answer: A

Many chemotherapy agents are considered cardiotoxic and can have either short- or long-term effects on cardiac function, so a baseline EKG or echocardiography is indicated along with interval checks as the child progresses through therapy.

36. Which of the following are typical characteristics of a child with neurofibromatosis type I?

a. Café au lait spots and Lisch nodules.

b. Café au lait spots and hearing loss.

c. Hearing loss and meningioma.

d. Lisch nodules and meningioma.

View Answer

Answer: A

There are two types of neurofibromatosis, identified as types I and II. Type I is usually diagnosed in infancy or at least prior to age 10 and involves the presence of café au lait spots in more than 90% of patients. Lisch nodules which are hamartomas of the iris are the defining characteristic. Type II neurofibromatosis occurs in patients in adult years and along with other findings, including glioma, meningioma, and hearing loss.

37. A 9-month-old infant arrives to the emergency department via emergency medical service after sustaining what was thought to be a short seizure. She has been afebrile with cold symptoms for the past 3 days and now has a temperature of 103°F rectally. She is sleeping, but arouses when stimulated. Appropriate management at this time is to:

a. Obtain laboratory tests, including complete blood count and blood culture.

b. Request a neurologist consult.

c. Administer antipyretic and observe the patient until she is fully awake.

d. Perform a lumbar puncture and administer loading dose of oral phenytoin.

View Answer

Answer: C

Simple febrile seizures typically do not cause any long-term effects, occurrence of a febrile seizure lasting less than 15 minutes does not require diagnostic evaluation or treatment unless there are clinical findings of concern, including meningeal signs. Imaging is also not recommended due to the radiation exposure and intracranial structural abnormalities are not common in young children.

38. A 13-year-old wakes up every morning with a severe headache and projectile vomiting and is generally lethargic. The top concern on the differential diagnosis list is:

a. Obstructive CNS tumor.

b. Nonobstructive CNS tumor.

c. Wilms tumor.

d. Neuroblastoma.

View Answer

Answer: A

A brain tumor that obstructs the flow of cerebrospinal fluid can cause increased intracranial pressure, identified by symptoms of headache, emesis, and altered neurologic state.

39. Which of the following children would be most at risk for a diagnosis of slipped capital femoral epiphysis (SCFE)?

a. An obese 15-year-old boy with complaints of pain in the right hip and a limp for the past months who denies trauma or injury.

b. A 5-year-old with a limp for 3 to 4 days, who has discomfort with internal rotation and abduction and no external signs.

c. An obese 6-year-old with a painful limp for 2 days, who had a viral illness last month with low-grade fever and has pain with internal rotation.

d. A 16-year-old lacrosse player who scraped her knee during a game last weekend and developed a fever of 101°F last night and presents with swelling and redness to the knee.

View Answer

Answer: A

The typical patient with a diagnosis of SCFE is an obese adolescent who presents with a limp. Complaints of pain to the hip, knee, or thigh and holding the leg in an externally rotated position are other findings. SCFE requires urgent intervention, and surgical correction is necessary to prevent further slippage. The 5-year-old with a limp is classic for Legg-Calvé-Perthes disease, which is caused by poor blood supply to the femoral head causing avascular necrosis. This occurs in prepubertal, immature children and it affects males more than females. The 6-year-old with a painful limp is common for transient synovitis or septic arthritis which is an inflammatory process often following a viral illness. It can be acute or gradual onset and is usually unilateral.

40. Pancreatitis, celiac disease, short gut syndrome, and inflammatory bowel disease may result in which of the following alterations in serum magnesium levels?

a. Hypomagnesemia.

b. Hypermagnesemia.

c. Severe, life-threatening hypermagnesemia.

d. No effect on serum magnesium levels.

View Answer

Answer: A

Gastrointestinal losses are one of the leading causes of hypomagnesemia in the hospitalized child.

41. A 6-year-old boy who is overweight has had a limp for the past 6 months which followed a car accident and is now complaining of pain in his hip. The most likely diagnosis is:

a. Slipped capital femoral epiphysis.

b. Osteomyelitis.

c. Legg-Calvé-Perthes disease (LCPD).

d. Fractured hip.

