Lessons Learned From NPs Who Have Failed the FNP and AGNP Primary Care Boards

Margaret A. Fitzgerald, DNP, FNP-BC, NP-C, FAANP, CSP, FAAN, DCC, FNAP

I occasionally speak with NPs who are among the approximately 20% of examinees who do not pass the NP exam on the first try. (Keep in mind, these are NPs who did not use Fitzgerald Review courses or who used another review course. People who use the Fitzgerald NP review have a 99%+ pass rate.) What have I learned from these conversations? This is a group of highly intelligent people who completed a course of rigorous graduate study. In spite of this, they were unsuccessful at passing an exam that dictates whether the NP can practice. This can be a devastating blow. However, in retrospect, most can say what got in the way of success. Here is what they have shared.

“I expected to read the question and quickly recognize the answer.”

While this could happen with a low-level, fact-oriented question, such as one identifying an anatomic landmark or a cranial nerve, few of the certification exam questions will be of this type. Most of the exam questions assess much higher-level knowledge and are much more complex. Most questions test your ability to assess, diagnose, and develop a plan of intervention and response to care (evaluation) for a clinical situation, requiring analysis and synthesis of the information critical to choosing the correct answer. Anticipate applying your clinical decision-making skills to each test question.

Test-taking tip: Make sure you think through each question. In particular, bear in mind how the pathophysiology of the condition affects its presentation, how the application of evidence-based practice influences the choice of diagnostics, how treatment modifies the course of disease, and how to evaluate patient care outcomes.

“I got through the test fairly quickly and did not think it was that difficult. I was stunned when I found out I failed.”

This is a comment I often hear from NPs who failed their board exam. Nearly every test question has what I call a “gotcha” answer, or an answer that appears quite self-evident. The error the test candidate makes is failing to consider all information presented, analyzing and synthesizing that information, and deeply considering the purpose of the test question. This approach can lead the candidate to view the question as being simple and having only one possible answer.

Test-taking tip: Seldom do questions on the NP boards have just one correct answer, but the question will have one BEST answer, once all information provided is carefully considered.

“I could not figure out what the question was asking.”

Sometimes identifying the verb in the question can help you determine the purpose of the question. In addition, look at the information presented, and then ask yourself, “Is this question a test of the ability to gather subjective or objective information? Is it a test of the ability to develop a diagnosis or to plan a course of intervention? Is this a question aimed at evaluating response to treatment?” Answering these questions will help focus your thought process as you chose the answer.

Test-taking tip: The acronym “ADPIE” is a helpful way to remember this approach to determining what the test question is asking (see Table 1). ADPIE stands for the five steps to keep in mind when reviewing a question.

Table 1. What is the question asking?

The clinical decision-making process has 5 major components, usually performed sequentially: ADPIE
~30% of exam
Collect subjective (health history including history of present illness) and objective (physical examination, available diagnostic results) data.
~25% of exam
Analyze assessment data to determine a (working) diagnosis, keeping in mind common health problems seen in primary care, not acute, specialty, or emergency care.
~25% of exam
Develop a plan of care and prescribe intervention to attain expected outcome.
Assume the resources needed to provide cost-effective diagnosis and treatment based on the evidence are available.
Implementation Actualizing the plan of care, the application portion of the above-mentioned process.
~20% of exam
Performed post-diagnosis, plan, and intervention. Evaluate patient’s attainment of treatment goals, keeping in mind the ongoing need to adjust the plan of care based on patient response.

“I did thousands of practice questions and figured that would be the best way to study for the exam.”

Keep in mind, this is a test to see whether you possess and can apply or utilize the knowledge base to be a safe, entry-level NP. Your study should focus on knowledge-building, so that you are able to discern the correct answer to all the exam questions. Use practice questions to confirm, but not to build, your knowledge base. I must also mention, many of the practice questions for sale are of poor quality and not representative of questions you will find on the NP boards. The deep knowledge-building questions found in my book, Nurse Practitioner Certification Exam Prep, Sixth edition, as well as the Fitzgerald NP Certification Exam Review and the Fitzgerald Test Bank will help you best prepare for boards. The Fitzgerald NP Certification Exam Review works on knowledge building and honing critical thinking skills, to ensure success on the NP boards.

Test-taking tip: You should be scoring 85% or higher on high-quality practice exams prior to taking the boards; a lower score means more work is needed on building your knowledge base and clinical decision-making skills.

“More than one answer was applicable to the situation presented. I was not sure which answer was correct.”

Take another look at the question, and then choose the response most specific to the given situation. Also, sometimes questions that relate to presentation of disease have more than one applicable answer. However, the response with the most common presentation is likely to be correct. For example, an adult with bacterial meningitis can present with nuchal rigidity and papilledema. However, since nuchal rigidity is seen in the majority of adults with this diagnosis, and papilledema is found far less often, nuchal rigidity is a better choice. In addition, on the family nurse practitioner (FNP) exam, childhood development questions often have more than one correct response. For example, a healthy 4½-month-old infant is expected to roll stomach to back and smile. However, smiling is a developmental milestone achieved by age 2 months, while rolling is typically not seen until the baby is 4 months old. Therefore, rolling stomach to back is the best response. It is also important to consider which answer best reflects evidence-based practice. For example, while azithromycin is commonly prescribed for the treatment of otitis media and acute bacterial rhinosinusitis, due to high rates of resistant organisms this antibiotic is not recommended for use in either condition, with amoxicillin-based therapies cited as the first-line evidence-based practice intervention.

