ANCC FNP-BC Certification Practice Examination — Version 2
(2026/2027)
Domain A: Assessment & Diagnosis (40 scored + 6 pretest)
1. A 58-year-old male with hypertension and type 2 diabetes presents with substernal chest pressure
when walking up one flight of stairs. Symptoms last 3–5 minutes and resolve with rest. No change in
pattern over 6 months. ECG normal. Next best step?
A. Exercise stress test
B. Coronary CT angiography
C. Start aspirin and statin, optimize risk factors
D. Refer for coronary angiography
2. A 32-year-old female with fatigue, diffuse joint pain, and a facial rash sparing the nasolabial folds.
ANA positive 1:640, anti-dsDNA positive, low C3. Urinalysis shows protein 2+ and RBC casts. Most
likely diagnosis?
A. Rheumatoid arthritis
B. Systemic lupus erythematosus with lupus nephritis
C. Mixed connective tissue disease
D. Sjögren’s syndrome
3. (Pretest) A 72-year-old male with sudden-onset severe headache, vomiting, and right-sided
weakness. Non-contrast head CT shows hyperdense crescent-shaped collection over the left
hemisphere. Most likely diagnosis?
A. Subarachnoid hemorrhage
B. Subdural hematoma
C. Epidural hematoma
D. Intraparenchymal hemorrhage
4. A 45-year-old female with palpitations, heat intolerance, weight loss, and tremor. TSH <0.01, free T4
3.2, free T3 elevated. Thyroid uptake scan shows diffusely increased uptake. Best initial treatment?
A. Methimazole
B. Radioactive iodine
,C. Propranolol alone
D. Thyroidectomy
5. A 6-month-old infant with fever 39°C, irritability, and poor feeding. No focal findings on exam.
Vaccines up to date. Appearance nontoxic. Next best step?
A. Lumbar puncture
B. Urinalysis and urine culture
C. Chest X-ray
D. Empiric antibiotics
6. A 28-year-old G2P1001 at 10 weeks gestation with right lower quadrant pain and spotting.
Transvaginal ultrasound shows empty uterus, left adnexal mass with fetal pole and cardiac activity.
Next best step?
A. Expectant management
B. Methotrexate
C. Salpingectomy
D. Serial beta-hCG
7. A 68-year-old male with chronic cough, hemoptysis, and 40 pack-year smoking history. Chest X-ray
shows left hilar mass. Next best step?
A. CT chest with contrast
B. PET scan
C. Bronchoscopy with biopsy
D. Sputum cytology
8. (Pretest) A 16-year-old male with acute scrotal pain for 4 hours. Testis is tender, high-riding, absent
cremasteric reflex. Next best step?
A. Scrotal ultrasound with Doppler
B. Immediate surgical exploration
C. Antibiotics and ice
D. Manual detorsion
9. A 55-year-old female with episodic dizziness, tinnitus, and ear fullness. Episodes last 2–4 hours,
associated with nausea and vomiting. Between episodes, she is asymptomatic. Most likely diagnosis?
A. BPPV
B. Ménière’s disease
,C. Vestibular neuritis
D. Labyrinthitis
10. A 4-year-old with fever, barking cough, and inspiratory stridor worse at night. No drooling, no toxic
appearance. Most likely diagnosis?
A. Epiglottitis
B. Croup
C. Bacterial tracheitis
D. Peritonsillar abscess
11. A 70-year-old male with history of stroke presents with urinary urgency, frequency, and urge
incontinence. Post-void residual 60 mL. Most likely type?
A. Stress incontinence
B. Urge incontinence
C. Overflow incontinence
D. Mixed incontinence
12. A 35-year-old obese female with right upper quadrant pain after fatty meals. Ultrasound shows
gallstones. WBC normal, LFTs normal, afebrile. Next best step?
A. Laparoscopic cholecystectomy
B. ERCP
C. Ursodiol
D. Low-fat diet and observation
13. (Pretest) A 50-year-old male with chronic low back pain worse at night, morning stiffness >1 hour.
ESR 60, CRP 25. X-ray shows bilateral sacroiliitis. Most likely diagnosis?
