Barkley PNP-AC Comprehensive Board Review Exam | 100
Predictor Questions and Answers 2026-2027
DOMAIN I: ASSESSMENT (Questions 1-30)
1. A 6-year-old, 20kg child is admitted to the PICU with suspected septic shock.
After two 20mL/kg boluses of normal saline, the heart rate remains 150 bpm,
capillary refill is 4 seconds, and blood pressure is 70/40mmHg. 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%
Answer: D
Rationale: An ScvO₂ < 70% indicates that oxygen delivery is insufficient to meet tissue
demand, a hallmark of ongoing shock. ScvO₂ provides a direct measure of the balance
between oxygen delivery and extraction. In pediatric septic shock, goal-directed therapy
targets ScvO₂ ≥ 70%.
2. A 3-month-old with bronchiolitis is on HFNC at 2L/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
C. The infant is entering a deep sleep cycle
D. The bronchiolitis is resolving and support can be weaned
Answer: B
,Rationale: 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.
3. A 14-year-old trauma patient arrives with a GCS of 7. Pupils are 4mm 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
Answer: C
Rationale: 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.
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
C. Peak expiratory flow rate of 40% predicted
D. Respiratory rate of 45 breaths per minute
Answer: B
,Rationale: 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.
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, which finding requires the MOST
urgent intervention?
A. Serum potassium of 5.2 mEq/L
B. Serum glucose of 450 mg/dL
C. pH of 7.1
D. Mental status changes
Answer: D
Rationale: Mental status changes in DKA indicate cerebral edema, the most feared
complication of DKA in children. This requires immediate intervention, including
possible mannitol and hypertonic saline, and consideration of ICU transfer.
6. A 2-month-old infant is brought to the ED with a history of poor feeding and
lethargy. On exam, the infant is afebrile but tachycardic with a capillary refill of 4
seconds. Which diagnostic study is MOST critical to obtain?
A. Chest X-ray
B. Serum glucose
C. Lumbar puncture
D. Complete blood count
Answer: B
Rationale: In an infant with lethargy and poor feeding, hypoglycemia must be ruled out
immediately as it can cause seizures and irreversible brain damage if not treated
promptly. The clinical presentation of hypoglycemia can mimic sepsis.
, 7. A 10-month-old infant is brought to the ED following a brief, resolved seizure at
home. During assessment, you note a full, tense fontanelle and a fever of 38.9°C.
What is the MOST critical piece of historical data to obtain?
A. Family history of febrile seizures
B. Recent antibiotic use and treatment duration
C. Immunization status and last vaccine administration
D. History of irritability, vomiting, or lethargy prior to the seizure
Answer: B
Rationale: A full, tense fontanelle in a febrile infant following a seizure is a major red
flag for meningitis. Recent use of antibiotics is the most critical question, as partially
treated meningitis can present with altered signs and symptoms, and CSF
analysis/cultures may be affected.
8. A 4-year-old, 16 kg child is admitted with septic shock. Which clinical finding is
the MOST reliable indicator of adequate fluid resuscitation?
A. Increase in blood pressure to normal for age
B. Urine output of 1.5 mL/kg/hr
C. Decrease in heart rate by 20 bpm
D. Resolution of metabolic acidosis on ABG
Answer: B
Rationale: In pediatric septic shock, urine output >1 mL/kg/hr is a direct and reliable
indicator of improved renal perfusion and cardiac output. Blood pressure is a late sign of
decompensation in children.
9. A 2-month-old infant with bronchiolitis is on HFNC. During assessment, the PNP
notes the infant is becoming increasingly somnolent, and the respiratory rate has
dropped from 65 to 18 breaths per minute over the last hour. SpO₂ is 85%. What is
the PRIORITY interpretation?
Predictor Questions and Answers 2026-2027
DOMAIN I: ASSESSMENT (Questions 1-30)
1. A 6-year-old, 20kg child is admitted to the PICU with suspected septic shock.
After two 20mL/kg boluses of normal saline, the heart rate remains 150 bpm,
capillary refill is 4 seconds, and blood pressure is 70/40mmHg. 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%
Answer: D
Rationale: An ScvO₂ < 70% indicates that oxygen delivery is insufficient to meet tissue
demand, a hallmark of ongoing shock. ScvO₂ provides a direct measure of the balance
between oxygen delivery and extraction. In pediatric septic shock, goal-directed therapy
targets ScvO₂ ≥ 70%.
2. A 3-month-old with bronchiolitis is on HFNC at 2L/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
C. The infant is entering a deep sleep cycle
D. The bronchiolitis is resolving and support can be weaned
Answer: B
,Rationale: 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.
3. A 14-year-old trauma patient arrives with a GCS of 7. Pupils are 4mm 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
Answer: C
Rationale: 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.
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
C. Peak expiratory flow rate of 40% predicted
D. Respiratory rate of 45 breaths per minute
Answer: B
,Rationale: 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.
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, which finding requires the MOST
urgent intervention?
A. Serum potassium of 5.2 mEq/L
B. Serum glucose of 450 mg/dL
C. pH of 7.1
D. Mental status changes
Answer: D
Rationale: Mental status changes in DKA indicate cerebral edema, the most feared
complication of DKA in children. This requires immediate intervention, including
possible mannitol and hypertonic saline, and consideration of ICU transfer.
6. A 2-month-old infant is brought to the ED with a history of poor feeding and
lethargy. On exam, the infant is afebrile but tachycardic with a capillary refill of 4
seconds. Which diagnostic study is MOST critical to obtain?
A. Chest X-ray
B. Serum glucose
C. Lumbar puncture
D. Complete blood count
Answer: B
Rationale: In an infant with lethargy and poor feeding, hypoglycemia must be ruled out
immediately as it can cause seizures and irreversible brain damage if not treated
promptly. The clinical presentation of hypoglycemia can mimic sepsis.
, 7. A 10-month-old infant is brought to the ED following a brief, resolved seizure at
home. During assessment, you note a full, tense fontanelle and a fever of 38.9°C.
What is the MOST critical piece of historical data to obtain?
A. Family history of febrile seizures
B. Recent antibiotic use and treatment duration
C. Immunization status and last vaccine administration
D. History of irritability, vomiting, or lethargy prior to the seizure
Answer: B
Rationale: A full, tense fontanelle in a febrile infant following a seizure is a major red
flag for meningitis. Recent use of antibiotics is the most critical question, as partially
treated meningitis can present with altered signs and symptoms, and CSF
analysis/cultures may be affected.
8. A 4-year-old, 16 kg child is admitted with septic shock. Which clinical finding is
the MOST reliable indicator of adequate fluid resuscitation?
A. Increase in blood pressure to normal for age
B. Urine output of 1.5 mL/kg/hr
C. Decrease in heart rate by 20 bpm
D. Resolution of metabolic acidosis on ABG
Answer: B
Rationale: In pediatric septic shock, urine output >1 mL/kg/hr is a direct and reliable
indicator of improved renal perfusion and cardiac output. Blood pressure is a late sign of
decompensation in children.
9. A 2-month-old infant with bronchiolitis is on HFNC. During assessment, the PNP
notes the infant is becoming increasingly somnolent, and the respiratory rate has
dropped from 65 to 18 breaths per minute over the last hour. SpO₂ is 85%. What is
the PRIORITY interpretation?