View Answer

Answer: C

LCPD is an avascular necrosis of the proximal femoral head resulting from compromise of the tenuous blood supply to this area. It usually occurs in prepubertal children aged 4 to 10 years and is more prominent in boys than in girls. In the vast majority of cases, the disorder is unilateral. Initial therapy for LCPD includes rest and slow restoration back to use. If not identified early and managed, a child may require surgical intervention.

42. A 9-month-old is intubated and ventilated in the pediatric intensive care unit following full cardiopulmonary arrest secondary to suspected nonaccidental trauma. After stabilization and central line placement, she is reported to have excessive urine output over the past 3 hours, which is calculated to be >4 mL/kg/hour. The most likely rationale and management is:

a. Syndrome of inappropriate antidiuretic hormone (SIADH); obtain a basic metabolic panel (BMP), urinalysis, urine electrolytes, urine and serum osmolarity.

b. Cerebral salt wasting (CSW); obtain BMP, complete blood count (CBC), urinalysis, urine electrolytes panel, and urine osmolarity.

c. Central diabetes insipidus (DI); obtain BMP, urinalysis, urine electrolytes, urine and serum osmolarity.

d. Increased urine output due to extensive fluid resuscitation during stabilization period; obtain BMP in 8 hours.

View Answer

Answer: C

Central DI is the inability to concentrate urine secondary to a vasopressin deficiency which can occur as a result of head trauma due to edema in the area surrounding the hypothalamus and pituitary gland. Classic findings of DI include excess urine output with low urine osmolarity (specific gravity <1.005), high serum osmolarity, and hypernatremia. Polyuria can be >4 mL/kg/hour in infants and 150 mL/kg/day in older children. Direct measurements of urine sodium excretion, in addition to serum and urine osmolality, are critical in diagnosing DI. Laboratory studies to confirm the diagnosis of DI and to differentiate it from cerebral salt wasting include a urine sodium <30 mEq/L, urine osmolarity <200 mOsm/L, serum sodium >150 mEq/L, and serum osmolarity >295 mOsm/L. DI should be identified as soon as possible to prevent profound hypovolemic hyperosmotic dehydration. SIADH results in decreased urine output due to an excess in antidiuretic hormone.

43. A 13-day-old female infant presents with lethargy and poor feeding. She is hypotonic, dehydrated, and has ambiguous genitalia. Laboratory evaluation reveals that the infant has hypoglycemia, hyponatremia, hyperkalemia with metabolic acidosis. Which of the following is the most likely diagnosis?

a. Hyponatremia secondary to improper formula mixing.

b. Congenital adrenal hyperplasia (CAH).

c. Acute renal failure.

d. Sepsis.

View Answer

Answer: B

CAH is characterized by a 21-hydroxylase deficiency, which typically presents with a salt-wasting crisis in the first few weeks of life. This enzyme deficiency results because of insufficient adrenal production of cortisol and aldosterone, in addition to an excess of androgens, which can also cause ambiguous genitalia in female infants. Clinical manifestation of acute adrenal crisis in CAH includes lethargy, poor feeding, altered sensorium, vomiting, hypotension, and hypothermia. Laboratory findings include hypoglycemia, hyperkalemia, hyponatremia, dehydration, and metabolic acidosis.

44. An obese school-age child is noted to be apneic with desaturation of 81% during a polysomnography (sleep study). The most likely cause is:

a. Obstructive apnea.

b. Central apnea.

c. Muscular dystrophy.

d. Congenital cardiomyopathy.

View Answer

Answer: A

Apnea is defined as cessation of airflow through the respiratory tract for 20 seconds or longer, or a shorter respiratory pause associated with bradycardia or cyanosis, significant enough to cause arterial hypoxemia and hypercapnia. There are several types of apnea; the two primary types are obstructive and central. Obstructive apnea occurs when the airway is occluded with tonsils or tissue, especially during relaxed phases, such as sleep.