A. Lumbar spinal stenosis
B. Ankylosing spondylitis
C. Metastatic cancer
D. Osteoporotic fracture
14. A 25-year-old female with 3 days of dysuria, frequency, suprapubic pain. Urinalysis: + leukocytes, +
nitrites. Pregnancy test negative. First-line antibiotic if local E. coli resistance to TMP-SMX is <20%?
A. Nitrofurantoin 100 mg BID x 5 days
B. TMP-SMX DS BID x 3 days
C. Ciprofloxacin 500 mg BID x 3 days
D. Fosfomycin 3 g x 1 dose
, 15. A 60-year-old with known heart failure with reduced ejection fraction (30%) presents with
worsening dyspnea, orthopnea, and 5 lb weight gain in 3 days. BP 110/70, HR 95, lungs with crackles
bilaterally. Next best step?
A. Increase furosemide
B. Start digoxin
C. Increase carvedilol
D. Admit for IV diuresis
16. A 3-year-old with fever for 5 days, bilateral conjunctival injection, red cracked lips, strawberry
tongue, rash, and cervical adenopathy. Most likely complication if untreated?
A. Coronary artery aneurysms
B. Meningitis
C. Myocarditis
D. Arthritis
17. A 45-year-old male with acute epigastric pain radiating to back, nausea, vomiting. He admits heavy
alcohol use. Lipase 1500. CT shows pancreatic necrosis. Next step?
A. IV fluids, pain control, NPO
B. ERCP
C. IV antibiotics
D. Immediate surgical debridement
18. (Pretest) A 28-year-old female with fatigue, photosensitivity, oral ulcers, and malar rash. ANA
positive, anti-Smith positive, low C4. Urinalysis normal. Best initial treatment?
A. Hydroxychloroquine
B. Prednisone 60 mg daily
C. Mycophenolate mofetil
D. Azathioprine
19. A 55-year-old male with acute onset of vertigo, dysarthria, and ataxia. Symptoms began 90 minutes
ago. Non-contrast head CT normal. Next best step?
A. IV tPA
B. Aspirin 325 mg
C. MRI brain
D. Observation
(2026/2027)
Domain A: Assessment & Diagnosis (40 scored + 6 pretest)
1. A 58-year-old male with hypertension and type 2 diabetes presents with substernal chest pressure
when walking up one flight of stairs. Symptoms last 3–5 minutes and resolve with rest. No change in
pattern over 6 months. ECG normal. Next best step?
A. Exercise stress test
B. Coronary CT angiography
C. Start aspirin and statin, optimize risk factors
D. Refer for coronary angiography
2. A 32-year-old female with fatigue, diffuse joint pain, and a facial rash sparing the nasolabial folds.
ANA positive 1:640, anti-dsDNA positive, low C3. Urinalysis shows protein 2+ and RBC casts. Most
likely diagnosis?
A. Rheumatoid arthritis
B. Systemic lupus erythematosus with lupus nephritis
C. Mixed connective tissue disease
D. Sjögren’s syndrome
3. (Pretest) A 72-year-old male with sudden-onset severe headache, vomiting, and right-sided
weakness. Non-contrast head CT shows hyperdense crescent-shaped collection over the left
hemisphere. Most likely diagnosis?
A. Subarachnoid hemorrhage
B. Subdural hematoma
C. Epidural hematoma
D. Intraparenchymal hemorrhage
4. A 45-year-old female with palpitations, heat intolerance, weight loss, and tremor. TSH <0.01, free T4
3.2, free T3 elevated. Thyroid uptake scan shows diffusely increased uptake. Best initial treatment?
A. Methimazole
B. Radioactive iodine
,C. Propranolol alone
D. Thyroidectomy
5. A 6-month-old infant with fever 39°C, irritability, and poor feeding. No focal findings on exam.
Vaccines up to date. Appearance nontoxic. Next best step?
A. Lumbar puncture
B. Urinalysis and urine culture
C. Chest X-ray
D. Empiric antibiotics
6. A 28-year-old G2P1001 at 10 weeks gestation with right lower quadrant pain and spotting.
Transvaginal ultrasound shows empty uterus, left adnexal mass with fetal pole and cardiac activity.
