PANRE-LA Exam Prep: Free Study Guide, Quarter Plan and Practice Questions
PANRE-LA is NCCPA's at-home recertification route for board-certified PAs: 25 questions a quarter, five minutes each, references allowed. Start with the checklist below, then work Question 1 with a reference open.
Start here
- Check your year. You apply in Year 6 of your 10-year cycle, and quarters run in Years 7–9. Your NCCPA dashboard shows your recertifying exam status.
- Never sit out a whole year early on. You must take part in at least one quarter in Year 7 and one in Year 8, or NCCPA withdraws you and keeps the $350 fee unless it approves an exception.
- Finish every quarter you open. Unanswered questions in a quarter you've started are scored as incorrect.
- Practice one reference check. Work Question 1 below with your usual clinical reference open.
- Read the explanation, then choose one concept to look up properly. That's one study session done.
Question 1: work through a reference check
Original, unofficial practice by Castleport Test Prep. Not an NCCPA question.
A 74-year-old woman is found to have atrial fibrillation on an ECG done for palpitations. She has hypertension controlled with amlodipine and no other medical conditions. Echocardiography shows no mitral stenosis, and she has no prosthetic valve. Renal function and complete blood count are normal. Which of the following is the most appropriate management to reduce her stroke risk?
Reveal answer and explanation
Answer: C. Apixaban
Her CHA₂DS₂-VASc score is 3: one point for age 65–74, one for female sex, one for hypertension. The 2023 ACC/AHA/ACCP/HRS AF guideline gives a Class 1 recommendation for oral anticoagulation when estimated annual stroke risk is at least 2%, which corresponds to a score of 2 or more in men and 3 or more in women. It prefers a direct oral anticoagulant (DOAC) over warfarin unless the patient has moderate-to-severe mitral stenosis or a mechanical heart valve.
- A: Aspirin is not recommended as an alternative to anticoagulation for stroke prevention in AF.
- B: Adding clopidogrel to aspirin still isn't an alternative to anticoagulation.
- D: Her age, hypertension and female sex give a CHA₂DS₂-VASc score of 3, meeting the guideline's Class 1 threshold for anticoagulation in women.
- E: Warfarin would protect her, but the guideline prefers a DOAC when there's no valve-related reason to use warfarin, so it isn't the most appropriate choice.
Worked lookup: The last line asks for the most appropriate management, so this is an intervention question. Choose apixaban as a provisional answer, since a 74-year-old woman with hypertension sounds like a clear anticoagulation case. The detail that separates your choices is the women's threshold and the DOAC-versus-warfarin preference, so search short keywords such as "CHA2DS2-VASc women anticoagulation" and open the AF guideline's stroke-prevention section. Score her (1 + 1 + 1 = 3), confirm the Class 1 threshold for women and the DOAC preference, and submit at about the 2:30 mark.
Source: Joglar JA, et al. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation. Circulation. 2024;149:e1–e156. (PDF) — Table 8 and Section 6.3.1, Antithrombotic Therapy, Recommendations 1, 2 and 4 (p. e33).
Use the four-week setup and quarterly routine to schedule this practice.
The 5-minute question routine
Five minutes goes faster than it sounds. This is the routine we suggest, built around how the real quarters work:
- Before you open a question, check the preview. NCCPA tells you the content category of the next question and whether it has an image. If it's a topic you want to read up on first, or you need a bigger screen for an image, you can wait and open it later in the quarter.
- 0:00–0:45 — Read the last line first. Is it asking for the history or exam finding, the diagnosis, a basic intervention or a complex one? Those are the four "performance expectations" on NCCPA's blueprint.
- 0:45–1:15 — Click a provisional answer. If time runs out while you're searching, a selected answer is still recorded and scored. If nothing is selected, the question counts as unanswered and incorrect.
- 1:15–4:00 — Verify one discriminating detail. Search the fact that separates your top two choices (a threshold, a contraindication, a first-line drug), using short keywords only. Stick to one source you trust.
- 4:00–4:30 — Confirm or change, then submit. Don't run the clock to zero.
- After each question — read the feedback. NCCPA shows the correct answer, an explanation and references, and you can return to questions you opened earlier while you're enrolled.
A dropped connection doesn't pause the clock. If you get back in within the five minutes, you can still answer; if you can't, a previously selected answer is scored and an unselected one counts as incorrect. NCCPA won't reset questions for internet or device problems, so answer on a connection and device you trust.
17 more practice questions
Original, unofficial practice by Castleport Test Prep. These are not NCCPA questions and aren't drawn from any real exam. Give yourself five minutes each and keep your references open. The 18 questions sample 14 of the 15 blueprint categories, with two each in Cardiovascular, Pulmonary, Gastrointestinal/Nutrition and Endocrine; Emergent Topics (legal, ethical and DEI) isn't sampled here. Your score on this set is feedback on these 18 items only, not a prediction of your PANRE-LA result.
Question 2 — Cardiovascular System · Screening
A 68-year-old man comes in for a routine visit. He has never been screened for an abdominal aortic aneurysm and has no abdominal or back pain. He smoked one pack a day for 20 years and quit 18 years ago. He would accept repair if a large aneurysm were found. Which screening approach does the U.S. Preventive Services Task Force recommend?
Reveal answer and explanation
Answer: B. One-time abdominal ultrasonography
The USPSTF recommends one-time ultrasound screening for men aged 65 to 75 who have ever smoked (grade B). "Ever smoked" includes former smokers; how long ago he quit doesn't change the recommendation.
