The MRCPCH AKP uses two question formats: standard best-of-five SBAs and N-of-many questions where you select two or three correct answers from eight to ten options. The N-of-many format uses all-or-nothing scoring — you score the mark only if you identify every correct answer. These examples demonstrate the format and the technique required.
How N-of-many scoring works
Each N-of-many question tells you exactly how many answers to select — "Select TWO answers" or "Select THREE answers." You must select exactly that number. If the question asks you to select two and you select one correct and one incorrect, you score zero. If you select both correct answers, you score the full mark. There is no partial credit.
This changes your approach fundamentally. In a standard SBA, you can use elimination — ruling out three wrong answers leaves you with two, and choosing between two is a 50/50 proposition. In N-of-many, elimination is still useful but the cognitive task is different. You need to identify multiple correct answers from a larger option pool, which requires broader knowledge of the topic rather than the ability to distinguish between two close options.
Sample question 1 — Select TWO answers
A 6-year-old boy presents with a 3-week history of periorbital oedema, abdominal distension, and frothy urine. Investigations show serum albumin 18 g/L, urine protein:creatinine ratio 850 mg/mmol, serum cholesterol 9.2 mmol/L, and normal renal function. A renal biopsy shows minimal change on light microscopy.
Which TWO of the following are most appropriate for initial management?
A. Oral prednisolone 60 mg/m²/day B. IV methylprednisolone C. Oral cyclophosphamide D. Dietary sodium restriction E. Albumin infusion F. Furosemide G. ACE inhibitor H. Mycophenolate mofetil
Answer: A, D
This is a first presentation of nephrotic syndrome with biopsy-confirmed minimal change disease. NICE and RCPCH guidelines recommend high-dose oral prednisolone (60 mg/m²/day for 4 weeks, then alternate-day weaning) as first-line treatment (A). Dietary sodium restriction (D) is recommended alongside corticosteroid therapy to manage oedema. IV methylprednisolone (B) is reserved for steroid-resistant or frequently relapsing disease. Cyclophosphamide (C) and mycophenolate (H) are second-line for steroid-dependent or frequently relapsing nephrotic syndrome. Albumin infusion (E) is only indicated for symptomatic hypovolaemia. Furosemide (F) can worsen hypovolaemia and is used cautiously, not as routine first-line. ACE inhibitors (G) are used for persistent proteinuria, not at first presentation.
Sample question 2 — Select THREE answers
A 14-year-old girl is brought to the emergency department after taking 30 paracetamol tablets approximately 4 hours ago. She weighs 50 kg. She is asymptomatic. Her paracetamol level at 4 hours is 210 mg/L.
Which THREE of the following are most appropriate?
A. Start IV N-acetylcysteine B. Administer activated charcoal C. Check ALT, creatinine, INR, and venous bicarbonate D. Arrange psychiatric assessment before medical discharge E. Observe for 8 hours then discharge if asymptomatic F. Contact the National Poisons Information Service G. Administer IV sodium bicarbonate H. Arrange urgent liver transplant assessment
Answer: A, C, D
The paracetamol level at 4 hours is 210 mg/L, which is above the treatment line on the current nomogram (100 mg/L at 4 hours). IV NAC must be started immediately (A). Baseline blood tests including ALT, creatinine, INR, and venous bicarbonate are mandatory (C). Following any intentional overdose in a young person, psychiatric assessment is required before discharge (D) — this is a safeguarding and mental health requirement. Activated charcoal (B) is only effective within 1 hour of ingestion — at 4 hours it has no role. Observation and discharge (E) is inappropriate given the level is above the treatment line. NPIS contact (F) is reasonable but not one of the three most appropriate actions when the management pathway is clear. IV bicarbonate (G) is not indicated. Liver transplant assessment (H) is premature — the patient is asymptomatic and has just presented.
Technique tips for N-of-many
Read the question stem carefully — it always specifies how many answers to select. Read all options before selecting any. Identify the options you are most confident about first, then evaluate the remaining options against each other. If the question asks you to select two and you are confident about one, focus your deliberation on choosing between the remaining candidates for the second selection.
Do not assume the correct answers are adjacent in the list. The option ordering is random, and the two or three correct answers may be scattered across the eight options.
iatroX is the only MRCPCH question bank that supports the N-of-many format. The AKP bank includes over 750 N-of-many questions alongside standard SBAs, with a multi-select interface that replicates the real exam experience. All included at £29 per month or £99 per year.