1
Barkley Pediatric Acute Care Nurse Practitioner
(PNP-AC) Certification Exam | 175 Actual
Questions and Answers
Domain I: Assessment (30% of Exam / ~53 Questions)
Question 1
A 4-year-old, 16 kg child is admitted to the PICU with suspected septic shock. The
nurse practitioner is assessing the hemodynamic response to a 20 mL/kg normal
saline fluid bolus. Which clinical finding is the MOST reliable indicator of adequate
fluid resuscitation in this patient?
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
: Correct Answer : B
Explanation:
In pediatric septic shock, the goals of fluid resuscitation are to restore tissue
perfusion. While blood pressure may initially be maintained through
compensatory mechanisms (even in shock), monitoring end-organ perfusion is
paramount. Urine output of >1 mL/kg/hr is a direct and reliable indicator of
improved renal perfusion and cardiac output. A decrease in heart rate and
resolution of acidosis are positive signs but may lag behind improvements in
organ perfusion. Blood pressure is a later sign of decompensation in children;
hypotension is a late and ominous finding. Therefore, urine output is the most
sensitive and reliable clinical sign of adequate fluid responsiveness in this
scenario.
pg. 1
,2
Question 2
A 2-month-old infant with bronchiolitis is on high-flow nasal cannula (HFNC).
During assessment, the PNP notices the infant is becoming increasingly
somnolent, and the respiratory rate has dropped from 65 to 18 breaths per
minute over the last hour. The SpO2 is 85%. What is the PRIORITY interpretation
of this data?
A. The infant is tiring and developing hypercapnic respiratory failure
B. The HFNC is effectively reducing the work of breathing
C. The infant is entering a restful sleep cycle
D. The bronchiolitis is resolving, and support can be weaned
: Correct Answer : A
Explanation:
This is a critical assessment point. A sudden decrease in respiratory rate in a
previously tachypneic infant with increased work of breathing is an ominous sign,
not a sign of improvement. When accompanied by worsening mental status
(somnolence) and hypoxemia, it indicates that the child is physically exhausted
and can no longer maintain the necessary minute ventilation. This heralds
impending hypercapnic respiratory failure and respiratory arrest. Immediate
escalation of respiratory support and preparation for intubation are required.
Question 3
A 10-month-old infant is brought to the emergency department following a brief,
resolved seizure at home. During your 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
: Correct Answer : B
pg. 2
,3
Explanation:
A full, tense fontanelle in a febrile infant following a seizure is a major red flag for
meningitis. While all historical data points are relevant, the recent use of
antibiotics is the most critical, as partially treated meningitis can present with
altered or subtle signs and symptoms, and the CSF analysis and cultures may be
affected. Knowing if the child has received antibiotics recently will drastically alter
the interpretation of diagnostic tests and guide empiric antibiotic selection.
Question 4
A 14-year-old trauma patient arrives with a Glasgow Coma Scale (GCS) score of 8.
What is the PRIORITY nursing and medical intervention?
A. Immediate CT scan of the head
B. Endotracheal intubation for airway protection
C. Placement of an intracranial pressure (ICP) monitor
D. Hyperventilation to a goal PCO2 of 25-30 mmHg
: Correct Answer : B
Explanation:
The adage "GCS ≤ 8, intubate" is a guiding principle in trauma. A GCS of 8
indicates a severe traumatic brain injury (TBI) and the patient is at high risk for
airway compromise, aspiration, and hypoventilation. The first step in managing
any TBI is to secure the airway to ensure adequate oxygenation and ventilation,
which is critical to preventing secondary brain injury from hypoxia and
hypercapnia. A head CT is essential but follows airway stabilization. ICP
monitoring is considered later, and prophylactic hyperventilation is harmful due
to the risk of cerebral ischemia.
Question 5
A 6-month-old with a history of a large ventricular septal defect (VSD) presents
with increased work of breathing, diaphoresis during feeds, and poor weight gain.
During your cardiovascular assessment, which finding distinguishes an innocent
murmur from this pathologic VSD murmur?
pg. 3
, 4
A. A grade 2/6 intensity
B. Location at the left lower sternal border
C. A holosystolic quality that does not change with position
D. Increased intensity with sitting
: Correct Answer : C
Explanation:
While a VSD murmur is holosystolic and located at the left lower sternal border,
the key differentiating factor from an innocent murmur (like Still's murmur) is its
behavior with position changes. A pathologic VSD murmur is generally constant in
quality. Innocent murmurs are often vibratory, musical, and will change in
intensity or quality with position changes (e.g., becoming softer when sitting or
standing due to decreased venous return). The presence of symptoms like
diaphoresis with feeds and poor weight gain is a critical clinical sign of heart
failure, which is consistent with a hemodynamically significant VSD.
Question 6
A 3-year-old is admitted after a near-drowning event. The child is awake and alert,
with an SpO2 of 92% on a non-rebreather mask. Crackles are auscultated
bilaterally. Which assessment parameter will provide the MOST accurate and non-
invasive continuous monitoring of this child's respiratory status?
A. Frequent arterial blood gas (ABG) sampling
B. Continuous end-tidal CO2 (EtCO2) monitoring
C. Continuous pulse oximetry and respiratory rate
D. Serial chest radiographs every 6 hours
: Correct Answer : B
Explanation:
After a submersion injury, pulmonary edema and acute respiratory distress
syndrome (ARDS) can develop. Continuous EtCO2 monitoring via capnography
provides invaluable, non-invasive, real-time data on ventilation (CO2 elimination),
perfusion, and airway patency. A rising EtCO2 or a sudden drop in EtCO2 can
signal hypoventilation or severe V/Q mismatch much faster than waiting for ABGs
or a change in vital signs. While ABGs and chest radiographs are important, they
pg. 4
Barkley Pediatric Acute Care Nurse Practitioner
(PNP-AC) Certification Exam | 175 Actual
Questions and Answers
Domain I: Assessment (30% of Exam / ~53 Questions)
Question 1
A 4-year-old, 16 kg child is admitted to the PICU with suspected septic shock. The
nurse practitioner is assessing the hemodynamic response to a 20 mL/kg normal
saline fluid bolus. Which clinical finding is the MOST reliable indicator of adequate
fluid resuscitation in this patient?