- A: CT adds radiation and cost and isn't the recommended screening test.
- C: Palpation is not accurate enough to serve as a screening test.
- D: The USPSTF's AAA screening recommendation has no 15-year quit-time cutoff.
- E: The USPSTF recommends one-time screening, not annual ultrasonography after a normal initial study. If an aneurysm is found, its size guides surveillance.
Source: U.S. Preventive Services Task Force. Abdominal Aortic Aneurysm: Screening. Final Recommendation Statement, December 10, 2019. — Recommendation Summary; Screening Tests and Intervals.
Question 3 — Pulmonary System · Intervention
A 34-year-old man with asthma uses an albuterol inhaler about twice a month for wheeze after exercise or cold air. He has had no exacerbations, urgent visits or oral steroids in the past year, and he uses no other asthma medicine. Which of the following changes is most consistent with the 2026 GINA recommendations?
Reveal answer and explanation
Answer: B. As-needed low-dose budesonide-formoterol
GINA recommends that adults and adolescents with asthma not be treated with a short-acting beta-agonist (SABA) alone, because SABA-only treatment raises the risk of severe exacerbations. For mild asthma (Steps 1–2), its preferred track uses low-dose inhaled corticosteroid–formoterol taken as needed for symptoms.
- A: SABA-only treatment is exactly what GINA advises against, even with infrequent symptoms.
- C: Montelukast is less effective than daily inhaled corticosteroids, particularly for preventing exacerbations.
- D: A long-acting beta-agonist without an inhaled corticosteroid is not appropriate asthma treatment.
- E: He isn't having an exacerbation; oral steroids add risk without improving long-term control.
Source: Global Initiative for Asthma. Summary Guide for Asthma Management and Prevention: For Adults, Adolescents and Children 6–11 Years. July 2026. (PDF) — Treatment steps for adults and adolescents and Track 1 Steps 1–2, pp. 23–24; leukotriene receptor antagonists, p. 27.
Question 4 — Pulmonary System · Diagnosis
A 56-year-old woman has had mild pleuritic left chest pain since yesterday. Pulse is 88/min, respirations are 16/min, and oxygen saturation is 97% on room air. She has no hemoptysis, leg swelling, recent surgery or trauma, history of venous thromboembolism, or estrogen use. She is not taking anticoagulants. Using a validated clinical prediction rule, you judge her pretest probability of pulmonary embolism to be low. Which of the following is the most appropriate next step?
Reveal answer and explanation
Answer: C. High-sensitivity D-dimer, interpreted with an age-adjusted cutoff
She has low pretest probability but doesn't meet all of the Pulmonary Embolism Rule-out Criteria (PERC) because she is 50 or older. A high-sensitivity D-dimer is the next test in this pathway. The 2026 AHA/ACC multisociety guideline supports an age-adjusted cutoff for patients older than 50 with low or intermediate clinical probability. For an assay reported in fibrinogen-equivalent units (FEU), the cutoff is age × 10 ng/mL FEU: 560 ng/mL FEU here. A result below that cutoff excludes PE without imaging in this pathway.
- A: Within the PERC pathway, no further testing requires low clinical probability and every PERC criterion to be met. She fails the age criterion.
- B: Imaging first isn't recommended for low or intermediate pretest probability.
- D: A V/Q scan is a CT alternative when CT is contraindicated, not a first test here.
- E: Nothing here justifies anticoagulating before testing.
Source: Creager MA, et al. 2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN Guideline for the Evaluation and Management of Acute Pulmonary Embolism in Adults. Circulation. 2026. doi:10.1161/CIR.0000000000001415. — Section 3.1.1, Clinical Assessment, Recommendation 2 and supportive text; Table 3, Clinical Decision Rules (original online PDF pp. 7–9).
Question 5 — Gastrointestinal System and/or Nutrition · Intervention
A 61-year-old man with alcohol-associated cirrhosis comes to the emergency department after vomiting bright red blood twice. Blood pressure is 94/58 mmHg and pulse is 112/min. Two large-bore IV lines are placed, an octreotide infusion is started, and gastroenterology plans urgent endoscopy. Which of the following is the most appropriate additional intervention now?
Reveal answer and explanation
Answer: A. IV ceftriaxone
Suspected variceal bleeding in cirrhosis rests on three early steps: a vasoactive drug, short-course antibiotic prophylaxis, and endoscopy. Bacterial infection is common after variceal bleeding in cirrhosis, and AASLD guidance pairs vasoactive therapy with prophylactic antibiotics, usually ceftriaxone, for 2–5 days.
- B: Acid suppression doesn't replace endoscopic therapy for suspected varices.
- C: Guidance favors restrictive transfusion; overtransfusion can raise portal pressure and worsen bleeding.
- D: Nonselective beta-blockers are started later to prevent rebleeding, not during hypotensive acute bleeding.
- E: Balloon tamponade is a temporary rescue for uncontrolled bleeding, not a routine first step.
Source: Kaplan DE, et al. AASLD Practice Guidance on risk stratification and management of portal hypertension and varices in cirrhosis. Hepatology. 2024;79(5):1180–1211. — Management of acute variceal hemorrhage; Guidance Statements 25–28 (original PDF pp. 14–15).
Question 6 — Gastrointestinal System and/or Nutrition · Intervention
A 45-year-old woman has a duodenal ulcer on upper endoscopy, and gastric biopsies are positive for Helicobacter pylori. She has never been treated for H. pylori. She developed hives after taking amoxicillin as a teenager. Antibiotic susceptibility is unknown. Which of the following is the most appropriate treatment?
