NPS Section I: the competencies shared by critical and general care

Sec I

Section I on one sheet

Section I is breadth. Thirteen areas share 80 items, the largest holds 12, and six of the thirteen hold four items or fewer. No single weak spot sinks you here, but a habit of skipping the small areas adds up: I-F, I-I, I-J, I-K and I-M together are 15 items, more than any one big area.

The outline also fixes the cognitive level of every item, and the per-area split is more useful than the section total. Four areas carry no recall at all: pulmonary status (I-C), diagnostic results (I-H), nutrition (I-I) and the interdisciplinary team (I-L). Pulmonary status is half analysis. Flashcards help you in I-A and I-B; they do very little for I-H.

Counts per form from the NPS Detailed Content Outline, effective October 1, 2025.

A B C H

Assessment and diagnostics: I-A, I-B, I-C, I-H

Four areas, 33 items, just over two-fifths of the section. They all ask the same thing in different clothes: what does this finding mean, and what happens next?

I-A Assess information (12 items)

History, physical exam, labs, imaging and system-by-system findings: cyanosis and syncope, swallowing and level of consciousness, chest wall deformity, reflux and failure to thrive, fluid and acid-base status. The stems hand you more data than you need. The tactic is to read the last line first, then go back for the one finding that separates two diagnoses. A child with recurrent wheeze and eczema is an asthma story; a first wheeze in an infant after a runny nose is a bronchiolitis story.

I-B Mechanisms of respiratory compromise (8 items)

Why the child is breathing badly, from outside the lungs as often as inside them: pulmonary hypertension and congenital heart disease, apnea of prematurity and muscular dystrophy, scoliosis and Jeune syndrome, necrotizing enterocolitis, inborn errors of metabolism, diabetic ketoacidosis, sickle cell disease. Expect the deep, fast breathing of DKA to be framed as a lung problem when it is compensation for a metabolic acidosis. Transitional physiology lives here too: pulmonary vascular resistance falls sharply at birth, and PPHN is what happens when it does not.

I-C Evaluate pulmonary status (4 items)

Gas exchange (SpO₂, blood gases, end-tidal and transcutaneous CO₂), pulmonary function (spirometry, peak flow, MIP and MEP, FE_NO, peak cough flow) and home monitoring and discharge, including the car seat challenge. Only four items, none of them recall: you will be asked whether a number is trustworthy and what it says about the patient, not what it is called.

I-H Anticipate care based on diagnostic results (9 items)

Labs (CBC, hemoglobin electrophoresis, electrolytes, albumin, sweat test, BNP, cultures and Gram stain, toxicology, blood gases and CO-oximetry) and imaging (chest and lateral neck films, CT, ultrasound, MRI, echocardiogram, fluoroscopy of the diaphragm and swallow). Zero recall, four analysis items: every one asks what you would do with the result. A procalcitonin that points away from bacteria, a sweat chloride that confirms cystic fibrosis, a sniff test that shows a paralyzed hemidiaphragm.

D E F

Airways and equipment: I-D, I-E, I-F

21 items about the hardware: getting an airway, keeping it, and keeping the devices around it honest. This is where bedside habit helps most and where adult habits hurt.

I-D Assess airway management (9 items)

Patent airway, intubation and its CO₂ confirmation, cuff and stoma care, airway clearance (HFCWO, PEP, IPV, insufflation-exsufflation, postural drainage), airway emergencies and the three named artificial airways: supraglottic, endotracheal and the newly placed tracheostomy. Three of the nine items are analysis, so expect a deteriorating patient and a choice of next step.

• Tube size. Newborn tubes are chosen by weight and gestational age; past infancy PALS uses an age-based formula or a length-based tape, with a cuffed tube a half size smaller than the uncuffed one. The exam tests the logic, so know why a tube is too big (no leak, high cuff pressure) or too small (large leak, lost volume).
• Placement. A colorimetric or waveform CO₂ signal confirms the trachea. With very low pulmonary blood flow, as in cardiac arrest, the detector may not change even with the tube in the right place.
• The fresh tracheostomy. Before the first tube change the tract is not formed, so accidental decannulation is an emergency: stay sutures, the obturator, a same-size spare and one a size smaller belong at the bedside. If an obstructed trach will not take a suction catheter, change the tube.

The laryngeal mask in a newborn

The supraglottic airway shows up twice in Section I: as an artificial airway in I-D and as resuscitation equipment in I-J. NRP places it as the alternative airway when face-mask ventilation is not working and intubation fails or is not feasible, in newborns of about 34 weeks' gestation or more. It is not a tool for suctioning the trachea, and it leaks when inflation pressures climb. Expect the question to be about when to reach for it, not how to size it.

I-E Equipment selection and troubleshooting (9 items)

Oxygen and aerosol devices, oral and nasal airways, tracheostomy tubes and speaking valves, transcutaneous and end-tidal monitors, and the home kit of a technology-dependent child: ventilator, PAP, humidifier, apnea monitor, pulse oximeter, suction. Troubleshooting items describe a symptom and ask for the cause, so learn each device by how it fails.

Transcutaneous monitors are the other favorite: the heated sensor needs site changes to avoid burns, and poor perfusion or edema makes the reading drift from the blood gas.

I-F Procedures and their efficacy (3 items)

Flexible bronchoscopy with lavage and biopsy, respiratory specimens (nasal swab, tracheal aspirate, sputum) and blood gas sampling. Three items, one at each cognitive level. Know which specimen answers which question and what you monitor during a bronchoscopy on a small airway already narrowed by the scope.

