PNCB PNP-PC Primary & Acute Care
Master Questions — 2025/2026 Study Bundle
(250 Questions)
These questions comprehensively cover: Acute Care (emergencies, critical illness, trauma),
Primary Care (well-child, developmental, preventive), Specialty Areas (cardiology,
neurology, oncology, nephrology, endocrinology, rheumatology, orthopedics, psychiatry),
Pharmacology, Evidence-Based Guidelines, PNCB Clinical Reasoning, and Adolescent
Medicine — fully aligned with the 2025/2026 PNCB PNP-PC examination blueprint.
1. A 3-year-old presents with a 2-day history of fever, barky cough, and inspiratory stridor at
rest. Which intervention should the PNP implement first?
A) Obtain a lateral neck X-ray immediately B) Administer nebulized racemic epinephrine and
oral dexamethasone C) Perform direct laryngoscopy to visualize the airway D) Start IV
antibiotics for bacterial tracheitis
B) Administer nebulized racemic epinephrine and oral dexamethasone (correct answer)
Rationale: Stridor at rest in a child with croup indicates moderate-to-severe disease
requiring immediate treatment with racemic epinephrine (reduces subglottic edema via
vasoconstriction) and dexamethasone (systemic anti-inflammatory effect lasting 24–72
hours). Laryngoscopy risks complete obstruction and is contraindicated outside of
controlled settings.
2. A 6-week-old infant presents with projectile vomiting after every feeding for the past 2 weeks.
The infant appears hungry after vomiting. The PNP palpates an olive-shaped mass in the right
upper quadrant. Which is the most appropriate next step?
A) Refer for immediate upper GI series B) Begin a trial of hypoallergenic formula C) Obtain an
abdominal ultrasound and metabolic panel D) Reassure parents that overfeeding is the likely
cause
C) Obtain an abdominal ultrasound and metabolic panel (correct answer)
Rationale: The presentation is classic for hypertrophic pyloric stenosis — projectile non-
bilious vomiting, hungry after vomiting, and an olive-shaped pyloric mass. Ultrasound
confirms the diagnosis (pyloric muscle thickness >4mm, channel length >16mm). A
,metabolic panel assesses for hypochloremic, hypokalemic metabolic alkalosis from
repeated vomiting.
3. A 14-year-old presents with acute onset of severe scrotal pain for 2 hours. The scrotum is
swollen and erythematous. The cremasteric reflex is absent. Which action is the highest priority?
A) Prescribe oral antibiotics for epididymitis B) Obtain a Doppler ultrasound to assess testicular
blood flow C) Immediately refer for surgical exploration D) Order a urine culture and begin
empiric antibiotics
C) Immediately refer for surgical exploration (correct answer)
Rationale: Absent cremasteric reflex with acute severe scrotal pain is testicular torsion
until proven otherwise — a urological emergency. Testicular salvage rate is >90% if
detorsion occurs within 6 hours but drops to <10% after 24 hours. Surgery must not be
delayed for imaging if clinical presentation is classic. Time is the critical factor.
4. A 9-month-old has been febrile for 5 days with bilateral conjunctival injection, cracked red
lips, a strawberry tongue, erythema of the palms and soles, and a cervical lymph node of 2.5 cm.
Which complication is the PNP most concerned about?
A) Bacterial meningitis B) Coronary artery aneurysm C) Immune complex nephritis D) Septic
arthritis
B) Coronary artery aneurysm (correct answer)
Rationale: This is Kawasaki disease. The most feared complication is coronary artery
aneurysm (CAA), occurring in up to 25% of untreated children. IVIG (2g/kg) and high-
dose aspirin are administered to reduce aneurysm risk. Echocardiogram is performed at
diagnosis and at 2 and 6 weeks. Early treatment dramatically reduces CAA incidence to
<5%.
5. A 16-year-old female presents with a 3-month history of amenorrhea, fatigue, cold
intolerance, constipation, and a 5 kg weight gain. TSH is 42 mIU/L and free T4 is low. What is
the most likely diagnosis?
A) Anorexia nervosa B) Polycystic ovarian syndrome C) Primary hypothyroidism D) Pituitary
adenoma
C) Primary hypothyroidism (correct answer)
,Rationale: Classic symptoms of hypothyroidism (fatigue, cold intolerance, constipation,
weight gain, amenorrhea) combined with elevated TSH and low free T4 confirm primary
hypothyroidism. Hashimoto's thyroiditis is the most common cause in adolescent females.