Reveal answer and explanation
Answer: B. Bismuth quadruple therapy (PPI, bismuth, tetracycline, metronidazole) for 14 days
The 2024 ACG guideline recommends optimized bismuth quadruple therapy for 14 days as first-line treatment for treatment-naive H. pylori when susceptibility is unknown. It contains no penicillin, so her amoxicillin allergy doesn't limit it.
- A: ACG advises against empiric clarithromycin-based regimens when susceptibility is unknown, and this one also contains amoxicillin.
- C: An acceptable first-line alternative only for patients without penicillin allergy.
- D: Healing the ulcer without eradicating H. pylori leaves the cause in place.
- E: Also a first-line alternative only when there's no penicillin allergy; it contains amoxicillin.
Source: Chey WD, et al. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol. 2024;119(9):1730–1753. — Recommendations for treatment-naive patients.
Also supporting this explanation: American College of Gastroenterology. Evidence-Based GI summary of the 2024 H. pylori guideline. September 17, 2024. — Results and Key Study Findings: optimized bismuth quadruple therapy and treatment-naive patients.
Question 7 — Endocrine System · Intervention
A 63-year-old man with type 2 diabetes takes metformin. His hemoglobin A1c is 7.6%. He also has heart failure with reduced ejection fraction (ejection fraction 30%), treated with sacubitril-valsartan, carvedilol and spironolactone. eGFR is 55 mL/min/1.73 m². Which of the following is the most appropriate addition to his regimen?
Reveal answer and explanation
Answer: A. Empagliflozin
ADA Standards of Care recommend an SGLT2 inhibitor for people with type 2 diabetes and established heart failure to reduce worsening heart failure and cardiovascular death. The indication is the heart failure, not the glucose, so it applies even with an A1c near goal.
- B: Thiazolidinediones cause fluid retention and can worsen heart failure; avoid them in symptomatic HF.
- C: Lowers glucose but doesn't reduce heart-failure hospitalization or cardiovascular death.
- D: Lowers glucose but adds hypoglycemia risk without heart-failure benefit.
- E: An A1c near goal isn't a reason to skip a therapy given for cardiorenal protection.
Source: American Diabetes Association Professional Practice Committee for Diabetes. 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2026. Diabetes Care. 2026;49(Suppl 1):S216–S245. — Recommendation 10.41a (p. S231); see also Section 9, Recommendation 9.8 (p. S190) and Table 9.2.
Also supporting this explanation: American Diabetes Association Professional Practice Committee for Diabetes. 9. Pharmacologic Approaches to Glycemic Treatment: Standards of Care in Diabetes—2026. — Recommendation 9.8, p. S190; Table 9.2.
Question 8 — Endocrine System · Intervention
A 24-year-old woman with type 1 diabetes comes to the emergency department with vomiting and abdominal pain. Glucose is 480 mg/dL, arterial pH is 7.12, bicarbonate is 9 mEq/L, the anion gap is 24, serum ketones are elevated, and potassium is 3.1 mEq/L. IV isotonic fluids have been started. Which of the following is the most appropriate next step?
Reveal answer and explanation
Answer: B. Replace potassium and delay insulin until potassium is above 3.5 mEq/L
Insulin drives potassium into cells. Starting it with a potassium of 3.1 can cause dangerous hypokalemia and arrhythmia. The 2024 ADA/EASD/JBDS/AACE/DTS consensus report advises starting potassium replacement and postponing insulin until potassium is above 3.5 mmol/L (mEq/L).
- A: Right insulin dose, wrong moment.
- C: Bicarbonate is not routine at this pH and can worsen hypokalemia.
- D: Basal insulin alone doesn't treat DKA, and the potassium problem still comes first.
- E: Fluid resuscitation continues; it's insulin, not fluid, that waits.
Source: Umpierrez GE, et al. Hyperglycemic crises in adults with diabetes: a consensus report. Diabetes Care. 2024;47(8):1257–1275. — Section 4, “Potassium” and “Bicarbonate.”.
Also supporting this explanation: The same 2024 joint consensus report, published in Diabetologia. — Section 4, Potassium and Bicarbonate.
Question 9 — Eyes, Ears, Nose, and Throat · Intervention
A 22-year-old man has had sore throat and fever for two days. Temperature is 38.6°C (101.5°F). He has tonsillar exudate, tender anterior cervical lymph nodes, and no cough. A rapid antigen test for group A streptococcus is positive. He has no drug allergies. Which of the following is the most appropriate treatment?
Reveal answer and explanation
Answer: A. Amoxicillin for 10 days
CDC names penicillin or amoxicillin as the drug of choice for confirmed group A strep pharyngitis. For oral amoxicillin, the recommended course is 10 days.
- B: Azithromycin is an alternative for patients with penicillin allergy, not the preferred choice here.
- C: Five days of amoxicillin is not the CDC-recommended duration.
- D: Fluoroquinolones are not recommended for strep pharyngitis.
- E: Confirmed group A strep pharyngitis is an indication for antibiotics.
Source: Centers for Disease Control and Prevention. Clinical Guidance for Group A Streptococcal Pharyngitis. Updated November 18, 2025. — Treatment — Recommended antibiotics; Other options for patients with a penicillin allergy.
Question 10 — Infectious Diseases · Diagnosis and intervention
A 38-year-old woman who hikes in Connecticut has an expanding, nontender red patch on her thigh, first noticed six days ago in June. It is now 8 cm across with partial central clearing. She has mild fatigue. Neurologic and cardiac examinations are normal, and she is not pregnant. Which of the following is the most appropriate next step?