45. An 18-month-old toddler with a recent history of endotracheal intubation presents with trismus, drooling, and dysphagia. The most likely diagnosis is:

a. Epiglottitis.

b. Laryngotracheobronchitis.

c. Bacterial tracheitis.

d. Retropharyngeal abscess (RPA).

View Answer

Answer: D

A history associated with RPA may include endotracheal intubation, oral foreign object, dental procedures, and recent infection of any structures that drain into the retropharyngeal space. Characteristic findings associated with RPA include trismus, drooling, dysphagia, sore throat, neck swelling, and fever.

46. Which of the following is a most important element of a quality improvement plan?

a. Careful planning that includes a stakeholder analysis and assembling a team.

b. Creation of a data bank that is used to rationalize a proposed change.

c. Testing changes in care that have occurred by history will result in improvement.

d. Following the criteria outlined by an administrator.

View Answer

Answer: A

Components of a quality improvement plan include initially identifying a clear aim, conducting a stakeholder analysis, and assembling a team. Continue by selecting “changes” or interventions that are hypothesized resulting in improvement. Next steps include selecting measures, creating a data collection process, testing changes to determine if they result in improvement, and developing a strategy for sustaining and spreading successful changes.

47. A teenager with Marfan syndrome is undergoing a dental procedure which includes tooth extraction. Which of the following is the appropriate preoperative management in regard to instituting endocarditis prophylaxis?

a. Should be instituted before dental procedures for all patients with Marfan syndrome.

b. Should be instituted if the patient has a prosthetic heart valve.

c. Should be instituted if the patient has tricuspid regurgitation.

d. Should be instituted if the patient has severe aortic root dilatation.

View Answer

Answer: B

There are some dental procedures including dental radiography, placement of orthodontic appliances, and shedding of deciduous teeth that do not require endocarditis prophylaxis. A dental extraction would qualify as an appropriate procedure prior to which patients with prosthetic heart valves should receive bacterial endocarditis prophylaxis. Based on the most recent American Heart Association guidelines, aortic root dilation and tricuspid regurgitation are not conditions that routinely require endocarditis prophylaxis.

48. While examining an infant, it is noted that the child failed his initial hearing screen and does not startle to loud noises. The outer ear appears wide and low with no earlobe. Which of the following should be considered as high on the differential list?

a. Angelman syndrome.

b. CHARGE syndrome.

c. Cystic fibrosis.

d. Rett syndrome.

View Answer

Answer: B

CHARGE syndrome is a genetic pattern of birth defects which include coloboma of the eyes, choanal atresia or stenosis, cranial nerve involvement, outer, inner, and middle ear abnormalities, cardiac defects, cleft lip and palate, and several others that are not typically associated with other patterned abnormalities. CHARGE syndrome includes hearing loss and outer ear abnormalities, such as the outer ear appearing wide, low, and with no earlobe. Angelman syndrome features are characteristically dysmorphic, inappropriately happy, and severe mental retardation. Cystic fibrosis is characterized by poor growth and lung dysfunction. Rett syndrome is usually found in females, and between 6 and 18 months development begins to regress, and microcephaly ensues.

49. A 3-year-old with an acute asthma exacerbation has mild hypoxia and is currently receiving albuterol inhalation treatments every 2 hours. In between, her oxygen saturations are between 90% and 93% on room air. The most efficient and effective type of oxygen therapy for this child is:

a. High-flow cannula at 4 to 6 L/minute flow.

b. Bilevel positive airway pressure ventilation.

c. Nasal cannula at 1 to 2 L/minute flow.

d. Simple face mask at 40%.

View Answer

Answer: C

Oxygen therapy to provide support for a child with an underlying respiratory illness includes nasal cannula, providing 24% to 44% based on liter flow. The nasal cannula is typically tolerated well and can be left in place during inhalation treatments.