Treatment with levothyroxine normalizes thyroid function and resolves symptoms.
6. A 2-year-old is brought to the acute care clinic with a sudden onset of choking while eating
peanuts. The child is now quiet with decreased breath sounds on the right and mild respiratory
distress but is maintaining oxygen saturation of 94%. Which is the most appropriate
management?
A) Perform back blows and abdominal thrusts immediately B) Obtain a chest X-ray and prepare
for rigid bronchoscopy C) Administer albuterol nebulization and monitor D) Discharge with
follow-up in 24 hours if symptoms persist
B) Obtain a chest X-ray and prepare for rigid bronchoscopy (correct answer)
Rationale: The clinical presentation (witnessed aspiration + unilateral decreased breath
sounds) strongly indicates right main bronchus foreign body aspiration (the right is wider
and more vertical). Chest X-ray may show hyperinflation or atelectasis. Rigid
bronchoscopy is both diagnostic and therapeutic. Back blows/thrusts are for complete
obstruction with inability to cry or cough.
7. A 5-year-old with known sickle cell disease presents with temperature 39.2°C, HR 130, RR
28, and appears ill. The CBC shows WBC 18,000 with 80% neutrophils, Hgb 7.2, platelets
210,000. ANC is 3,200. Which initial intervention is most important?
A) Transfuse packed red blood cells immediately B) Administer IV ceftriaxone after blood
culture is drawn C) Begin exchange transfusion D) Admit for IV hydration and pain management
only
B) Administer IV ceftriaxone after blood culture is drawn (correct answer)
Rationale: Febrile children with sickle cell disease are at high risk for overwhelming
bacteremia from encapsulated organisms (Streptococcus pneumoniae, Haemophilus
influenzae). Blood culture is drawn, then broad-spectrum antibiotics (ceftriaxone) are
administered within 1 hour. This reduces sepsis mortality. Functional asplenia makes these
children immunocompromised regardless of ANC.
8. A 4-year-old presents with a 6-hour history of high fever, drooling, dysphagia, and preference
for the tripod position. The child appears toxic and anxious. Which action should the PNP take?
, A) Examine the throat with a tongue depressor for visualization B) Obtain a lateral neck X-ray
immediately before any intervention C) Keep the child calm, call anesthesia/ENT, and prepare
for controlled airway management D) Start IV antibiotics and discharge with close follow-up
C) Keep the child calm, call anesthesia/ENT, and prepare for controlled airway
management (correct answer)
Rationale: This is epiglottitis — a life-threatening emergency. The tripod position,
drooling, dysphagia, and toxic appearance are classic. ANY agitation or instrumentation
(tongue depressor, examination) can precipitate complete airway obstruction. The child
must be kept calm, with anesthesia/ENT at bedside for controlled intubation in the OR. IV
antibiotics (ceftriaxone) are given after airway is secured.
9. A 10-year-old presents for well-child care. BMI is at the 97th percentile. Fasting glucose is
104 mg/dL, A1c is 5.9%, BP is 128/82 mmHg, and ALT is elevated. Which condition should the
PNP prioritize evaluating?
A) Type 1 diabetes mellitus B) Metabolic syndrome with possible non-alcoholic fatty liver
disease (NAFLD) C) Essential hypertension D) Cushing syndrome
B) Metabolic syndrome with possible non-alcoholic fatty liver disease (NAFLD) (correct
answer)
Rationale: The constellation of obesity (BMI >95th%), impaired fasting glucose,
hypertension, and elevated transaminases in a child represents metabolic syndrome with
likely NAFLD. This requires further evaluation with liver ultrasound, full lipid panel, and
hepatology referral. NAFLD is the most common liver disease in children with obesity and
can progress to cirrhosis.
10. A 3-week-old presents with poor feeding, hypotonia, constipation for 10 days, and a weak
cry. The mother reports using honey in the infant's pacifier. What diagnosis does the PNP
suspect?
A) Congenital hypothyroidism B) Spinal muscular atrophy type I C) Infant botulism D) Sepsis
C) Infant botulism (correct answer)
Rationale: Infant botulism results from ingestion of Clostridium botulinum spores (found
in honey, soil) that colonize the intestine and produce toxin. Classic presentation:
constipation followed by descending flaccid paralysis — weak cry, poor feeding, hypotonia,
and loss of head control. Honey is absolutely contraindicated before 12 months. Treatment
is BabyBIG (botulism immune globulin).