Reveal answer and explanation
Answer: B. Doxycycline for 10 days
This is typical erythema migrans in an endemic area. The IDSA/AAN/ACR guideline recommends a clinical diagnosis without lab testing in that setting, and treatment with a 10-day course of doxycycline (or 14 days of amoxicillin or cefuroxime axetil).
- A: Serology is often negative this early; testing is for lesions that are atypical for erythema migrans.
- C: A single dose is prophylaxis after a high-risk tick bite, not treatment of established infection.
- D: IV therapy is for selected disseminated disease, not uncomplicated erythema migrans.
- E: The rash may fade, but treatment speeds resolution and helps prevent dissemination.
Source: Lantos PM, et al. Clinical Practice Guidelines by IDSA, AAN and ACR: 2020 Guidelines for the Prevention, Diagnosis and Treatment of Lyme Disease. Clin Infect Dis. 2021;72(1):e1–e48. — Sections V.1, VI.1 and VII.1: clinical diagnosis, oral agents and erythema migrans treatment duration.
Question 11 — Musculoskeletal System · Diagnosis and intervention
A 72-year-old woman has had a new right temporal headache for three weeks, pain in her jaw when chewing, and scalp tenderness. Erythrocyte sedimentation rate is 88 mm/hr. She has no visual symptoms, and the fundoscopic examination is normal. Which of the following is the most appropriate next step?
Reveal answer and explanation
Answer: A. Start high-dose oral glucocorticoids now and arrange temporal artery biopsy
New headache, jaw claudication and scalp tenderness in an older adult with a high ESR strongly suggest giant cell arteritis, which can cause permanent vision loss. Treatment shouldn't wait for confirmation. The 2021 ACR/Vasculitis Foundation guideline favors high-dose oral glucocorticoids for new GCA without cranial ischemic signs, and a biopsy within two weeks of starting steroids rather than delaying it.
- B: Waiting for biopsy risks vision loss; biopsy findings persist after steroids start.
- C: Treats the headache, not the vasculitis.
- D: Low doses aren't adequate initial therapy.
- E: Treats migraine, not vasculitis.
Source: Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation Guideline for the Management of Giant Cell Arteritis and Takayasu Arteritis. Arthritis Rheumatol. 2021;73(8):1349–1365. — Table 1, cranial ischemia; diagnostic Recommendation 3; treatment Recommendations 8–9.
Question 12 — Hematologic System · Diagnosis
A 67-year-old man reports three months of fatigue. Hemoglobin is 10.1 g/dL, MCV is 74 fL, and ferritin is 9 ng/mL. He has no abdominal symptoms, no visible bleeding, takes no anticoagulants or NSAIDs, and has never had a colonoscopy. Which of the following is the most appropriate next step?
Reveal answer and explanation
Answer: B. Upper endoscopy and colonoscopy
This is iron deficiency anemia (small red cells, ferritin well below the AGA's 45 ng/mL cutoff) in an older man with no obvious cause. The AGA strongly recommends bidirectional endoscopy for asymptomatic men and postmenopausal women with iron deficiency anemia, because a gastrointestinal cancer is a real possibility.
- A: Iron alone treats the number and misses the cause.
- C: Capsule endoscopy is for selected patients after a negative upper and lower evaluation.
- D: Doesn't fit a clearly iron-deficient picture.
- E: A thalassemia workup doesn't fit a ferritin of 9.
Source: Ko CW, et al. AGA Clinical Practice Guidelines on the Gastrointestinal Evaluation of Iron Deficiency Anemia. Gastroenterology. 2020;159(3):1085–1094. — Recommendations 1–2 (pp. 1086–1087) and 7: ferritin cutoff, bidirectional endoscopy and subsequent capsule evaluation.
Question 13 — Renal System · Intervention
A 66-year-old man with stage 4 chronic kidney disease takes lisinopril and spironolactone. He comes in with generalized weakness. Serum potassium is 7.1 mEq/L, and the ECG shows peaked T waves and a widened QRS complex. Which of the following should be given first?
Reveal answer and explanation
Answer: A. IV calcium gluconate
Hyperkalemia with ECG changes is an emergency. IV calcium stabilizes the cardiac cell membrane within minutes. It doesn't lower potassium, so treatments that shift potassium into cells (insulin with glucose, inhaled beta-agonist) and remove it (binders, diuretics if the kidneys respond, or dialysis) must also be started promptly.
- B: Sodium polystyrene sulfonate has a delayed effect and does not stabilize cardiac membranes.
- C: Diuretics remove potassium slowly and unreliably in advanced CKD.
- D: Stopping the offending drugs is necessary but nowhere near enough.
- E: Oral bicarbonate has no role in emergency stabilization.
Source: Lindner G, et al. Acute hyperkalemia in the emergency department: a summary from a Kidney Disease: Improving Global Outcomes conference. Eur J Emerg Med. 2020;27(5):329–337. — Cellular membrane stabilization; Potassium shift to the intracellular compartment; Potassium elimination from the body; Figure 3.
Question 14 — Genitourinary System · Intervention
An otherwise healthy, nonpregnant 31-year-old woman has a urine culture growing more than 100,000 CFU/mL of Escherichia coli, ordered during a routine visit. She has no dysuria, frequency, urgency, suprapubic pain, flank pain or fever. No urologic procedure is planned. Which of the following is the most appropriate management?
