PNCB Acute Care CPNP-AC Exam : Complete Practice Test with 150+ Verified Q&A – Pediatric Critical Care, DKA, Shock, Respiratory Failure, Sepsis, Trauma & NICU/PICU Management

This comprehensive acute care pediatric nurse practitioner exam preparation guide is fully updated for the 2025–2026 PNCB testing cycle and is specifically designed for the Certified Pediatric Nurse Practitioner – Acute Care (CPNP-AC) certification examination. It contains over 150 real exam-style questions with verified answers and detailed rationales, covering all major content areas required for success on the PNCB Acute Care exam. Content is organized into the following major topic areas: 1. Fluid, Electrolytes, and Nutrition Refeeding syndrome – hypophosphatemia (phosphate 3.5 mg/dL), hypokalemia (K+ 3.5 mEq/L), hypomagnesemia (Mg 1.8 mg/dL), thiamine deficiency Enteral nutrition in severe malnutrition – laboratory values indicative of refeeding syndrome (phosphate 3.0 mg/dL & potassium 2.8 mEq/L) Parenteral nutrition – triglycerides should be monitored 48-72 hours after initiation to adjust formulation Maintenance fluids for child with pneumonia and adequate urine output – D5 normal saline + potassium chloride 20 mEq/L Indirect calorimetry – BEST estimate of energy requirements for mechanically ventilated child Cholestatic liver disease – complication of long-term parenteral nutrition Positive nitrogen balance – main objective of parenteral nutrition in septic shock 2. Respiratory Disorders and Mechanical Ventilation Tracheal plug in mechanically ventilated child – low tidal volumes, high respiratory rate, high peak inspiratory pressure (PIP) Readiness for extubation – infant with bronchiolitis on pressure support ventilation with tidal volumes 6-7 mL/kg Pneumomediastinum – chest radiograph shows air (increased lucency) in mediastinum; presenting with chest pain and mild dyspnea Bronchiolitis – diffuse wheezes and crackles, RSV most common, hypoxia may be present Pneumonia – fever, cough, decreased breath sounds, rales over affected lobe Croup (laryngotracheobronchitis) – parainfluenza virus, barky cough, stridor (high-pitched whistling on inspiration) Foreign body aspiration – sudden onset wheezing in previously healthy child during playtime Pulmonary contusion after trauma – low tidal volumes (6-8 mL/kg), permissive hypercapnia, PaO2 55-80 mmHg ARDS management – lower tidal volumes (6-8 mL/kg), PEEP 8-12 cm H2O, permissive hypercapnia, SpO2 88-95% Positive end-expiratory pressure (PEEP) of 10 – decreased preload (decreased venous return) 3. Cardiovascular Disorders Coarctation of the aorta – right upper extremity hypertension, weak femoral pulses, asymptomatic school-age child Medical management of coarctation – monitoring upper extremity blood pressures for hypertension Ductal-dependent congenital heart lesion in neonate – alprostadil (PGE1) to reopen ductus arteriosus Tetralogy of Fallot – hypercyanotic spells indicate urgent surgical intervention Post-pericardiotomy syndrome – 1-2 weeks after cardiac surgery, fever, pleuritic chest pain, pericardial friction rub Pericarditis – PR-segment depression on ECG, jugular venous distention, muffled heart sounds, friction rub Cardiac tamponade – CVP 20 mmHg with BP 70/55 mmHg (high CVP, narrowed pulse pressure) Hypertrophic cardiomyopathy – autosomal dominant, family history of early sudden death, ECG with LVH and ST changes Mitral valve prolapse – most consistent echocardiogram finding in Marfan syndrome Critical congenital heart disease (CCHD) screening – failed screen (SpO2 90%), hyperoxia test no improvement → initiate alprostadil Supraventricular tachycardia (SVT) in infant – heart rate 290, likely outgrow by 1 year of age Endocarditis – Janeway lesions (nontender erythematous macules on soles/palms), Osler nodes (tender nodules on finger/toe pads) 4. Neurologic Disorders Epidural hematoma – lucid interval followed by acute decline in GCS from 15 to 8 Subdural hematoma – hyperdense crescentic mass along cerebral convexities → neurosurgical consult Abusive head trauma – retinal hemorrhages, rib fractures, classic metaphyseal lesions (CML) Stage III hepatic encephalopathy – confusion, arousable from stupor, asterixis, hyperreflexia Pseudotumor cerebri – overweight adolescent female, headaches with Valsalva, pulsatile tinnitus, vision changes Cerebral