In the course of talking to candidates for certification, I often speak with NPs who are among the approximately 1 in 4 or 5 exam takers who do not pass the adult or family NP exam. What have I learned from these conversations? This is a group of intelligent people who completed a course of rigorous graduate study. In spite of this, they were unsuccessful at an exam that often dictates whether the NP can practice.  This can be a devastating blow. However, in retrospect, most can say what it was that got in the way of success. Here is what they have shared.

I expected to read a question and instantly recognize the answer.

While this may happen with a low level fact oriented question, such as one identifying an anatomic landmark, you should not expect the majority of the questions to be of this type. Most items test your ability to assess or develop a plan of intervention for a clinical situation. Therefore, you should expect to apply clinical decision-making skills to the test question.  Make sure you think through each question. In particular, bear in mind how the pathophysiology of the condition affects the presentation and treatment.

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? The ability to develop a diagnosis or to plan a course of intervention?”  This will help focus your thought process as you chose the answer.

More than one answer was applicable to the situation presented. I was not sure which response 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 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 found on far less often, nuchal rigidity is a better choice. In addition, childhood development questions often have more than one correct response. For example, 4 month-olds are 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.

I work in an acute care setting. The scenarios and treatment options presenting in the questions were quite different than what I am accustomed to seeing in my RN practice. I had a hard time choosing the best answer.

Most new NP’s are seasoned RN’s. It is important to remember that, in the acute care setting, you are typically seeing the “worst case scenario” of a disease state, rather than how it would present in primary care, the practice setting of most NP’s. Recall that the NP certification exam is a test of entry-level NP knowledge.  The acute care nurse is accustomed to seeing exceptions; the exam is likely to present situation that is more the rule. For example, the chest pain associated with preinfarct angina can last for hours and is present at rest.  Since the acute care nurse likely has experience in caring for patients with preinfarct or unstable angina, this presentation may become the nurse’s mindset of the typical presentation of angina pectoris. However, the chest pain episode of the community dwelling elder with stable angina pectoris is usually infrequent and lasts less than 10 minutes. Relief of symptoms usually occurs promptly and is relieved with rest or cessation of the provoking activity.  The test taker needs to apply primary, not acute care, rules the test. 

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

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This article originally appeared in my quarterly certification column in Advance for Nurse Practitioners and is made available here by the courtesy of Advance. For other articles of interest to Nurse Practitioners, be sure to subscribe to this outstanding journal.