Reveal answer and explanation
Answer: E. No antibiotic treatment
An incidental positive urine culture without urinary symptoms is not evidence of symptomatic cystitis. The IDSA guideline recommends against screening for or treating asymptomatic bacteriuria in healthy nonpregnant women. Screening and treatment are recommended in pregnancy and before endoscopic urologic procedures associated with mucosal trauma.
- A: Treats a culture result, not an infection; antibiotics here add side effects and resistance without benefit.
- B: Same problem, with a broader-spectrum drug.
- C: Same problem in a single dose.
- D: Repeating the culture is screening by another name; a persistent positive still wouldn't need treatment.
Source: Nicolle LE, et al. Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2019;68(10):e83–e110. — Definitions; Recommendations II.1, III.1 and XIII.1.
Question 15 — Reproductive System · Intervention
A 29-year-old woman, gravida 1, at 35 weeks' gestation has a blood pressure of 168/112 mmHg, still in the severe range when rechecked 15 minutes later. She has a severe headache, and urine dipstick shows 2+ protein; quantitative protein testing is not immediately available. IV labetalol has been ordered. Which of the following is also most appropriate?
Reveal answer and explanation
Answer: A. Magnesium sulfate, with delivery planned after maternal stabilization
She has preeclampsia with severe features because of persistent severe-range blood pressure; the headache adds concern. ACOG Practice Bulletin 222 recommends magnesium sulfate to prevent eclampsia in that setting, and delivery once she is stabilized when severe features are diagnosed at 34 weeks or later.
- B: Expectant management to 37 weeks is for preeclampsia without severe features.
- C: ACE inhibitors are contraindicated in pregnancy.
- D: Magnesium is more effective than benzodiazepines for preventing eclamptic seizures.
- E: This is an inpatient emergency.
Source: American College of Obstetricians and Gynecologists. Gestational Hypertension and Preeclampsia: ACOG Practice Bulletin No. 222. Obstet Gynecol. 2020;135(6):e237–e260. — Recommendations on magnesium sulfate and timing of delivery.
Also supporting this explanation: California Maternal Quality Care Collaborative. Improving Health Care Response to Hypertensive Disorders of Pregnancy: A California Quality Improvement Toolkit, educational slide set. November 2021. Hosted by SMFM. (PDF) — pp. 15, 27–29 and 41–42: delivery timing, diagnostic criteria and magnesium sulfate.
Question 16 — Dermatologic System · Intervention
A healthy 31-year-old man has a 3-cm tender, fluctuant swelling on his thigh with about 1 cm of surrounding redness. He is afebrile, vital signs are normal, and he has no immune compromise. Which of the following is the most appropriate treatment?
Reveal answer and explanation
Answer: A. Incision and drainage
A fluctuant collection is a purulent skin infection, and the IDSA guideline names incision and drainage as the primary treatment for abscesses. Whether to add an antibiotic after drainage depends on systemic signs, extent and host factors; an antibiotic can't replace drainage.
- B: Doesn't drain the pus, which is the main problem.
- C: Nothing here suggests severe infection or a need for IV therapy.
- D: A 3-cm fluctuant abscess usually needs drainage, not watchful waiting.
- E: Topical treatment doesn't reach an abscess.
Source: Stevens DL, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59(2):e10–e52. — Purulent Skin and Soft Tissue Infections, Recommendations II.3–4.
Question 17 — Neurologic System · Intervention
A 41-year-old woman woke up yesterday with weakness of the entire left side of her face, including her forehead. She can't fully close her left eye. She has no limb weakness, other cranial nerve findings, ear vesicles, rash or trauma. Which of the following is the most appropriate management?
Reveal answer and explanation
Answer: A. Oral corticosteroids, plus eye protection
Acute one-sided facial weakness that includes the forehead, with no other findings, fits Bell palsy. The AAO-HNSF guideline strongly recommends oral steroids within 72 hours of onset for patients 16 and older, and eye protection when eye closure is impaired.
- B: The guideline recommends against antiviral therapy alone; an antiviral may be added to steroids.
- C: Routine imaging isn't recommended for typical new-onset Bell palsy.
- D: Electrodiagnostic testing isn't routine early; it's an option for selected complete paralysis.
- E: Steroids improve recovery, and her eye needs protection now.
Source: Baugh RF, et al. Clinical Practice Guideline: Bell's Palsy. Otolaryngol Head Neck Surg. 2013;149(3 Suppl):S1–S27. — Action statements in the primary publication abstract: steroids within 72 hours, eye care, antivirals, imaging and electrodiagnostic testing.
Question 18 — Psychiatry/Behavioral Science · Intervention
A 52-year-old man admitted for pneumonia reports drinking heavily every day for years and had his last drink 30 hours ago. He is tremulous, sweaty and anxious, with a pulse of 112/min. His CIWA-Ar score is 18. He had a withdrawal seizure two years ago. Which of the following is the most appropriate treatment?
Reveal answer and explanation
Answer: A. Benzodiazepine therapy
His history and symptoms support alcohol withdrawal, and his previous withdrawal seizure increases the risk of complications. A CIWA-Ar score of 18 is in the moderate range, but pneumonia can influence the score, so it must be interpreted in clinical context. The 2020 ASAM guideline names benzodiazepines as first-line treatment because they reduce seizures and withdrawal delirium. He should also receive thiamine.
- B: Antipsychotics can be adjuncts for refractory delirium or hallucinosis but shouldn't be used alone.
- C: An option in mild-to-moderate withdrawal when benzodiazepines are contraindicated, not first-line with prior seizures.
- D: Alpha-2 agonists treat autonomic symptoms as adjuncts; they don't prevent seizures.