Master Questions — 2025/2026 Study Bundle
(250 Questions)
These questions comprehensively cover: Acute Care (emergencies, critical illness, trauma),
Primary Care (well-child, developmental, preventive), Specialty Areas (cardiology,
neurology, oncology, nephrology, endocrinology, rheumatology, orthopedics, psychiatry),
Pharmacology, Evidence-Based Guidelines, PNCB Clinical Reasoning, and Adolescent
Medicine — fully aligned with the 2025/2026 PNCB PNP-PC examination blueprint.
1. A 3-year-old presents with a 2-day history of fever, barky cough, and inspiratory stridor at
rest. Which intervention should the PNP implement first?
A) Obtain a lateral neck X-ray immediately B) Administer nebulized racemic epinephrine and
oral dexamethasone C) Perform direct laryngoscopy to visualize the airway D) Start IV
antibiotics for bacterial tracheitis
B) Administer nebulized racemic epinephrine and oral dexamethasone (correct answer)
Rationale: Stridor at rest in a child with croup indicates moderate-to-severe disease
requiring immediate treatment with racemic epinephrine (reduces subglottic edema via
vasoconstriction) and dexamethasone (systemic anti-inflammatory effect lasting 24–72
hours). Laryngoscopy risks complete obstruction and is contraindicated outside of
controlled settings.
2. A 6-week-old infant presents with projectile vomiting after every feeding for the past 2 weeks.
The infant appears hungry after vomiting. The PNP palpates an olive-shaped mass in the right
upper quadrant. Which is the most appropriate next step?
A) Refer for immediate upper GI series B) Begin a trial of hypoallergenic formula C) Obtain an
abdominal ultrasound and metabolic panel D) Reassure parents that overfeeding is the likely
cause
C) Obtain an abdominal ultrasound and metabolic panel (correct answer)
Rationale: The presentation is classic for hypertrophic pyloric stenosis — projectile non-
bilious vomiting, hungry after vomiting, and an olive-shaped pyloric mass. Ultrasound
confirms the diagnosis (pyloric muscle thickness >4mm, channel length >16mm). A
,metabolic panel assesses for hypochloremic, hypokalemic metabolic alkalosis from
repeated vomiting.
3. A 14-year-old presents with acute onset of severe scrotal pain for 2 hours. The scrotum is
swollen and erythematous. The cremasteric reflex is absent. Which action is the highest priority?
A) Prescribe oral antibiotics for epididymitis B) Obtain a Doppler ultrasound to assess testicular
blood flow C) Immediately refer for surgical exploration D) Order a urine culture and begin
empiric antibiotics
C) Immediately refer for surgical exploration (correct answer)
Rationale: Absent cremasteric reflex with acute severe scrotal pain is testicular torsion
until proven otherwise — a urological emergency. Testicular salvage rate is >90% if
detorsion occurs within 6 hours but drops to <10% after 24 hours. Surgery must not be
delayed for imaging if clinical presentation is classic. Time is the critical factor.
4. A 9-month-old has been febrile for 5 days with bilateral conjunctival injection, cracked red
lips, a strawberry tongue, erythema of the palms and soles, and a cervical lymph node of 2.5 cm.
Which complication is the PNP most concerned about?
A) Bacterial meningitis B) Coronary artery aneurysm C) Immune complex nephritis D) Septic
arthritis
B) Coronary artery aneurysm (correct answer)
Rationale: This is Kawasaki disease. The most feared complication is coronary artery
aneurysm (CAA), occurring in up to 25% of untreated children. IVIG (2g/kg) and high-
dose aspirin are administered to reduce aneurysm risk. Echocardiogram is performed at
diagnosis and at 2 and 6 weeks. Early treatment dramatically reduces CAA incidence to
<5%.
5. A 16-year-old female presents with a 3-month history of amenorrhea, fatigue, cold
intolerance, constipation, and a 5 kg weight gain. TSH is 42 mIU/L and free T4 is low. What is
the most likely diagnosis?
A) Anorexia nervosa B) Polycystic ovarian syndrome C) Primary hypothyroidism D) Pituitary
adenoma
C) Primary hypothyroidism (correct answer)
,Rationale: Classic symptoms of hypothyroidism (fatigue, cold intolerance, constipation,
weight gain, amenorrhea) combined with elevated TSH and low free T4 confirm primary
hypothyroidism. Hashimoto's thyroiditis is the most common cause in adolescent females.