50. A 3-month-old infant is admitted with a diagnosis of RSV (respiratory syncytial virus) bronchiolitis and respiratory distress. Currently on a high-flow heated nasal cannula at 4 L flow, the infant has not been maintaining acceptable oxygen saturation and is breathing 80 times per minute with visible intercostal and substernal retractions. A chest radiograph indicates hyperexpansion, but no focal infiltrates. What is the next step in oxygenation?

a. Increase the oxygen liter flow.

b. Consider using bilevel positive airway pressure (BiPAP).

c. Obtain a blood gas measurement.

d. Switch to oxygen by face mask.

View Answer

Answer: A

Heated high-flow oxygen delivery systems include Vapotherm. High-flow therapy is effective for any age child, particularly young children and infants. When lower liter flow is not effective, increasing the flow is appropriate prior to considering a more invasive type of therapy such as BiPAP or continuous positive airway pressure.

51. A 5-year-old with status asthmaticus was treated with three back-to-back albuterol/ipratropium bromide inhalations; also, an intravenous catheter was placed and a 20-mL/kg normal saline bolus was given. Methylprednisolone was also administered. The child continues to be in distress, with audible expiratory wheezing and an oxygen saturation of 95% on 2-L nasal cannula. What is the next appropriate intervention?

a. Intubation.

b. Continuous albuterol.

c. Terbutaline bolus.

d. Bilevel positive airway pressure (BiPAP) therapy.

View Answer

Answer: B

After back-to-back albuterol treatments and corticosteroids, the next intervention for a child in status asthmaticus should be continuous albuterol. A terbutaline bolus is not given before continuous albuterol is attempted. Magnesium as a bolus would also be an appropriate choice at this time. Intubation or BiPAP therapy may be needed if the child deteriorates.

52. Which of the following is an invasive means of securing a difficult airway?

a. Cricothyrotomy.

b. Laryngeal mask airway (LMA).

c. Wisconsin 2 blade.

d. Light wand.

View Answer

Answer: A

A cricothyrotomy is an invasive surgical procedure that will secure an airway in a patient with difficult airway. The American Society of Anesthesiologists’ Difficult Airway Algorithm describes “surgical or percutaneous tracheostomy or cricothyrotomy” as invasive airway access. Use of an LMA, Wisconsin 2 blade, or a light wand is a noninvasive strategy for a difficult airway.

53. A 4-month-old, born at 28 weeks’ gestation, with a history of mechanical ventilation is seen in the emergency department for increased work of breathing, particularly on expiration. The saturations are 94% on room air with a respiratory rate of 44 breaths/minute. She is alert and smiling and has no clinical evidence of wheezing or stridor. The infant’s caregiver reports a history of tracheomalacia. The most appropriate initial management for her increased work in breathing is:

a. Continuous positive pressure.

b. High-flow oxygen by nasal cannula.

c. Continuous albuterol therapy.

d. Mechanical ventilation.

View Answer

Answer: A

Some infants who have been mechanically ventilated in the neonatal period develop a narrowing of their tracheal tissue, as the cartilage has “molded” to the endotracheal tube. With continuous positive pressure, a set level of continuous pressure is provided throughout the entire respiratory cycle. The area of narrowing is stented open with additional pressure, improving the airway obstruction and reducing the work of breathing.

54. Appropriate therapy for a 2-year-old presenting with cold symptoms for 1 week, low-grade fever, and significant stridor includes:

a. A single dose of dexamethasone.

b. Albuterol inhalation.

c. A 5-day treatment of prednisolone.

d. Antibiotic therapy.

View Answer

Answer: A

The American Academy of Pediatrics has indicated that one single dose of Decadron at 0.6 mg/kg/dose given orally to a young child with croup symptoms is beneficial at preventing worsening respiratory distress.

55. The bidirectional Glenn procedure is a second-stage procedure completed for which of the following cardiac defects?

a. Patent ductus arteriosus.

b. Ventricular septal defect.

c. Tricuspid atresia.

d. Atrial septal defect.

View Answer

Answer: C

The bidirectional Glenn procedure is completed as the stage 2 repair for tricuspid atresia. The surgery involves disconnecting the superior vena cava (SVC) from the right atrium and connecting the SVC directly to the right pulmonary artery. This procedure is also used for single ventricle anatomy.