- E: His withdrawal symptoms and past withdrawal seizure warrant treatment; the score helps assess severity.
Source: American Society of Addiction Medicine. The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management. J Addict Med. 2020;14(3S Suppl 1):1–72. (PDF) — Recommendations I.6, II.5, II.12–13, V.7, V.13, V.16, V.28, V.36 and VI.20.
How did it go? For each miss, sort out why: you didn't know the fact, you couldn't find it fast, or you misread what was asked. The first fix is reading, the second is your reference setup, the third is the routine above.
Your PANRE-LA study plan
Before Quarter 1: a four-week setup
This optional plan uses two 30-minute sessions a week, about four hours in all. Stretch it, shrink it or skip parts you already know; NCCPA doesn't prescribe study hours, and this plan doesn't guarantee a result.
| Week | Session 1 (30 min) | Session 2 (30 min) | What you'll have |
|---|---|---|---|
| 1 | Work Question 1 and its lookup. Set up your reference kit (below) and bookmark the blueprint. | Questions 2–5, five minutes each. Read every explanation. | A working lookup routine |
| 2 | Questions 6–9. For each, name the one patient detail that decided the answer. | Read up on one blueprint category you rarely see in practice, then retry any missed question without peeking. | One weak area turned into notes |
| 3 | Questions 10–14. Say out loud why each wrong option is wrong. | Lookup drill: pick two questions and find the exact guideline section in under three minutes each. | Faster source-finding |
| 4 | Questions 15–18. Pick an unsampled topic from the blueprint to review next. | Revisit every miss, put each quarter's open and close dates in your calendar, and plan your first quarter's sessions. | A dated plan for Quarter 1 |
Every quarter: a repeatable routine
| When | What to do |
|---|---|
| When the quarter opens | Put the close date in your calendar and plan to finish at least a week early. |
| Before your first session | Review last quarter's questions and rationales in NCCPA's system, and read up on one area you missed. |
| During the quarter | Work in short blocks. Five sessions of five questions is one easy split, but leave time to read feedback after each question. |
| Before each question | Use the preview. Open it now, or come back after reviewing that topic or switching to a bigger screen. |
| After the quarter | Note what you'll review next, and confirm your CME and maintenance fee are on track in the portal. |
Across all 12 quarters (2030 group)
Dates to know (NCCPA): Due to recertify in 2030? Your application window is July 1 – December 18, 2026. The 2031 group applies July 1 – December 18, 2027. If you're already enrolled, the current quarter runs October 1 – December 10, 2026. Confirm your own dates on NCCPA's Key Dates page or in your NCCPA Portal. Last verified November 5, 2026.
If you're due to recertify in a different year, apply in your recertification year minus 4. Keep the cycle-year sequence, but use NCCPA's published application and quarter dates for your own cohort; don't shift these calendar dates automatically.
| Year of your cycle | Calendar year | Quarters | Official windows | What to do |
|---|---|---|---|---|
| Year 6 | 2026 | — | Apply July 1 – December 18, 2026 | Apply, pay the $350 fee, and request accommodations with your application if you need them. Do the four-week setup. |
| Year 7 | 2027 | Q1–Q4 | Jan 4–Mar 12 · Apr 1–Jun 10 · Jul 1–Sep 10 · Oct 1–Dec 10 | Do all four. Q1 meets the Year 7 minimum. |
| Year 8 | 2028 | Q5–Q8 | Check NCCPA's Key Dates page when these dates are published | Do all four. Q5 meets the Year 8 minimum. After your eighth quarter of participation, NCCPA makes the first pass/fail decision. |
| Year 9 | 2029 | Q9–Q12 | Check NCCPA's Key Dates page when these dates are published | Only if you haven't passed. Each extra quarter can replace a weaker one in your best 8. |
| Year 10 | 2030 | — | Traditional PANRE windows | Only if needed: up to three PANRE attempts, normally at least 90 days apart; see the final-attempt exception below. |
Front-loading Years 7 and 8 is our editorial recommendation, and NCCPA's policies point the same way: doing quarters early gives you room to skip one later if life gets in the way, and more chances to pull your score up.
Keep a study log (the safe way)
A log turns misses into a plan. Keep it to our practice questions and your own reading. Never copy, screenshot, save or summarize actual PANRE-LA questions, options or rationales; NCCPA treats that as irregular behavior. Review real PANRE-LA items only inside NCCPA's system.
| Question or topic | Source you used | The rule, in your own words | What you'll practice next | Revisit on |
|---|---|---|---|---|
| Castleport Question 1: AF anticoagulation | 2023 ACC/AHA/ACCP/HRS AF guideline | In this patient, a CHA₂DS₂-VASc score of 3 meets the guideline's Class 1 anticoagulation threshold; a DOAC is preferred over warfarin without moderate-to-severe mitral stenosis or a mechanical valve | Find the guideline's section on when warfarin is still preferred | A date you choose |
What to review: the PANRE/PANRE-LA blueprint
PANRE and PANRE-LA share one content blueprint (PDF), effective January 2023. NCCPA notes the percentages may vary slightly, so treat them as a guide to emphasis, not a count of questions per quarter.