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
: Correct Answer : B
Explanation:
In pediatric septic shock, the goals of fluid resuscitation are to restore tissue
perfusion. While blood pressure may initially be maintained through
compensatory mechanisms (even in shock), monitoring end-organ perfusion is
paramount. Urine output of >1 mL/kg/hr is a direct and reliable indicator of
improved renal perfusion and cardiac output. A decrease in heart rate and
resolution of acidosis are positive signs but may lag behind improvements in
organ perfusion. Blood pressure is a later sign of decompensation in children;
hypotension is a late and ominous finding. Therefore, urine output is the most
sensitive and reliable clinical sign of adequate fluid responsiveness in this
scenario.
pg. 1
,2
Question 2
A 2-month-old infant with bronchiolitis is on high-flow nasal cannula (HFNC).
During assessment, the PNP notices the infant is becoming increasingly
somnolent, and the respiratory rate has dropped from 65 to 18 breaths per
minute over the last hour. The SpO2 is 85%. What is the PRIORITY interpretation
of this data?
A. The infant is tiring and developing hypercapnic respiratory failure
B. The HFNC is effectively reducing the work of breathing
C. The infant is entering a restful sleep cycle
D. The bronchiolitis is resolving, and support can be weaned
: Correct Answer : A
Explanation:
This is a critical assessment point. A sudden decrease in respiratory rate in a
previously tachypneic infant with increased work of breathing is an ominous sign,
not a sign of improvement. When accompanied by worsening mental status
(somnolence) and hypoxemia, it indicates that the child is physically exhausted
and can no longer maintain the necessary minute ventilation. This heralds
impending hypercapnic respiratory failure and respiratory arrest. Immediate
escalation of respiratory support and preparation for intubation are required.
Question 3
A 10-month-old infant is brought to the emergency department following a brief,
resolved seizure at home. During your 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
: Correct Answer : B
pg. 2
,3
Explanation:
A full, tense fontanelle in a febrile infant following a seizure is a major red flag for
meningitis. While all historical data points are relevant, the recent use of
antibiotics is the most critical, as partially treated meningitis can present with
altered or subtle signs and symptoms, and the CSF analysis and cultures may be
affected. Knowing if the child has received antibiotics recently will drastically alter
the interpretation of diagnostic tests and guide empiric antibiotic selection.
Question 4
A 14-year-old trauma patient arrives with a Glasgow Coma Scale (GCS) score of 8.
What is the PRIORITY nursing and medical intervention?
A. Immediate CT scan of the head
B. Endotracheal intubation for airway protection
C. Placement of an intracranial pressure (ICP) monitor
D. Hyperventilation to a goal PCO2 of 25-30 mmHg
: Correct Answer : B
Explanation:
The adage "GCS ≤ 8, intubate" is a guiding principle in trauma. A GCS of 8
indicates a severe traumatic brain injury (TBI) and the patient is at high risk for
airway compromise, aspiration, and hypoventilation. The first step in managing
any TBI is to secure the airway to ensure adequate oxygenation and ventilation,
which is critical to preventing secondary brain injury from hypoxia and
hypercapnia. A head CT is essential but follows airway stabilization. ICP
monitoring is considered later, and prophylactic hyperventilation is harmful due
to the risk of cerebral ischemia.
Question 5
A 6-month-old with a history of a large ventricular septal defect (VSD) presents
with increased work of breathing, diaphoresis during feeds, and poor weight gain.
During your cardiovascular assessment, which finding distinguishes an innocent
murmur from this pathologic VSD murmur?
pg. 3
, 4
A. A grade 2/6 intensity
B. Location at the left lower sternal border
C. A holosystolic quality that does not change with position
D. Increased intensity with sitting
: Correct Answer : C
Explanation:
While a VSD murmur is holosystolic and located at the left lower sternal border,
the key differentiating factor from an innocent murmur (like Still's murmur) is its
behavior with position changes. A pathologic VSD murmur is generally constant in
quality. Innocent murmurs are often vibratory, musical, and will change in
intensity or quality with position changes (e.g., becoming softer when sitting or
standing due to decreased venous return). The presence of symptoms like
diaphoresis with feeds and poor weight gain is a critical clinical sign of heart
failure, which is consistent with a hemodynamically significant VSD.
Question 6
A 3-year-old is admitted after a near-drowning event. The child is awake and alert,
with an SpO2 of 92% on a non-rebreather mask. Crackles are auscultated
bilaterally. Which assessment parameter will provide the MOST accurate and non-
invasive continuous monitoring of this child's respiratory status?
A. Frequent arterial blood gas (ABG) sampling
B. Continuous end-tidal CO2 (EtCO2) monitoring
C. Continuous pulse oximetry and respiratory rate
D. Serial chest radiographs every 6 hours
: Correct Answer : B
Explanation:
After a submersion injury, pulmonary edema and acute respiratory distress
syndrome (ARDS) can develop. Continuous EtCO2 monitoring via capnography
provides invaluable, non-invasive, real-time data on ventilation (CO2 elimination),
perfusion, and airway patency. A rising EtCO2 or a sudden drop in EtCO2 can
signal hypoventilation or severe V/Q mismatch much faster than waiting for ABGs
or a change in vital signs. While ABGs and chest radiographs are important, they
pg. 4