56. Secondary hypertension is typically caused by which of the following etiologies?

a. Adrenal insufficiency.

b. Renal disease.

c. Type 2 diabetes mellitus.

d. Genetic predisposition.

View Answer

Answer: B

Secondary hypertension is more common in children than in adults and is most often caused by renal disease. Adrenal insufficiency, certain medications (including corticosteroids), sleep apnea, stress, and anxiety can also be causative factors. Genetic predisposition is the most common cause of primary hypertension in children.

57. A 14-year-old obese teen who has moderate persistent asthma and plays football is found to have secondary hypertension, which is not improving with diet modifications. What is the best choice of pharmacologic therapy for this child?

a. Calcium channel blocker.

b. Diuretic.

c. Angiotensin II-converting enzyme (ACE) inhibitor.

d. Clonidine.

View Answer

Answer: A

Calcium channel blockers work by widening blood vessels which decreases cardiovascular resistance. They slow the movement of calcium into the cells and are recommended for children with asthma. Clonidine is a sympatholytic medication which is not first line for pediatric hypertension therapy and a diuretic may contribute to dehydration in an athlete. ACE inhibitors may not be a first choice as they also can contribute to dehydration, especially in an athlete who needs continuous hydration.

58. An alert, immunized 5-year-old presents with a bad headache, nausea, photophobia, and fever. His immunizations are up to date and he is not toxic in appearance. He has mild photophobia and mild nuchal discomfort without rigidity. A lumbar puncture reveals WBC 190 × 106/L, protein 48 g/L, glucose 50 mmol/L (blood glucose 87 mg/dL), pending Gram staining and culture. Based on these results, what would be highest on the differential list?

a. Bacterial meningitis.

b. Viral meningitis.

c. Encephalitis.

d. Influenza.

View Answer

Answer: B

Typical cerebrospinal fluid results for viral meningitis include a slightly elevated WBC count (<500 × 106/L), protein close to normal (<100 g/L), and a normal glucose level. Gram stainings and cultures are negative. A positive herpes simplex virus (HSV) polymerase chain reaction would indicate a HSV infection.

59. A 10-year-old patient is now 100 days out from a living donor liver transplant, and presents with dysuria and fever for 2 days. A urine culture is positive for Aspergillus. In choosing an antifungal agent, which of the following treatment options is the most appropriate?

a. Oral fluconazole.

b. IV amphotericin B.

c. IV voriconazole.

d. No treatment for a fungal source urinary tract infection.

View Answer

Answer: B

Oral formulations for invasive fungal disease are seldom appropriate, especially in an immunocompromised child. Fluconazole has no activity against Aspergillus. IV voriconazole is a reasonable choice, but would be inappropriate in light of its interactions with many immunosuppressive medications, which this patient is likely prescribed. Amphotericin is the most appropriate therapy, and urine isolates of invasive fungal species are real and should be treated as such.

60. In the month of December, a 15-year-old presents to the emergency department with complaints of fever, cough, malaise, and headache. The temperature is 103°F axillary and the respiratory rate is 35 breaths/minute, with a pulse oximetry reading of 97% on room air. What is the next needed action?

a. Determine history of influenza vaccination.

b. Obtain complete blood count and electrolytes panel.

c. Obtain IV access and administer fluid bolus.

d. Obtain a chest radiograph.

View Answer

Answer: A

Symptoms of headache, fever, malaise, myalgias, and cough represent influenza, especially during the winter months. It is important to determine the history of illness prior to completing laboratory testing or beginning management. Asking about history of vaccination and obtaining influenza screening are appropriate initial assessment or evaluation. It is also important to assess for risk factors, including underlying cardiac, neurologic, or respiratory conditions, which could contribute to secondary illness or worsening symptoms.

