Stepping across the table from the scrub role to the first assistant role is a big change, and the certification exam that goes with it reflects that. The Certified Surgical First Assistant (CSFA)® exam from the National Board of Surgical Technology and Surgical Assisting (NBSTSA) expects you to think like the surgeon’s second pair of hands: exposing, dissecting, controlling bleeding, closing, and knowing the anatomy underneath every move.

It can feel like a lot to cover. The good news is that NBSTSA publishes exactly how many questions come from each area, so you can build a plan around the blueprint instead of guessing.

In this guide, we’ll walk you through the exam format, every section and subsection of the current content outline, the official resources worth downloading, and answers to the questions candidates ask most.

What Is the NBSTSA CSFA Exam?

The CSFA is NBSTSA’s national credential for surgical first assistants. NBSTSA describes the surgical first assistant, also called a surgical assistant or first assist, as someone who “plays a vital role in the operating room during surgeries.” In practice, that means providing hands-on help to the surgeon: positioning and prepping, retracting and providing exposure, suctioning, achieving hemostasis, handling tissue, and closing wounds.

The exam is built for graduates of accredited surgical first assistant programs. Many candidates already work as Certified Surgical Technologists (CSTs), so the test goes beyond scrub duties. It emphasizes intraoperative technique and advanced anatomy, pathophysiology, microbiology, and pharmacology as they apply to assisting.

What Is the NBSTSA CSFA Exam Format?

Here is the exam at a glance, based on the CSFA Candidate Handbook (2025) and the NBSTSA CSFA certification page:

  • Questions: 175 multiple-choice questions.
  • Scored vs. unscored: 150 scored questions plus 25 unscored pretest items distributed randomly throughout the exam. You won’t know which are pretest items, so answer every question carefully.
  • Time: 4 hours.
  • Delivery: Computer-based, at PSI testing centers (Monday through Saturday, 9 a.m. and 1:30 p.m. appointments) or on campus through your school’s testing arrangement.
  • Passing score: NBSTSA states that answering 99 of the 150 scored questions correctly means you’ve passed (about 66%).
  • Results: Campus testers receive scores after completing graduation requirements, and the school releases them. Graduates testing at PSI typically get a score report link by email within about 48 business hours, and those testing 45 or more days after graduation may receive a score report on test day.

With 240 minutes for 175 questions, you have a little more than 80 seconds per question. That is comfortable for recall items, but scenario questions about exposure or hemostasis reward candidates who can picture the procedure quickly.

What Content Outline Does the CSFA Exam Use?

The current exam is based on the Surgical First Assistant Certifying Examination Content Outline (the 2024 PDF), which took effect January 1, 2023. It divides the 150 scored items into three sections and eight subsections. Percentages below are calculated from NBSTSA’s item counts.

  • I. Perioperative Care: 83 items (about 55%)
  • II. Ancillary Duties: 21 items (14%)
  • III. Advanced Science: 46 items (about 31%)

I.A. Preoperative Preparation (8 items)

This subsection covers everything from meeting the patient to the Time Out. It’s a long task list for only eight items, so expect questions that test specific safety steps rather than broad concepts.

  • Review the chart, verify consent, and confirm that grafts, implants, and special supplies are available.
  • Select positioning devices, position the patient, and apply the dispersive electrode pad and tourniquet.
  • Insert urinary catheters, perform skin preparation, and drape using aseptic technique.
  • Test equipment, manage thermoregulatory devices, and actively participate in the Time Out.

Study tip: Know positioning injuries by position (for example, brachial plexus stretch with arm abduction beyond 90 degrees, and common peroneal nerve compression in lithotomy) and correct tourniquet and dispersive pad placement.

I.B. Intraoperative Procedures (67 items)

This is the heart of the exam. At 67 of 150 scored items, it outweighs any other subsection by a wide margin and describes what a first assistant does with their hands during the case.

  • Manipulate tissue using Halsted’s principles, traction and countertraction, and appropriate dissection techniques.
  • Operate specialty equipment such as endoscopic devices, ultrasonic (harmonic) scalpels, stapling devices, and power equipment.
  • Assist in minimally invasive and robotic cases, including trocar insertion and camera management for visualization.
  • Provide temporary and permanent hemostasis, place drains and catheters, and inject local anesthetic.
  • Close tissue with appropriate suturing techniques, and tie, tag, and cut sutures.
  • Maintain sterile technique, handle specimens, and complete counts.

What questions look like: A stem describes a step in a procedure, such as bleeding from a small vessel during dissection, and asks for the best assistant action. The right answer usually matches the technique to the tissue and the situation (for example, pressure and suction to identify the source before applying a clip or energy).

I.C. Postoperative Procedures (8 items)

Postoperative items cover the end of the case and the immediate recovery period.

  • Apply dressings, negative pressure wound therapy, splints, casts, and immobilization devices.
  • Remove drapes, cords, and instruments, and remove contaminated gown and gloves correctly.
  • Maintain patient safety during emergence from anesthesia.
  • Change dressings, remove sutures and staples, and assist with room turnover.

