Preparing for NP Certification

Test Question Analysis

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

The big day is approaching! As you prepare for your certification exam, you study content and concepts. However, in order to be successful, you must apply this information by answering examination questions. While you are unlikely to pass the exam without having the necessary knowledge base, you can increase your likelihood of success through proper analysis of the exam questions.

Exam questions are written on a number of levels. The lowest level is usually the fact-oriented or knowledge questions. This type of question requires recalling a piece of information that has been memorized, so that you instantly recognize the correct answer. Alternatively, this type of question is used as a test of generalizations, principles, or theories. With lower-level questions, there is one and only one correct response. The following is an example of a fact-oriented question.

Pupillary response to light is, in part, a function of cranial nerves:

A. I and II C. III and IV
B. II and III D. IV and V

Mnemonics or other memory aids can be helpful in answering a fact-oriented question. In this case, the correct answer is B, CN II-Optic and CNIII-Oculomotor. However, the certification exams will likely contain many more complex types of questions that require application of clinical assessment and management skills. Examples of these include the comprehension question, where you must interpret the fact. Again, with comprehension questions, there is typically only one correct answer. An example of a comprehension question is as follows:

The person with Bell palsy has paralysis of cranial nerve:


In order to respond correctly to this question, you must know that Bell palsy is a condition where the facial nerve (cranial nerve VII) is affected. In addition, consider that the boards often have questions with images, such as a facial photo of a person with Bell palsy. The associated question might ask which cranial nerve is involved in a person with this finding.

Likely the most common type of question found on the certification exams is the application question. In this kind of question, you must analyze information in order to decide what is pertinent to the given situation. Look for key words in the stem (the question itself) that help set a priority. These include words such as first, initially, or most important action. With questions at this level, often more than one answer is correct, but only one answer is the best response given the clinical information presented. If you are having difficulty ascertaining which action should be done first, particularly when the question poses many plausible actions, you should ask yourself, “What is the greatest risk in this situation?” Here is an example.

You are seeing Ms. Thomas, a 53-year-old woman who presents for a health exam. She smokes cigarettes, with a 35 pack-year history, and has a strong family history of premature heart disease. The most important part of her assessment is:

A. Chest x-ray
B. Auscultation for extra heart sounds
C. Blood pressure measurement
D. Cervical examination with Pap testing

When looking at this question, you might be struck by the fact that you would certainly perform a cardiac exam and Pap test, and perhaps a chest x-ray if clinically indicated, as part of Ms. Thomas’ assessment. So, how do you determine what is the most important part of the assessment? Start by teasing out the facts and assumptions. Facts include two risk factors for cardiovascular disease: cigarette smoking and family history of premature heart disease. In addition, heart disease is the leading cause of death in American women. Assume she is postmenopausal, since the average woman reaches this by age 50. This gives her an additional cardiovascular risk factor. Thus, the stage is set for her to be at high risk for cardiovascular disease. Another assumption is that the best evaluation is one that picks up early disease. Now, look at the answers offered and think what you can expect for results.

In assessing Ms. Thomas, a chest x-ray could reveal lung cancer or smoking- related lung disease. However, such changes will not be evident on chest x-ray until these diseases are rather advanced. As a result, while periodic low-dose thoracic computed tomography is recommended for select patients with considerable lung cancer risk, chest x-ray is not recommended for this purpose. The presence of extra heart sounds would likely indicate systolic and/or diastolic cardiac dysfunction, again a marker of significant, usually advanced cardiac problems. However, blood pressure measurement is critical, as it can detect hypertension in its asymptomatic, earliest state, and early hypertension would increase Ms. Thomas’ risk of heart disease. While screening for cervical neoplasia is important, intervening in hypertension would be more likely to improve this woman’s shorter-term health.

The NP certification exams test the broad knowledge base needed to be a safe entry-level NP in practice as well as the application of this knowledge. Highly developed skills in clinical assessment and intervention are critical to NP practice. You should expect that the certification exam will reflect this content. Here are a few hints about how to prepare for the exam and NP practice.

Know that the health history forms the primary database necessary to arrive at a diagnosis.

A 38-year-old woman presents with a 12-hour history of sudden-onset vomiting, diarrhea, and cramping abdominal pain, with three episodes of emesis and six episodes of watery, brown stools. Which of the following health history questions is most relevant to this clinical situation?