Test-taking tip: When the question involves diagnosis or intervention in a given clinical scenario, choose the answer that is most reflective of the most common clinical presentation and evidence-based practice.

“I currently practice as an RN in an acute care setting. The scenarios and treatment options presented in the questions were quite different from what I am accustomed to seeing in my current clinical setting. I had a hard time choosing the best answer”

Many new NPs are experienced RNs and take this background to the certification examination. Remember that in the acute care setting you are typically seeing the “worst case scenario” of a disease state or the exceptions to the rule, rather than how a patient would present in outpatient or primary care, the practice setting of FNPs and adult-gerontology primary care NPs (AGNPs). The NP certification exams are likely to present a situation that is more the rule than the exception. For example, the chest pain associated with acute coronary syndrome (ACS), including unstable or pre-infarction angina, can last for hours and is often present at rest. Since the acute care RN likely has experience in caring for patients with ACS, this presentation has likely become the nurse’s mindset concerning the typical presentation of angina pectoris. However, the chest pain episode of the community-dwelling elderly person with stable angina pectoris is usually infrequent, lasts less than 10 minutes, and is usually precipitated by increased physical activity or other provoking activity. Relief of symptoms usually occurs promptly with rest or cessation of the provoking activity and with the use of nitroglycerine.

Test-taking tip: For the FNP and AGNP primary care exams, the test taker needs to apply primary care, not acute care, rules. You should also be familiar with the most common diagnoses seen in primary care, not acute care, and focus your study accordingly (see Table 2).

Table 2. Patient Visits to Primary Care Offices: Top 20 Diagnoses*

The Fitzgerald Health FNP, AGNP primary care reviews cover all of these diagnoses.
1. Essential hypertension
2. Diabetes mellitus
3. Acute respiratory infections
4. Attention deficit disorder
5. Allergic rhinitis
6. Joint disorders**
7. Acute and chronic sinusitis
8. Osteoarthritis
9. Depressive disorders, excluding bipolar depression and adjustment reaction with depressed mood
10. Otitis media and Eustachian tube disorders
11. Hyperlipidemias
12. Acute pharyngitis
13. Coronary atherosclerosis
14. Asthma
15. Cardiac dysrhythmias, excluding ventricular fibrillation
16. Cataracts (excluding diabetic cataracts)
17. Conditions of the spine and back, excluding low back pain
18. Opioid-related disorders
19. Glaucoma
20. Acne

*Data for this table are pre-Covid-19. The current Fitzgerald Review includes COVID-19 clinical information.

**Excluding rheumatoid arthritis, infectious and inflammatory arthropathies, osteoarthritis, acquired deformities of fingers and toes, internal derangement of knee.

“I have horrid test anxiety and have always been a poor test taker.”

Please reflect on what input you have received that has led you to come to this conclusion. Often, a person of importance, such as a teacher or parent, earlier in your life mentioned you are a poor test taker or have test anxiety. Is this now truthful? Consider what you have accomplished; you have taken the SAT, GRE, and countless other tests in your undergraduate and graduate education. How would you have progressed to a point where you are eligible for the NP boards if you are incapable of taking a test or have crippling test anxiety? Anxiety is a normal part of test taking. Rather than allowing the anxiety to overwhelm you, use the energy to focus your concentration on the exam question.

Test-taking tip: To minimize test anxiety, increase your knowledge base. Knowledge is the best treatment for test anxiety. For a helpful guide in improving your test-taking skills and minimizing test-taking anxiety, consider reviewing How to Study for Standardized Tests, by Daniel Sefcik, Gillian Bice, and Frank Prerost. Jones & Bartlett Publishers:).

“I graduated from a highly competitive NP program with a solid GPA. I believed I was well-prepared for the test.”

This is a common comment. Your NP program does help you prepare for practice and boards; however, additional review pulls together all the knowledge you’ve gained through your NP program and helps you recognize areas where you need to knowledge-build.

Test-taking tip: As with virtually every other discipline that requires a professional qualifying exam, such as law or medicine, additional study that includes a review course is required for success on the exam.


Finally, the best approach to preparing for both the exam and practice is to have a deep grasp of knowledge critical to safe practice, so that you are able to analyze and synthesize data presented to you, with the goal that you know what to do and why you are doing it, both in the exam room and at the public healthcare level. This is accomplished by critical thinking: the mental process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and evaluating information to reach an answer or conclusion.

You have worked hard and sacrificed much to become an NP. Passing the NP certification exam marks another landmark achievement. Make it a successful part of the journey.

Source: Centers for Disease Control and Prevention. National Center for Health Statistics. National Ambulatory Medical Care Survey: 2016 National Summary Tables. https://www.cdc.gov/nchs/data/ahcd/namcs_summary/2016_namcs_web_tables.pdf