Treatment with levothyroxine normalizes thyroid function and resolves symptoms.
6. A 2-year-old is brought to the acute care clinic with a sudden onset of choking while eating
peanuts. The child is now quiet with decreased breath sounds on the right and mild respiratory
distress but is maintaining oxygen saturation of 94%. Which is the most appropriate
management?
A) Perform back blows and abdominal thrusts immediately B) Obtain a chest X-ray and prepare
for rigid bronchoscopy C) Administer albuterol nebulization and monitor D) Discharge with
follow-up in 24 hours if symptoms persist
B) Obtain a chest X-ray and prepare for rigid bronchoscopy (correct answer)
Rationale: The clinical presentation (witnessed aspiration + unilateral decreased breath
sounds) strongly indicates right main bronchus foreign body aspiration (the right is wider
and more vertical). Chest X-ray may show hyperinflation or atelectasis. Rigid
bronchoscopy is both diagnostic and therapeutic. Back blows/thrusts are for complete
obstruction with inability to cry or cough.
7. A 5-year-old with known sickle cell disease presents with temperature 39.2°C, HR 130, RR
28, and appears ill. The CBC shows WBC 18,000 with 80% neutrophils, Hgb 7.2, platelets
210,000. ANC is 3,200. Which initial intervention is most important?
A) Transfuse packed red blood cells immediately B) Administer IV ceftriaxone after blood
culture is drawn C) Begin exchange transfusion D) Admit for IV hydration and pain management
only
B) Administer IV ceftriaxone after blood culture is drawn (correct answer)
Rationale: Febrile children with sickle cell disease are at high risk for overwhelming
bacteremia from encapsulated organisms (Streptococcus pneumoniae, Haemophilus
influenzae). Blood culture is drawn, then broad-spectrum antibiotics (ceftriaxone) are
administered within 1 hour. This reduces sepsis mortality. Functional asplenia makes these
children immunocompromised regardless of ANC.
8. A 4-year-old presents with a 6-hour history of high fever, drooling, dysphagia, and preference
for the tripod position. The child appears toxic and anxious. Which action should the PNP take?
, A) Examine the throat with a tongue depressor for visualization B) Obtain a lateral neck X-ray
immediately before any intervention C) Keep the child calm, call anesthesia/ENT, and prepare
for controlled airway management D) Start IV antibiotics and discharge with close follow-up
C) Keep the child calm, call anesthesia/ENT, and prepare for controlled airway
management (correct answer)
Rationale: This is epiglottitis — a life-threatening emergency. The tripod position,
drooling, dysphagia, and toxic appearance are classic. ANY agitation or instrumentation
(tongue depressor, examination) can precipitate complete airway obstruction. The child
must be kept calm, with anesthesia/ENT at bedside for controlled intubation in the OR. IV
antibiotics (ceftriaxone) are given after airway is secured.
9. A 10-year-old presents for well-child care. BMI is at the 97th percentile. Fasting glucose is
104 mg/dL, A1c is 5.9%, BP is 128/82 mmHg, and ALT is elevated. Which condition should the
PNP prioritize evaluating?
A) Type 1 diabetes mellitus B) Metabolic syndrome with possible non-alcoholic fatty liver
disease (NAFLD) C) Essential hypertension D) Cushing syndrome
B) Metabolic syndrome with possible non-alcoholic fatty liver disease (NAFLD) (correct
answer)
Rationale: The constellation of obesity (BMI >95th%), impaired fasting glucose,
hypertension, and elevated transaminases in a child represents metabolic syndrome with
likely NAFLD. This requires further evaluation with liver ultrasound, full lipid panel, and
hepatology referral. NAFLD is the most common liver disease in children with obesity and
can progress to cirrhosis.
10. A 3-week-old presents with poor feeding, hypotonia, constipation for 10 days, and a weak
cry. The mother reports using honey in the infant's pacifier. What diagnosis does the PNP
suspect?
A) Congenital hypothyroidism B) Spinal muscular atrophy type I C) Infant botulism D) Sepsis
C) Infant botulism (correct answer)
Rationale: Infant botulism results from ingestion of Clostridium botulinum spores (found
in honey, soil) that colonize the intestine and produce toxin. Classic presentation:
constipation followed by descending flaccid paralysis — weak cry, poor feeding, hypotonia,
and loss of head control. Honey is absolutely contraindicated before 12 months. Treatment
is BabyBIG (botulism immune globulin).