II.A. Administrative and Personnel (6 items)

This small subsection covers professional and emergency responsibilities.

  • Serve as a technical subject matter expert to the rest of the surgical team.
  • Use communication and interpersonal skills to relay patient-specific considerations.
  • Apply ethical and legal practices, and maintain awareness of environmental controls such as temperature, air exchanges, and humidity.
  • Assist with resuscitation during cardiac arrest or other life-threatening events.

II.B. Equipment Sterilization and Maintenance (15 items)

This section focuses on how operative equipment works and how to keep it safe and functional.

  • Electrosurgical units (monopolar, bipolar, and vessel sealing).
  • Endoscopic instruments, positioning and stabilizing equipment, and Doppler.
  • Dermatome and mesher, robotics, and power equipment such as drills and saws.

Study tip: Be able to explain why bipolar is safer near nerves and implanted devices, and what causes a dispersive pad burn.

III.A. Advanced Anatomy and Physiology (36 items)

The second-largest subsection asks you to apply pathophysiology and histology to how you handle tissue.

  • Abnormal anatomy in the gastrointestinal, genitourinary, neurological, and cardiothoracic systems, plus congenital defects.
  • Disease processes affecting the gastrointestinal, genitourinary, cardiovascular, respiratory, and endocrine systems.
  • Fractures of the hip, shoulder, wrist, ankle, and pelvis or spine.
  • Malignancies, including carcinomas, sarcomas, neurological and lymphatic malignancies, and metastatic disease.

III.B. Advanced Principles of Microbiology (5 items)

Expect questions on Standard Precautions, classification and pathogenesis of microorganisms, factors that influence wound healing (such as patient condition and wound type), and infection control procedures.

III.C. Surgical Pharmacology and Anesthesia (5 items)

This subsection covers treating pharmacologic complications, handling and administering agents, recognizing drug reactions and interactions, assisting anesthesia providers, and verifying, calculating, and mixing medications and solutions at the sterile field.

How Should You Use the CSFA Blueprint to Build a Study Plan?

Two subsections, Intraoperative Procedures and Advanced Anatomy and Physiology, account for 103 of the 150 scored items, or about 69% of your score. That should guide where you spend your hours. At the same time, you need about 66% correct to pass, so you can’t afford to give away the smaller subsections.

  1. Take a mixed baseline. Answer a timed set of questions from every subsection before you start reviewing so you know where you actually stand.
  2. Map each miss to a subsection. Label wrong answers by outline area (for example, “I.B hemostasis” or “III.A GU anatomy”) to reveal patterns.
  3. Prioritize big and weak areas first. A weak score in Intraoperative Procedures costs far more points than a weak score in Microbiology.
  4. Study anatomy procedure by procedure. Pair each common procedure with the structures at risk, the positioning, and the closure. This connects III.A to I.B.
  5. Finish with timed, mixed practice. In the final weeks, practice at exam pace so 175 questions in 4 hours feels routine.

What Official CSFA Resources Should You Use?

Commonly used NBSTSA CSFA study textbooks:

  • Principles of Anatomy and Physiology, 16th Edition (ISBN 978-1119662792)
  • Pharmacology for the Surgical Technologist, 6th Edition (ISBN 978-0443109096)
  • Berry & Kohn’s Operating Room Technique, 15th Edition (ISBN 978-0443105234)
  • Schwartz’s Principles of Surgery, 11th Edition (ISBN 978-1259835353)
  • Kirk’s Basic Surgical Techniques, 8th Edition (ISBN 978-0443113673)

Frequently Asked Questions About the NBSTSA CSFA Exam

What score do I need to pass the CSFA exam?
NBSTSA states that 99 correct answers on the 150 scored questions is a passing score. The 25 pretest items don’t count toward your result.

Who is eligible to take the CSFA exam?
You must be a graduate of a surgical first assistant program accredited by the Commission on Accreditation of Allied Health Education Programs (CAAHEP), or a current or previously certified CSFA. Details are on the NBSTSA CSFA eligibility page.

How many times can I retake the CSFA exam?
According to the handbook, you can take the exam up to three times in a calendar year. There’s no waiting period between attempts, but each retake requires a new application and the full fee.

How hard is the CSFA exam?
It’s challenging. NBSTSA’s certification data reports a 62% national first-time pass rate for the CSFA in 2025, across 1,207 first-time candidates. A structured plan and plenty of scenario practice make a real difference.

How do I maintain my CSFA credential?
The CSFA renews every two years. Under AST’s continuing education policies, CSFAs need 38 CE credits in the two-year cycle, including at least 8 live credits. See NBSTSA’s renewals and recertification page for current fees and steps.

Start Preparing for the NBSTSA CSFA Exam With Pocket Prep

Pocket Prep’s NBSTSA CSFA practice questions include 750 exam-style questions organized by the content outline, each with a detailed explanation, plus a full-length 175-question mock exam to rehearse for test day. Use Weakest Subject to find the areas costing you the most points and Timed Quiz to build your pace.

You’ve already done the hard work of first assistant training, and with steady practice, you can walk into the testing center with confidence.