| Content area | Share | Make your reference fastest for |
|---|---|---|
| Cardiovascular System | 12% | AF, ACS, heart failure, hypertension, lipids, VTE |
| Gastrointestinal System and/or Nutrition | 10% | GI bleeding, liver disease, pancreatitis, colon cancer, IBD |
| Pulmonary System | 10% | Asthma, COPD, pneumonia, PE, lung nodules |
| Endocrine System | 8% | Diabetes and DKA/HHS, thyroid, osteoporosis, obesity |
| Eyes, Ears, Nose, and Throat | 8% | Pharyngitis, otitis, sinusitis, eye emergencies |
| Musculoskeletal System | 8% | Fractures, gout, GCA, septic arthritis, back pain |
| Infectious Diseases | 7% | STIs, sepsis, tick-borne disease, TB, HIV |
| Psychiatry/Behavioral Science | 7% | Depression, anxiety, substance use, suicide risk |
| Dermatologic System | 5% | Skin infections, skin cancers, drug reactions |
| Genitourinary System | 5% | UTI, prostate disease, testicular emergencies |
| Neurologic System | 5% | Stroke/TIA, headache, seizures, Bell palsy |
| Reproductive System | 5% | Hypertensive disorders of pregnancy, contraception, bleeding |
| Hematologic System | 4% | Anemias, coagulation disorders |
| Renal System | 4% | AKI, CKD, electrolytes |
| Emergent Topics (Legal, Ethical, DEI) | 2% | Consent, capacity, professional obligations |
The full blueprint lists each disease and the level it's tested at: history and physical, diagnosis, basic intervention or complex intervention. Use the marked expectations to set the depth of your review; don't assume every condition requires complex management.
Not every question is drawn straight from the percentages. From the second quarter onward, 20 of each quarter's 25 questions follow the blueprint distribution; five revisit previously encountered topics. NCCPA selects those repeated topics using earlier responses and confidence and relevance ratings, and scores the better response when a topic is repeated (NCCPA Performance Guide; PANRE-LA FAQs).
Build your reference kit before Quarter 1
Practice finding the key detail in under three minutes, leaving time to read the question and submit your answer.
- One general clinical reference you already use at work and can search quickly.
- Bookmarked guideline summaries for the high-share areas above. The 18 sources in the practice set are a reasonable start.
- A drug reference for contraindications, pregnancy use and renal dosing.
- NCCPA's own materials: the blueprint, the sample PANRE/PANRE-LA questions (PDF) and the PANRE-LA tutorial, so the interface isn't new on day one.
- A private place to work. NCCPA requires that no one else can see the questions while you answer them.
Using references, search and AI within NCCPA's rules
- Allowed: printed and online medical references, including AI-enhanced search tools, as long as you search with short, discrete keywords.
- Not allowed: entering or uploading the question, the answer options, the rationale, or a substantial part of any of them into a website, search engine or chatbot, whether by typing, screenshot or voice, during or after testing.
- Not allowed: getting help from anyone, helping another PA, or telling others which topics a quarter covered before it ends.
- Not allowed: copying, saving, screen-capturing, memorizing and reproducing, or sharing exam content anywhere, including social media.
NCCPA collects response timing, device and location data to detect irregular behavior, and penalties can include revocation of certification. Read the PANRE-LA Acknowledgement (PDF) before Quarter 1. AI output still needs a real clinical source behind it before you trust it.
Rules that decide your result
| The rule | What it means for you |
|---|---|
| At least one quarter in Year 7 and one in Year 8. Opening a single question counts as taking part. | Miss either year and you're withdrawn, and the fee is forfeited, unless NCCPA approves an exception. |
| Unanswered questions in a quarter you've opened score as incorrect. | Once you start a quarter, finish it. |
| Pass/fail decisions start after 8 quarters of participation and use your best 8 of up to 12. If you end Year 9 with fewer than 8, the missing quarters count as incorrect. | Do quarters early so later ones can replace weak ones. |
| You can't do more than one quarter's questions in a quarter, and NCCPA won't move quarter dates. | Calendar every window. |
| No grievances or resets for your own internet or device problems. | Don't leave a quarter for its last day. |
| CME and the certification maintenance fee are due by December 31 of your applicable two-year cycle. Eligible PAs may use the January 1–31 Administrative Certification Extension (ACE); incomplete requirements then mean withdrawal on February 1 unless NCCPA approves an extension. PAs who fail their second audit requirements are not eligible for ACE. | Track your CME cycle alongside your quarters. |
Sources: PANRE-LA Operational Policies, Procedures, and Authorization (July 1, 2025) (PDF), participation, scoring and CME sections; NCCPA FAQs, PANRE-LA section.
How PANRE-LA is scored
- Passing score: 1150 on a scale of 1000 to 1500. Traditional PANRE uses a separate 200–800 scale with a passing score of 379 (NCCPA Exam Development & Scoring).
- No fixed percent-correct target. Scores are scaled for the difficulty of the questions you received, so the number you need right differs from person to person. Be wary of anyone quoting a "you need X%" figure.
- Repeated topics help you. From the second quarter on, five questions each quarter revisit topics you've already seen. When a topic repeats, only the better of your two answers counts; a correct answer is never replaced by an incorrect one.
- Interim scores. After each quarter you get a cumulative graph showing where you stand against the passing standard and other participants. Scores for the first quarter of each calendar year are delayed for item analysis and arrive no later than the start of the second quarter.
- An unscored policy question. The first question each quarter is about acceptable test-taking behavior and doesn't affect your score.
- Passing ends the process. Once you pass after 8 or more quarters, NCCPA notifies you and exits you; you can't keep going for a higher score or extra CME. A bad quarter isn't a failed PANRE-LA. For PAs who meet the participation and certification-maintenance requirements, the pass/fail decision is based on the best-8 cumulative score.
