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Barkley PNP-AC Comprehensive Board Review
Exam | 100 Predictor Questions and Answers
Domain I: Assessment (25 Questions)
Question 1
A 6-year-old, 20 kg child is admitted to the PICU with suspected septic shock.
After two 20 mL/kg boluses of normal saline, the heart rate remains 150 bpm,
capillary refill is 4 seconds, and blood pressure is 70/40 mmHg. Which finding
BEST indicates that tissue perfusion is still inadequate?
A. Serum lactate of 2.0 mmol/L
B. Urine output of 0.5 mL/kg/hr for the past 2 hours
C. Central venous pressure (CVP) of 8 mmHg
D. ScvO₂ of 58%
: Correct Answer : D
Explanation:
An ScvO₂ < 70% indicates that oxygen delivery is insufficient to meet tissue
demand, a hallmark of ongoing shock. A lactate of 2.0 is borderline, but ScvO₂ is a
direct measure of the balance between oxygen delivery and extraction. Urine
output < 1 mL/kg/hr and hypotension also signal inadequate perfusion, but ScvO₂
provides a global picture. In pediatric septic shock, goal-directed therapy targets
ScvO₂ ≥ 70%.
Question 2
A 3-month-old with bronchiolitis is on HFNC at 2 L/kg/min. The nurse notes that
the infant’s work of breathing has decreased, but the SpO₂ is now 88% and the
infant is less interactive. What is the PRIORITY interpretation?
A. The HFNC is successfully reducing work of breathing
B. The infant is developing hypercapnic respiratory failure and exhaustion
pg. 1
,2
C. The infant is entering a deep sleep cycle
D. The bronchiolitis is resolving and support can be weaned
: Correct Answer : B
Explanation:
A decrease in work of breathing accompanied by worsening hypoxemia and
altered mental status is ominous. It signals that the infant can no longer sustain
the increased minute ventilation required and is decompensating into
hypercapnic respiratory failure. Immediate escalation of respiratory support,
including possible intubation, is required.
Question 3
A 14-year-old trauma patient arrives with a GCS of 7. Pupils are 4 mm and
sluggishly reactive. What is the PRIORITY intervention?
A. Obtain a STAT head CT
B. Place an intracranial pressure monitor
C. Perform rapid sequence intubation to secure the airway
D. Administer hypertonic saline
: Correct Answer : C
Explanation:
The mantra “GCS ≤ 8, intubate” applies. A GCS of 7 indicates a severe brain injury
with inability to protect the airway. Securing the airway with endotracheal
intubation is the first step to prevent aspiration, ensure oxygenation, and control
ventilation. The CT scan follows, not precedes, airway management.
Question 4
An 8-year-old with status asthmaticus has been receiving continuous albuterol for
2 hours. Breath sounds are now markedly diminished, and the patient is
becoming drowsy. Which assessment finding is MOST concerning?
A. Pulsus paradoxus of 15 mmHg
B. Silent chest on auscultation
pg. 2
,3
C. Peak expiratory flow rate of 40% predicted
D. Respiratory rate of 45 breaths per minute
: Correct Answer : B
Explanation:
A silent chest in a severe asthma exacerbation indicates that airflow is so limited
that wheezing can no longer be generated. This is a pre-arrest sign and
necessitates immediate intervention, including possible intubation. Pulsus
paradoxus, low PEFR, and tachypnea are expected in severe asthma, but silent
chest is the most critical finding.
Question 5
A 4-year-old with DKA has a serum glucose of 450 mg/dL, pH 7.1, and K⁺ 5.2
mEq/L. After a 10 mL/kg normal saline bolus, what is the NEXT priority before
starting an insulin infusion?
A. Administer sodium bicarbonate
B. Obtain a head CT
C. Begin potassium replacement in IV fluids
D. Start maintenance fluids with D5 ½ NS
: Correct Answer : C
Explanation:
Insulin drives potassium into cells, which can unmask severe hypokalemia.
Potassium replacement must be initiated (usually 20–40 mEq/L in IV fluids) once
urine output is confirmed and serum K⁺ is < 5.5 mEq/L. Starting insulin without
adequate potassium can precipitate life-threatening cardiac arrhythmias.
Question 6
A 10-month-old with a history of a large VSD presents with diaphoresis during
feeds and poor weight gain. On cardiac exam, which characteristic differentiates a
pathologic VSD murmur from an innocent Still’s murmur?
pg. 3
, 4
A. Grade 2/6 intensity
B. Location at the left lower sternal border
C. A holosystolic quality that does not change with position
D. A musical, vibratory quality
: Correct Answer : C
Explanation:
A VSD murmur is holosystolic and typically constant, not changing with position.
Still’s murmur is a classic innocent murmur that is vibratory, musical, and changes
intensity or disappears with position changes (e.g., sitting up). The presence of
heart failure symptoms further supports a hemodynamically significant VSD.
Question 7
A 5-year-old is intubated for acute respiratory distress syndrome (ARDS). The
ventilator alarms for high peak inspiratory pressure (PIP). The chest rises
asymmetrically, and the trachea is deviated to the left. What is the most likely
cause?
A. Mucus plugging of the endotracheal tube
B. Right-sided tension pneumothorax
C. Mainstem intubation
D. Severe bronchospasm
: Correct Answer : B
Explanation:
Asymmetric chest rise with tracheal deviation to the opposite side is classic for a
tension pneumothorax. This is a life-threatening emergency requiring immediate
needle decompression followed by chest tube placement.
Question 8
A 12-year-old with sickle cell disease (HbSS) presents with sudden pallor,
splenomegaly, and a hemoglobin drop from 8.0 to 4.0 g/dL. Reticulocyte count is
8% (elevated). What type of crisis is this?
pg. 4
Barkley PNP-AC Comprehensive Board Review
Exam | 100 Predictor Questions and Answers
Domain I: Assessment (25 Questions)
Question 1
A 6-year-old, 20 kg child is admitted to the PICU with suspected septic shock.