I-G

Medications: I-G

I-G carries 9 items across seven drug families: aerosolized agents, sedatives and analgesics, reversal agents, vasoactive and inotropic drugs, diuretics, systemic smooth muscle relaxants, and targeted treatments for asthma, neuromuscular disease and cystic fibrosis. The verb in the area name is anticipate: the exam names the drug and asks what happens next, so learn effects and side effects, not doses.

Sedation questions in chronically ventilated infants reward the cautious answer: the lowest dose that settles the child, titrated, with spontaneous effort preserved. Neither "none" nor "deep" survives the stem.

Asthma

Pediatric asthma, as the NPS tests it

For a child with occasional symptoms, the first-line treatment is an inhaled short-acting beta-2 agonist as the reliever; once asthma is persistent, a daily low-dose inhaled corticosteroid is the preferred controller. That is also the answer the NPS rewards. Asthma is one of the outline's largest patient types, with a floor of at least 12 items in the item pool, spread across both sections, and in Section I it appears in I-B (mechanism), I-G (targeted treatment) and I-M (the asthma action plan). This block covers asthma as the exam frames it; it is not a treatment guideline, and dosing stays with the prescriber and the local protocol.

Step-up logic

1. Classify, then reassess

   Severity is graded at the first visit; after that the question is control: daytime symptoms, night waking, reliever use, activity limits.

2. Before stepping up, check the basics

   Inhaler technique, adherence, triggers at home and comorbid problems come first. A stem that describes a child using a metered-dose inhaler without a spacer is asking you to fix the technique, not to add a drug.

3. Step up one step and look again

   NAEPP suggests reassessing two to six weeks after a change.

4. Step down when control holds

   After at least three months of good control, the plan steps back down.

The 2020 NAEPP focused update changed two things for children: a short course of daily inhaled corticosteroid at the start of a cold for toddlers with recurrent wheeze, and a single inhaler of inhaled steroid plus formoterol used as both controller and reliever from age four at the middle steps. GINA no longer advises a short-acting reliever alone for adolescents. Exam items need one defensible answer, so they lean on what the guideline families agree on: reliever for symptoms, steroid for control, technique before escalation.

Judging an exacerbation

The order of acute treatment

Oxygen to the saturation target, a repeated or continuous short-acting beta-agonist, ipratropium added in the emergency department for a moderate or severe attack, and a systemic corticosteroid early. If the child is not responding, intravenous magnesium sulfate comes next, then heliox-driven aerosol or noninvasive support by protocol. Intubation is reserved for fatigue, rising CO₂ or a falling level of consciousness, and ventilating that child, with its long expiratory times and accepted hypercapnia, is Section II material: see the critical care guide.

I–M

Feeding, resuscitation, protocols, team and family: I-I to I-M

Five small areas, 17 items, and the ones most people skim. Read them once with the outline open; most of the points are protocol and judgment, not memorization.

I-I Nutritional status (2 items)

Feeding intolerance, a malpositioned feeding tube, aspiration, and morbid obesity with its airway and sleep-disordered breathing. If a tube-fed child coughs and desaturates during a feed, stop the feed before anything else.

I-J Resuscitation (3 items)

Equipment (T-piece resuscitator, self-inflating bag, flow-inflating bag, supraglottic mask) and protocols (NRP, PALS, the Golden Hour for a preterm delivery). A self-inflating bag cannot give free-flow oxygen through its mask, a flow-inflating bag needs a gas source and a seal to fill, and the T-piece gives the most consistent inflation and end-expiratory pressure. That comparison is a classic recall item.

I-K Patient care protocols (4 items)

Prevention of ventilator-associated events and of skin injury from adhesives, prongs and masks, plus disaster and pandemic readiness: triage and supply management. Pediatric mass-casualty triage uses JumpSTART, the child version of START. In an outbreak of a resistant organism, cohorting patients who carry the same organism is the protocol answer.

I-L The interdisciplinary team (5 items)

Suggesting a change to the care plan from your assessment, answering a change someone else proposes, escalating a concern, supporting palliative care, and patient-centered, culturally aware, trauma-informed interaction. No recall here. The right option is usually the one where you bring a specific finding to the team, not the one where you act alone or say nothing.

I-M Patient and family education (3 items)

Discharge teaching (artificial airway care, CPR, car seat positioning, the asthma action plan, the emergency plan, safe sleep), equipment set-up and cleaning, and medication technique. The area name says evaluate understanding, so the best answer checks the teaching: have the parent show you, or explain it back. A child who will not wear a new CPAP mask is a desensitization problem, solved in the daytime and in small steps.

Traps

Traps the shared-care rows keep setting

The twelve rows at the top of this page come from across Section I, and their rationales keep returning to the same handful of mistakes.

• Fixing the ventilator for a plumbing problem. Profound cyanosis in a newborn with a mixing lesion such as transposition does not improve with more oxygen or more pressure; keeping the ductus open does.
• Moving an unstable patient for a test. When the stem says the child is too unstable to transport, the answer is the bedside tool, such as lung ultrasound.
• Treating the secretions before the airway. Massive hemoptysis in cystic fibrosis is an airway problem first; mucolytics and scans can wait.
• Swinging the FiO₂. In a preterm infant, oxygen moves in small steps toward a saturation target, in both directions.
• Calling the first wheeze asthma. Atopy and recurrence point to asthma; a viral prodrome and a first episode in an infant point to bronchiolitis.

For both sections in proportion, run the 60-row NPS practice test.

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Cog

How Section I asks: recall, application, analysis

Section I holds 16 of the exam's 22 recall items, which makes it the more memorizable half. It still asks 47 application items, and those decide the section: a finding, a device or a drug, and what you do about it. Section II flips the balance toward analysis. Pace, retakes and scoring are on the NPS exam page.

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