palsy – non-progressive, increased DTRs, peripheral hypertonia, weakness, cognitive impairment Guillain-Barré syndrome – ascending weakness, areflexia, post-viral illness, treatment with IVIG Myasthenia gravis – myasthenic crisis = respiratory distress (NOT excessive salivation – that's cholinergic crisis) Long QT syndrome – syncope with sudden auditory stimuli (school bell), prolonged QT interval on ECG Intracranial mass with herniation – hypertension, bradycardia, anisocoria, fixed dilated pupil → hypertonic saline SIADH post-resection of astrocytoma – hyponatremia, decreased UOP, increased urine osmolality → fluid restriction (D5 NS at 2/3 maintenance) Diabetes insipidus – UOP 8 mL/kg/hour, serum Na+ 150, urine specific gravity 1.001 → IV vasopressin 5. Endocrine and Metabolic Disorders Diabetic ketoacidosis (DKA) – initial management: NS fluid bolus 20 mL/kg, insulin infusion 0.1 units/kg/hr (bicarbonate contraindicated, bolus insulin contraindicated) Transition from insulin infusion to subcutaneous insulin – venous pH 7.30 DKA first hour priority – initiate fluid resuscitation (electrolyte replacement, acidosis reversal, hyperglycemia correction come later) New onset diabetes – polyuria, weight loss, pH 7.12, HCO3 9, glucose 567, positive ketones → NS bolus + insulin infusion Hypoglycemia in infant – bedside glucose 65 mg/dL (normal 45 mg/dL) → reassess prior to next feeding Hyperthyroidism (Graves' disease) – decreased TSH, elevated free T4, decline in school performance, weight loss Hypothyroidism – elevated TSH, decreased T4 Adrenal insufficiency – hypoglycemia, hyponatremia, hyperkalemia → serum cortisol Inborn error of metabolism – first priority: IV dextrose (stop enteral intake, avoid protein) 6. Renal and Genitourinary Disorders Hemolytic uremic syndrome (HUS) – fever, abdominal pain, bloody diarrhea, decreased UOP, hematuria, schistocytes, thrombocytopenia, normal coagulation labs HUS history question – "What has the child eaten in the past week?" (undercooked beef, E. coli O157:H7) Acute poststreptococcal glomerulonephritis (APSGN) – 1-2 weeks after pharyngitis, hypertension, periorbital edema, hematuria, proteinuria → serum antistreptolysin O titer Nephrotic syndrome – first-line treatment: corticosteroids (prednisone 2 mg/kg/day) Nephrolithiasis prevention – ensure at least 2 liters of fluid intake daily Pyelonephritis – fever 102.2°F (39°C) with UTI (leukocyte esterase and nitrites positive) Type I renal tubular acidosis (RTA) – normal anion gap metabolic acidosis, hypokalemia, failure to thrive Renal injury (grade II) – most important to monitor: hemoglobin and hematocrit (hematuria common sign) 7. Infectious Diseases Occult bacteremia – highest risk: 1 month old with decreased capillary refill and fever 102°F Meningitis – bacterial: urine output 8 mL/kg/hr, serum Na+ 150 → IV vasopressin for DI Osteomyelitis – MOST common cause of secondary hypertension in school-age children? (No – renal parenchymal disease is #1) Septic shock – intubation agent of choice: ketamine (maintains cardiovascular stability; etomidate not recommended) Sepsis therapeutic endpoints – UOP 1 mL/kg/hr, capillary refill ≤2 seconds, normal BP, warm extremities Transition from aerobic to anaerobic metabolism – serum lactate 6.2 mmol/L Pertussis in infant 6 months – apnea (not cough) after catarrhal stage Measles – cough, coryza, conjunctivitis, Koplik spots (greyish-white spots on posterior buccal mucosa) Rocky Mountain spotted fever (RMSF) – erythematous maculopapular rash on wrists and ankles, fever, myalgias, headache Necrotizing fasciitis – pain out of proportion to clinical findings, crepitus, elevated CK indicates myonecrosis → urgent surgical debridement Cellulitis – treatment: cephalexin or cloxacillin PO Skin abscess (purulent, 1.5 cm, afebrile) – incision & drainage with Gram stain (antibiotics not indicated without systemic symptoms) Human bite – most common location: over dorsal MCP from punch in mouth → urgent surgical exploration Dog/cat bite pathogens – Pasturella, S. aureus, S. viridans; treatment: Clavulin Chylothorax post-aortic arch repair – high protein, low fat diet (medium-chain triglycerides) 8. Hematology and Oncology Leukemia – hyperleukocytosis (WBC 105,000), thrombocytopenia (plt 10,000), anemia (Hgb 6.1) → fluid bolus + oncology consult Trisomy 21 with leukemia – higher incidence, presents with fever, pallor, decreased activity, pancytopenia Tumor lysis syndrome – Chvostek sign and Trousseau sign (hypocalcemia) after chemotherapy initiation Wilms tumor – nephrectomy followed by chemotherapy (always) Neuroblastoma with urinary retention – medical emergency (spinal cord compression) Immune thrombocytopenic purpura (ITP) – post-viral, isolated thrombocytopenia (plt 95,000), bleeding gums, bruises Osteosarcoma – sunburst pattern on radiograph Splenectomy preventive care – pneumococcal, Haemophilus influenzae, and meningococcal vaccines Intrathecal chemotherapy – desired intervertebral space: L4-L5 (below spinal cord termination) Opiate withdrawal risk – infant on morphine infusion for 6 days (minimum 3 days, 100% after 10 days) Platelet transfusion threshold – post-op epidural hematoma evacuation with plt 72,000 (active bleeding/risk) Transfusion-related acute lung injury (TRALI) – hypoxia and bilateral infiltrates within 6 hours of transfusion Propofol infusion syndrome – refractory bradycardia, metabolic acidosis, hyperkalemia, rhabdomyolysis Factor V Leiden deficiency with femur fracture – high risk for thrombosis and embolus Sickle cell disease – penicillin prophylaxis until 5 years of age 9. Trauma and Surgical Conditions Blast injury – abdominal manifestations delayed 8-36 hours after exposure Compartment syndrome in children – most sensitive early indicator: increasing analgesic requirement (not the 5 Ps) Tension pneumothorax after chest trauma – needle thoracostomy priority (2nd ICS, midclavicular line) Slipped capital femoral epiphysis (SCFE) – adolescent, overweight, groin pain, "pop" while playing basketball → plain radiograph (AP and lateral) Septic arthritis vs. transient synovitis – temperature 38.5°C (101.3°F) most helpful differentiating finding Appendicitis – right lower quadrant pain, N/V, low-grade fever (standard presentation) Intussusception – currant jelly stool (not in this file but classic) Necrotizing enterocolitis (NEC) history – peritoneal drain placement → risk for intestinal strictures Vascular ring – intermittent tracheal narrowing, posterior pulsatile indentation of esophagus on swallowing study Burn management – keep patient covered and warm, fluid resuscitation, antimicrobial dressings, tetanus prophylaxis Burn depth – first degree (erythema, painful), superficial partial thickness (blisters, sensate, heals 2-3 weeks) Rule of Nines – head/neck 9%, each UE 9%, each LE 9%, front trunk 18%, back trunk 18% Parkland formula – fluid resuscitation in burn patients Escharotomy – for circumferential burns Nutritional support in burns – enteral nutrition within 24 hours, consult nutrition service 10. Medications and Toxicology Propranolol (Inderal) – bradycardia adverse effect (beta-blocker) Succinylcholine contraindication – family history of Duchenne muscular dystrophy (risk of hyperkalemia, rhabdomyolysis) Opiate intoxication – pinpoint pupils, respiratory depression, depressed LOC, bradycardia Anticholinergic toxicity (diphenhydramine overdose) – agitation, mydriasis, flushing ("Mad as a hatter, blind as a bat, red as a beet, hot as a hare, dry as a bone") Dextromethorphan abuse – euphoric effects, popular among adolescents Fentanyl chest wall rigidity – treatment: neuromuscular blocking agent (rocuronium) Propofol infusion syndrome – refractory bradycardia, metabolic acidosis Alprostadil (PGE1) – for ductal-dependent congenital heart lesions Terbutaline – adverse effect: heart palpitations (preterm labor) Magnesium sulfate toxicity – calcium gluconate as antidote Betamethasone – stimulates fetal lung maturity Rho(D) immune globulin – for Rh-negative mother with Rh-positive newborn Acyclovir – for genital herpes (antiviral) Metronidazole – for bacterial vaginosis, trichomoniasis Oxytocin induction – contraindicated with active genital herpes Methylergonovine – contraindicated with hypertension (BP 142/92) 11. Developmental and Behavioral Pediatrics Preschooler behavioral/psychiatric disorder – frequent temper tantrums 2-year-old psychomotor development – builds tower of 6-7 blocks Palliative care primary focus – develop desirable goals of care, recommend life-prolonging therapies, enhance quality of life Beneficence – prescribing antibiotics for bacterial pneumonia (providing care that benefits the child) Informed