Next best step?
A. Expectant management
B. Methotrexate
C. Salpingectomy
D. Serial beta-hCG
7. A 68-year-old male with chronic cough, hemoptysis, and 40 pack-year smoking history. Chest X-ray
shows left hilar mass. Next best step?
A. CT chest with contrast
B. PET scan
C. Bronchoscopy with biopsy
D. Sputum cytology
8. (Pretest) A 16-year-old male with acute scrotal pain for 4 hours. Testis is tender, high-riding, absent
cremasteric reflex. Next best step?
A. Scrotal ultrasound with Doppler
B. Immediate surgical exploration
C. Antibiotics and ice
D. Manual detorsion
9. A 55-year-old female with episodic dizziness, tinnitus, and ear fullness. Episodes last 2–4 hours,
associated with nausea and vomiting. Between episodes, she is asymptomatic. Most likely diagnosis?
A. BPPV
B. Ménière’s disease
,C. Vestibular neuritis
D. Labyrinthitis
10. A 4-year-old with fever, barking cough, and inspiratory stridor worse at night. No drooling, no toxic
appearance. Most likely diagnosis?
A. Epiglottitis
B. Croup
C. Bacterial tracheitis
D. Peritonsillar abscess
11. A 70-year-old male with history of stroke presents with urinary urgency, frequency, and urge
incontinence. Post-void residual 60 mL. Most likely type?
A. Stress incontinence
B. Urge incontinence
C. Overflow incontinence
D. Mixed incontinence
12. A 35-year-old obese female with right upper quadrant pain after fatty meals. Ultrasound shows
gallstones. WBC normal, LFTs normal, afebrile. Next best step?
A. Laparoscopic cholecystectomy
B. ERCP
C. Ursodiol
D. Low-fat diet and observation
13. (Pretest) A 50-year-old male with chronic low back pain worse at night, morning stiffness >1 hour.
ESR 60, CRP 25. X-ray shows bilateral sacroiliitis. Most likely diagnosis?
A. Lumbar spinal stenosis
B. Ankylosing spondylitis
C. Metastatic cancer
D. Osteoporotic fracture
14. A 25-year-old female with 3 days of dysuria, frequency, suprapubic pain. Urinalysis: + leukocytes, +
nitrites. Pregnancy test negative. First-line antibiotic if local E. coli resistance to TMP-SMX is <20%?
A. Nitrofurantoin 100 mg BID x 5 days
B. TMP-SMX DS BID x 3 days
C. Ciprofloxacin 500 mg BID x 3 days
D. Fosfomycin 3 g x 1 dose
, 15. A 60-year-old with known heart failure with reduced ejection fraction (30%) presents with
worsening dyspnea, orthopnea, and 5 lb weight gain in 3 days. BP 110/70, HR 95, lungs with crackles
bilaterally. Next best step?
A. Increase furosemide
B. Start digoxin
C. Increase carvedilol
D. Admit for IV diuresis
16. A 3-year-old with fever for 5 days, bilateral conjunctival injection, red cracked lips, strawberry
tongue, rash, and cervical adenopathy. Most likely complication if untreated?
A. Coronary artery aneurysms
B. Meningitis
C. Myocarditis
D. Arthritis
17. A 45-year-old male with acute epigastric pain radiating to back, nausea, vomiting. He admits heavy
alcohol use. Lipase 1500. CT shows pancreatic necrosis. Next step?
A. IV fluids, pain control, NPO
B. ERCP
C. IV antibiotics
D. Immediate surgical debridement
18. (Pretest) A 28-year-old female with fatigue, photosensitivity, oral ulcers, and malar rash. ANA
positive, anti-Smith positive, low C4. Urinalysis normal. Best initial treatment?
A. Hydroxychloroquine
B. Prednisone 60 mg daily
C. Mycophenolate mofetil
D. Azathioprine
19. A 55-year-old male with acute onset of vertigo, dysarthria, and ataxia. Symptoms began 90 minutes
ago. Non-contrast head CT normal. Next best step?
A. IV tPA
B. Aspirin 325 mg
C. MRI brain
D. Observation