After two 20 mL/kg boluses of normal saline, the heart rate remains 150 bpm,
capillary refill is 4 seconds, and blood pressure is 70/40 mmHg. Which finding
BEST indicates that tissue perfusion is still inadequate?
A. Serum lactate of 2.0 mmol/L
B. Urine output of 0.5 mL/kg/hr for the past 2 hours
C. Central venous pressure (CVP) of 8 mmHg
D. ScvO₂ of 58%
: Correct Answer : D
Explanation:
An ScvO₂ < 70% indicates that oxygen delivery is insufficient to meet tissue
demand, a hallmark of ongoing shock. A lactate of 2.0 is borderline, but ScvO₂ is a
direct measure of the balance between oxygen delivery and extraction. Urine
output < 1 mL/kg/hr and hypotension also signal inadequate perfusion, but ScvO₂
provides a global picture. In pediatric septic shock, goal-directed therapy targets
ScvO₂ ≥ 70%.
Question 2
A 3-month-old with bronchiolitis is on HFNC at 2 L/kg/min. The nurse notes that
the infant’s work of breathing has decreased, but the SpO₂ is now 88% and the
infant is less interactive. What is the PRIORITY interpretation?
A. The HFNC is successfully reducing work of breathing
B. The infant is developing hypercapnic respiratory failure and exhaustion
pg. 1
,2
C. The infant is entering a deep sleep cycle
D. The bronchiolitis is resolving and support can be weaned
: Correct Answer : B
Explanation:
A decrease in work of breathing accompanied by worsening hypoxemia and
altered mental status is ominous. It signals that the infant can no longer sustain
the increased minute ventilation required and is decompensating into
hypercapnic respiratory failure. Immediate escalation of respiratory support,
including possible intubation, is required.
Question 3
A 14-year-old trauma patient arrives with a GCS of 7. Pupils are 4 mm and
sluggishly reactive. What is the PRIORITY intervention?
A. Obtain a STAT head CT
B. Place an intracranial pressure monitor
C. Perform rapid sequence intubation to secure the airway
D. Administer hypertonic saline
: Correct Answer : C
Explanation:
The mantra “GCS ≤ 8, intubate” applies. A GCS of 7 indicates a severe brain injury
with inability to protect the airway. Securing the airway with endotracheal
intubation is the first step to prevent aspiration, ensure oxygenation, and control
ventilation. The CT scan follows, not precedes, airway management.
Question 4
An 8-year-old with status asthmaticus has been receiving continuous albuterol for
2 hours. Breath sounds are now markedly diminished, and the patient is
becoming drowsy. Which assessment finding is MOST concerning?
A. Pulsus paradoxus of 15 mmHg
B. Silent chest on auscultation
pg. 2
,3
C. Peak expiratory flow rate of 40% predicted
D. Respiratory rate of 45 breaths per minute
: Correct Answer : B
Explanation:
A silent chest in a severe asthma exacerbation indicates that airflow is so limited
that wheezing can no longer be generated. This is a pre-arrest sign and
necessitates immediate intervention, including possible intubation. Pulsus
paradoxus, low PEFR, and tachypnea are expected in severe asthma, but silent
chest is the most critical finding.
Question 5
A 4-year-old with DKA has a serum glucose of 450 mg/dL, pH 7.1, and K⁺ 5.2
mEq/L. After a 10 mL/kg normal saline bolus, what is the NEXT priority before
starting an insulin infusion?
A. Administer sodium bicarbonate
B. Obtain a head CT
C. Begin potassium replacement in IV fluids
D. Start maintenance fluids with D5 ½ NS
: Correct Answer : C
Explanation:
Insulin drives potassium into cells, which can unmask severe hypokalemia.
Potassium replacement must be initiated (usually 20–40 mEq/L in IV fluids) once
urine output is confirmed and serum K⁺ is < 5.5 mEq/L. Starting insulin without
adequate potassium can precipitate life-threatening cardiac arrhythmias.
Question 6
A 10-month-old with a history of a large VSD presents with diaphoresis during
feeds and poor weight gain. On cardiac exam, which characteristic differentiates a
pathologic VSD murmur from an innocent Still’s murmur?
pg. 3
, 4
A. Grade 2/6 intensity
B. Location at the left lower sternal border
C. A holosystolic quality that does not change with position
D. A musical, vibratory quality
: Correct Answer : C
Explanation:
A VSD murmur is holosystolic and typically constant, not changing with position.
Still’s murmur is a classic innocent murmur that is vibratory, musical, and changes
intensity or disappears with position changes (e.g., sitting up). The presence of
heart failure symptoms further supports a hemodynamically significant VSD.
Question 7
A 5-year-old is intubated for acute respiratory distress syndrome (ARDS). The
ventilator alarms for high peak inspiratory pressure (PIP). The chest rises
asymmetrically, and the trachea is deviated to the left. What is the most likely
cause?
A. Mucus plugging of the endotracheal tube
B. Right-sided tension pneumothorax
C. Mainstem intubation
D. Severe bronchospasm
: Correct Answer : B
Explanation:
Asymmetric chest rise with tracheal deviation to the opposite side is classic for a
tension pneumothorax. This is a life-threatening emergency requiring immediate
needle decompression followed by chest tube placement.
Question 8
A 12-year-old with sickle cell disease (HbSS) presents with sudden pallor,
splenomegaly, and a hemoglobin drop from 8.0 to 4.0 g/dL. Reticulocyte count is
8% (elevated). What type of crisis is this?
pg. 4