61. An adolescent girl presents with complaints of fever of 39°C orally, maculopapular rash which has been present for 3 days, and acute difficulty breathing. In addition to fever, the adolescent has a blood pressure of 72/34 mmHg with prolonged capillary refill. After addressing respiratory issues, initial important management includes:

a. Fluid bolus of 20 mL/kg.

b. Administration of antibiotics to include gentamycin for synergy.

c. Administration of diphenhydramine for allergic anaphylaxis.

d. Placement of a central venous catheter.

View Answer

Answer: A

After management of airway and breathing, circulation should be addressed in this case of potential toxic shock syndrome (TSS). Fluid bolus of 20 mL/kg can be repeated multiple times to manage blood pressure. Placement of a central line would be appropriate if fluid therapy was not sufficient. Antibiotics for the treatment of TSS include a second- or third-generation cephalosporin such as ceftriaxone and vancomycin.

62. Two siblings who have just traveled from Africa present with intermittent fever and are found to be anemic with mild metabolic acidosis. What diagnosis needs to be first on the differential list?

a. Septic shock.

b. Tularemia.

c. Malaria.

d. Smallpox.

View Answer

Answer: C

Malaria is a parasitic illness which is transmitted through a mosquito bite in areas that are endemic. Plasmodium vivax and Plasmodium falciparum are the most common species that affect humans. P. falciparum is prevalent in Africa and Papua New Guinea. Symptoms of malaria include high fever, with chills, rigor, sweats, and headache and are cyclic in occurrence. Infection with P. falciparum is fatal and can manifest with multisystem involvement, including neurologic findings, renal failure, nephrotic syndrome, anemia, respiratory failure, and metabolic acidosis without pulmonary edema, among other significant problems. People traveling to these areas should receive prophylaxis prior to travel with pharmacologic agents based on potential exposure.

63. Which of the following patients would require a head CT prior to a lumbar puncture?

a. A 5-month-old with irritability, who fixes and follows, with a soft and flat fontanelle.

b. A 3-year-old who is drowsy, wakes to verbal stimulation, and follows commands.

c. An 8-month-old who is clinically diagnosed with meningitis and is crying on examination.

d. An 8-year-old with complaints of headache and vomiting and who has arrived in the emergency department for evaluation of vision changes.

View Answer

Answer: D

An 8-year-old with headache, vomiting, and visual changes is symptomatic for increased intracranial pressure, and a head CT is indicated prior to a lumbar puncture to evaluate for cerebral edema, space-occupying lesion, or hemorrhage.

64. A 3-year-old with new-onset status epilepticus is treated with fosphenytoin. The phenytoin total level is reported as 4.2 µg/mL. What other laboratory value should be reviewed?

a. Albumin.

b. Sodium.

c. Glucose.

d. Blood urea nitrogen.

View Answer

Answer: A

Phenytoin is protein bound; therefore, if the albumin is low, the phenytoin level may not be correctly interpreted. A free-phenytoin level should also be obtained prior to administering another bolus of fosphenytoin.

65. The Children’s Oncology Group long-term guidelines for childhood cancer survivors include obtaining a ferritin level. Potential complication(s) associated with an elevated ferritin level includes:

a. Development of thromboemboli.

b. Increased risk of secondary malignancy or metastases.

c. Damage to the heart and liver.

d. Development of steatosis.

View Answer

Answer: C

Iron overload has been reported in patients following chemotherapy and hematopoietic stem cell transplant. A prolonged elevated ferritin level can lead to liver dysfunction, endocrine disorders, and altered cardiac function.

66. A 20-month-old presents with watery diarrhea for 5 days with new-onset high fever. The infant has been tired and listless with loss of appetite. The diarrhea is described as nonbloody recurrent loose stools with unknown urine output. Physical examination reveals a pale, lethargic toddler who has periorbital edema with fine scattered petechiae over face and extremities. In considering the diagnostic evaluation for this child, laboratory findings for diarrhea-associated (D+) hemolytic uremic syndrome (HUS) would be supported by which of the following?

a. Prolonged PT, prolonged PTT, and thrombocytopenia.

b. Uremia, anemia, thrombocytopenia, and reticulocytosis.

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Jan 30, 2021 | Posted by in NURSING | Comments Off on 200-Item Acute Care Examination

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