consent comprehension – have person explain in own words what will be done Transition from pediatric to adult care – care coordination initiated by pediatric team Telehealth – MOST important consideration: patient location (across state lines determines regulations) Privileging for NP – hospital permits NP to perform procedures after demonstrating competence Evidence-based practice – interprofessional team reviewing literature to develop algorithms Child Protective Services reporting – focus on child's well-being when informing family Sexual abuse reporting – provide information to law enforcement as requested (mandated reporter) 12. Genetic and Congenital Disorders Turner syndrome – pedal edema, low hairline, loose skinfolds at nape of neck → echocardiogram (cardiac defects common: bicuspid aortic valve, coarctation) DiGeorge syndrome (22q11.2 deletion) – interrupted aortic arch, dysmorphic features, thymic aplasia → immune dysfunction Down syndrome (trisomy 21) – atlantoaxial instability screening before contact sports Prader-Willi syndrome – severe hypotonia, feeding difficulties, hypogonadism, small hands/feet, risk for FTT Marfan syndrome – mitral valve prolapse most common on echocardiogram Noonan syndrome – short stature, developmental delay, cardiac defects Fragile X syndrome – most common inherited form of intellectual disability Fetal alcohol syndrome – developmental delay, growth retardation 13. Rheumatology and Immunology Henoch-Schönlein purpura (HSP) – classic triad: abdominal pain, purpura, arthritis → ask about joint pain Systemic lupus erythematosus (SLE) – malar rash (photosensitive), leukopenia, thrombocytopenia, proteinuria Juvenile idiopathic arthritis (JIA) – routine ophthalmology screening for uveitis (slit lamp exam) Patellofemoral pain syndrome – adolescent, bilateral knee pain, worsens with stairs/sitting with knees flexed, grinding sensation Reactive arthritis post-gastroenteritis – PT and OT to maximize return to mobility 14. Neonatology Vitamin K deficiency in premature neonate (30 weeks) – prolonged PT/aPTT, normal fibrinogen → diagnosis confirmed by IV vitamin K administration Newborn screening – ensure newborn has been feeding for 24 hours prior to specimen Apgar scoring – heart rate, respiratory effort, muscle tone, reflex irritability, color Newborn reflexes – Babinski (positive – normal), tonic neck, Moro, rooting, sucking Neonatal abstinence syndrome (NAS) – swaddle in flexed position, initiate seizure precautions, exaggerated reflexes Newborn of mother with narcotic use disorder – contraindication: frequent stimulation (need quiet, calm environment) Phototherapy – remove all clothing except diaper, ensure eyes closed beneath shield, turn/reposition q2-3 hours Hypoglycemia in newborn – glucose 20 mg/dL requires intervention; 65 mg/dL is normal (reassess prior to next feeding) 15. Ethics, Legal, and Professional Issues Mandated reporting – report suspected abuse to Child Protective Services, focus on child's well-being Informed consent – have legal guardian explain procedure in own words to verify comprehension Privileging – hospital grants specific procedural privileges after competence demonstrated Evidence-based practice – reviewing literature, grading evidence, developing practice guidelines Telehealth – patient location determines applicable state regulations Transition to adult care – pediatric team initiates care coordination (not family-led) Beneficence vs. nonmaleficence – beneficence = providing beneficial care (antibiotics for pneumonia); nonmaleficence = avoiding harm (double-checking dosage) Key features: 150+ multiple-choice questions with verified answers Detailed rationales for many questions Comprehensive coverage of acute care pediatrics: PICU, NICU, trauma, infectious disease, cardiology, neurology, endocrinology, hematology/oncology, nephrology, pulmonology, gastroenterology, rheumatology, genetics, neonatology, ethics, and professional issues Original page-numbered layout (106 pages) High-yield for PNCB CPNP-AC certification exam, acute care pediatric nurse practitioner boards, and pediatric critical care nursing exams Perfect for acute care pediatric nurse practitioner (CPNP-AC) candidates, PICU nurses, NICU nurses, pediatric hospitalists, and any advanced practice provider preparing for PNCB acute care certification.