A. Have you had an appendectomy?
B. Are you sexually active?
C. Has anyone else in your home or workplace had similar problems?
D. When was your last menstrual period?

The correct response is C. While the information given about this patient is scant, the scenario is most consistent with an infectious gastroenteritis, most likely viral in origin. This diagnosis is supported by report of contact with others who have recently had the same illness. Obtaining the information that would be gleaned by asking questions A, B, and D is unlikely to be useful in the differential diagnosis of her presenting condition, as this clinical scenario is not consistent with the typical presentation of appendicitis, pelvic inflammatory disease, or pregnancy-related gastrointestinal upset. Although not directly relevant to this patient’s present clinical situation, her acute illness, it is important to ask women of childbearing age about their last menstrual period in order to identify gaps in family planning and possible early pregnancy.

Patient assessment starts with the health history, and there should be few surprises when you get to the physical exam. Increasing your skill in obtaining an accurate health history in a timely manner will help you in your NP practice and enhance your certification exam performance.

Know which pathogens cause which diseases.

One of the most common causative pathogens for community-acquired pneumonia in the older adult is:

A. Streptococcus pneumoniae
B. Staphylococcus aureus
C. Legionella species
D. Pseudomonas aeruginosa

The correct response is A. The newly graduated NP often comes to outpatient practice with experience providing inpatient care as an RN. In hospitals, care is provided to the sickest of the sick, and these often are patients who have not improved with outpatient care or have multiple health problems that complicate every illness, no matter how minor. In contrast, the majority of primary care (FNP, AGNP) NP practice is delivered in the ambulatory care setting. The organisms that cause community-acquired pneumonia differ significantly from those that cause nosocomial or healthcare-acquired pneumonia. If the NP sitting for certification knows only the pneumonia pathogens that commonly cause inpatient cases of pneumonia, he/she is likely to give an incorrect exam response.

The most common outpatient pathogen responsible for community-acquired pneumonia in older patients is S. pneumoniae. Haemophilus influenzae, the atypical pathogens (Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella species), and viruses are less common causes of pneumonia in community-dwelling patients. Pneumonia caused by pathogens such as P. aeruginosa or S. aureus is more likely to be nosocomial or healthcare acquired in origin and quite unlikely to be found in the older adult with community-acquired pneumonia.

Know why and when to use different types of history-taking questions.

A 65-year-old man presents with a chief complaint of “having no pep for the past few months.” You start the interview by asking:

A. Exactly when did this start?
B. Tell me what you mean by having “no pep.”
C. Are you taking any medications?
D. Have you had this problem in the past?

The correct answer is B. Choice B is an example of an open-ended question. This question usually starts with a statement such as “Tell me…” The benefit of asking a question this way is that you hear the patient’s perception of the problem. The drawback can be the quality and quantity of information gathered.

Responses A, C, and D are closed-ended questions that ask the patient to provide a specific response, providing you with focused information. Patient responses to such questions are usually short and precise. Another example of a closed-ended question is, “How many days have you had no pep?” If the examiner only asks closed-ended questions in a clinical scenario, the patient information will be limited to quantifiable measures, such as location, severity, and duration of a problem. What will be missed is the impact of the problem on the person’s life as well as the patient’s hunch about what has contributed to or caused the problem.

Know the difference between a symptom and a sign.

A common symptom in early appendicitis is:

A. Fever
B. Vague periumbilical or epigastric pain
C. Rebound tenderness
D. Leukocytosis

The correct answer is B. A symptom is the patient’s description of a problem, while a sign is an objective finding. Since fever, rebound tenderness, and leukocytosis are objective findings, or signs, these options are incorrect. By the way, fever and rebound tenderness are late, rather than early, findings in appendicitis.

Know how to quantify tobacco use.

Tamara is a 28-year-old woman who started to smoke cigarettes at age 13. Until around age 23, she smoked an average of one pack of cigarettes per day (PPD), and since then has smoked about two PPD. She has a ___ pack-year history.

A. 13 C. 20
B. 15 D. 28

The correct answer is C. A pack-year cigarette smoking history is calculated by multiplying the number of years as a smoker by the number of packs-per-day (PPD × years smoking). Tamara smoked one PPD × 10 years (10 pack-years) followed by two PPD × 5 years (another 10 pack-years), yielding 20 pack-years.


Successfully passing your certification exam not only marks a critical rite of passage, but also represents tangible evidence of your considerable achievement. Make sure you do everything possible to maximize your likelihood of success.