PANRE-LA vs. traditional PANRE
Both use the same blueprint, both cost $350, and passing either meets your recertification exam requirement. You can be registered for only one at a time.
| Feature | PANRE-LA | Traditional PANRE |
|---|---|---|
| When | Apply in Year 6; quarters in Years 7–9 | Years 9 and 10 |
| Where | Online, on a compatible device and supported browser | Pearson VUE test center |
| Format | 25 questions a quarter, 5 minutes each | One sitting: 4 hours of testing (about 1 minute per question), plus break and tutorial time |
| References | Printed and online references allowed | Not allowed |
| Feedback | Answer, explanation and references after each question | Score report about two weeks after the exam |
| If you don't pass | Up to three PANRE attempts in Year 10 | Up to two attempts in Year 9 and three in Year 10, with no more than four total; normally at least 90 days apart |
NCCPA waives the 90-day interval for one final PANRE attempt when fewer than 90 days remain in Year 10 and you still have an attempt available for that year (NCCPA PANRE rules).
PANRE-LA suits PAs who want to spread the work out and learn from feedback. The traditional PANRE can make sense if you'd rather finish in one day, or if you've missed the PANRE-LA application window. If your certification has lapsed, PANRE-LA isn't available; you regain certification through PANRE.
If you withdraw, miss a quarter, or don't pass
- Completed the process without passing: you get up to three traditional PANRE attempts in Year 10, normally at least 90 days apart, as long as your other certification maintenance requirements are met.
- Withdrawn before eight quarters of participation, after opening a question: PANRE-LA counts as one recertification attempt, you lose access to your content and performance data, and you may have up to three PANRE attempts in Years 9–10 while you remain certified.
- Withdrawn without ever opening a question: it doesn't count as an attempt, and you may keep up to four PANRE attempts.
- After eight or more quarters of participation: choosing not to complete additional quarters does not count as withdrawal; NCCPA evaluates your best eight quarters under its scoring rules.
- Refunds: a written withdrawal request to NCCPA before the first quarter closes, with no questions accessed, gets the full $350 back. After the first quarter closes, there's no refund unless NCCPA approves an exception to policy.
- Missed the application deadline: with documented extenuating circumstances, you can request an exception to policy until April 30 of Year 7. If approved, you start in the next available quarter and can't make up the ones you missed.
- A health crisis mid-process: NCCPA's exceptions during PANRE-LA are limited to personal medical circumstances (and NCCPA system problems), with specific deadlines. Contact NCCPA promptly rather than letting quarters lapse.
Does PANRE-LA count for CME?
Yes. For each quarter in which you access all 25 exam questions, you earn 2 AAPA Category 1 Self-Assessment CME credits. NCCPA adds its 50% self-assessment bonus, so each quarter counts as 3 credits toward NCCPA's requirement only; your state board may count it differently. You still need 100 CME credits, including at least 50 Category 1, in each two-year cycle, plus the certification maintenance fee.
Other PANRE-LA questions
Can I answer on my phone? Yes, through a supported browser on a compatible device. You can't answer PANRE-LA questions in the NCCPA mobile app.
What accommodations are available? Accommodations are individualized. They can include extra response time—such as time-and-a-half or double time—and delivery-format changes supported by the platform. Extra time applies to each question, not to the quarter window. Request accommodations with your application; NCCPA must normally receive complete documentation within 10 calendar days after the application deadline, unless it approves a late-application exception. If a need arises or wasn't requested initially, contact NCCPA as soon as practicable; an approved accommodation starts with the next available quarter (NCCPA accommodations policy, pp. 2–3 (PDF)).
Can I do two quarters at once to catch up? No. Each quarter's questions are available only during that quarter's window.
I passed early. Can I keep going? No. NCCPA exits you once you pass after eight or more quarters.
Sources and verification
NCCPA facts on this page were checked against these sources on November 5, 2026:
- NCCPA, PANRE-LA Operational Policies, Procedures, and Authorization (PDF) (July 1, 2025): eligibility, participation, scoring, refunds, withdrawal, CME, exceptions and exam security.
- NCCPA, PANRE-LA Acknowledgement (PDF) (July 1, 2025): reference, AI and content-protection rules.
- NCCPA, FAQs, PANRE-LA and PANRE sections: format, preview, timer, disconnection, repeat topics, accommodations, mobile use.
- NCCPA, Exam Development & Scoring: scales, passing standards, repeat-topic scoring, interim scores.
- NCCPA, Key Dates: application windows and 2026–2027 quarter windows.
- NCCPA, Maintain Certification and Continuing Medical Education: exam fee, PANRE attempt limits, maintenance requirements and CME.
- NCCPA, Content Blueprint for PANRE and PANRE-LA (PDF) (effective January 2023) and PANRE/PANRE-LA Performance Guide.
The clinical source for each practice question is linked in its explanation. Those sources and explanations were checked on November 5, 2026. Clinical content here is for exam preparation, not patient care.
This guide was developed with AI assistance. The verification described here consists of source and editorial checks, not a documented clinician review. See how we develop and check content.
By the Castleport Test Prep Editorial Team. Quarter dates, fees and policies change, so confirm deadlines in your NCCPA Portal before acting on them.
Independence and trademarks: Castleport Test Prep is an independent exam prep publisher. We are not affiliated with, endorsed by, or approved by the National Commission on Certification of Physician Assistants (NCCPA). PANRE, PANRE-LA and other exam and credential names identify their subjects; trademarks belong to their respective owners. Our practice questions are original and unofficial. Using this guide doesn't guarantee a passing score or recertification.