NURS 5433 FNP II Actual FINAL EXAM PRACTICE –
University of Texas at Arlington | Comprehensive
Review & Verified Guide
Section 1: Complex Chronic Disease Management (Questions 1-25)
CASE STUDY 1 (Questions 1-3):
A 68-year-old African American male with uncontrolled Type 2 diabetes mellitus
(diagnosed 12 years ago), Stage 3b CKD (eGFR 38 mL/min/1.73m², urine
albumin-to-creatinine ratio 285 mg/g), and hypertension presents for follow-up. Current
medications: metformin 1000mg BID, glipizide 10mg daily, lisinopril 20mg daily,
amlodipine 5mg daily. Labs today: HbA1c 9.2%, potassium 5.1 mEq/L, creatinine 1.9
mg/dL. He reports polyuria, nocturia x4 nightly, and occasional mild dyspnea with
exertion. BMI 34 kg/m². BP 148/88 mmHg. Fundoscopic exam reveals moderate
non-proliferative diabetic retinopathy.
Q1: What is the most appropriate NEXT step in adjusting his antihyperglycemic
regimen?
A) Continue metformin but reduce to 500mg BID due to eGFR <45 mL/min/1.73m².
B) Discontinue glipizide and initiate empagliflozin 10mg daily.
C) Add insulin glargine 10 units at bedtime and continue current oral agents.
D) Discontinue metformin and initiate combination therapy with dulaglutide 0.75mg
weekly and basal insulin.
Correct Answer: B
Complete Solution:
, ● Concept: Renoprotective diabetes management in moderate-to-advanced CKD
with albuminuria.
● Guideline: ADA Standards of Care 2024; KDIGO 2022 Diabetes Guideline. SGLT2
inhibitors are first-line for T2DM with CKD (eGFR ≥20) independent of HbA1c or
metformin use due to proven kidney and cardiovascular protection.
● Justification: Empagliflozin is FDA-approved for eGFR down to 20
mL/min/1.73m². It reduces progression of albuminuria and ESRD risk. Glipizide
provides minimal benefit and carries hypoglycemia risk in CKD. The patient's
HbA1c is significantly above target (通常 <7-8% individualized), but SGLT2i offers
organ protection beyond glucose lowering.
● Distractor Analysis:
○ A: Incorrect. While metformin requires dose reduction when eGFR 30-45,
and discontinuation if <30, this option misses the opportunity to initiate
guideline-directed therapy (SGLT2i) that addresses both glucose control
and kidney protection.
○ C: Incorrect. Adding basal insulin without first maximizing
organ-protective oral agents is premature. Insulin addresses
hyperglycemia but offers no renal protection. Risk of hypoglycemia is high
in CKD without kidney-protective strategy.
○ D: Incorrect. Discontinuing metformin is unnecessary at eGFR 38
(contraindicated only if <30). While GLP-1 RA is appropriate, initiating
basal insulin alongside it without first trying SGLT2i (which is specifically
indicated for albuminuric CKD) overtreats glycemia while undertreating
nephropathy.
Q2: Two months later, the patient returns. He is tolerating empagliflozin well but his BP
remains 146/86 mmHg. Potassium is now 5.3 mEq/L. eGFR is stable at 39. You note
mild lower extremity edema. Which modification to his antihypertensive regimen is
most appropriate?
A) Increase lisinopril to 40mg daily to maximally reduce proteinuria.
B) Add hydrochlorothiazide 25mg daily for volume management and BP control.
C) Switch amlodipine to chlorthalidone 12.5mg daily and monitor potassium closely.
D) Add losartan 50mg daily for dual RAAS blockade in proteinuric CKD.
Correct Answer: C
Complete Solution:
● Concept: Refractory hypertension management in diabetic kidney disease with
hyperkalemia risk.
, ● Guideline: KDIGO 2021 Blood Pressure Guideline; ACC/AHA 2017 Hypertension
Guidelines. Thiazide-like diuretics are effective in Stage 3 CKD and help manage
volume status and hyperkalemia.
● Justification: The patient has volume-mediated hypertension (edema, nocturia)
and borderline hyperkalemia (5.3 mEq/L). Chlorthalidone provides better BP
reduction than HCTZ and increases renal potassium excretion. Switching from
amlodipine (which causes edema) addresses both volume status and AEs.
Potassium requires monitoring but exchanging a CCB for a thiazide addresses
both BP and metabolic concerns.
● Distractor Analysis:
○ A: Incorrect. Increasing ACE-I with potassium 5.3 mEq/L risks dangerous
hyperkalemia (>5.5). Additionally, the patient likely has volume overload
contributing to resistant hypertension; maximizing RAAS blockade without
addressing volume is ineffective and unsafe.
○ B: Incorrect. While thiazides are appropriate, adding HCTZ to amlodipine
preserves the edema-causing agent. Chlorthalidone is preferred over
HCTZ for superior outcomes data in CKD, and switching allows
discontinuation of the CCB responsible for edema.
○ D: Incorrect. Dual RAAS blockade (ACE-I + ARB) is contraindicated due to
increased risk of hyperkalemia, hypotension, and acute kidney injury
(ALTITUDE, VA NEPHRON-D trials). His potassium is already borderline
elevated.
Q3: Six months later, the patient develops progressive dyspnea on exertion and
orthopnea. Echocardiogram reveals EF 35-40%, left ventricular hypertrophy, moderate
diastolic dysfunction, and elevated filling pressures. Which medication adjustment is
CONTRAINDICATED at this time?
A) Initiation of metoprolol succinate 25mg daily for HFrEF cardioprotection.
B) Continuation of empagliflozin 10mg daily for heart failure risk reduction.
C) Addition of spironolactone 25mg daily for persistent albuminuria despite ACE-I
therapy.
D) Initiation of sacubitril/valsartan 49/51mg BID to reduce HF hospitalization risk.
Correct Answer: C
Complete Solution:
● Concept: Heart failure with reduced ejection fraction (HFrEF) pharmacology in
the context of hyperkalemia and moderate CKD.
, ● Guideline: ACC/AHA 2022 Heart Failure Guideline; EMPEROR-Reduced/DAPA-HF
trials. Mineralocorticoid receptor antagonists (MRA) require careful monitoring
but are not absolutely contraindicated; however, this specific patient has multiple
risk factors for severe hyperkalemia.
● Justification: While MRAs are guideline-directed therapy for HFrEF and
albuminuric CKD, this patient has baseline potassium 5.3 mEq/L on ACE-I alone.
Adding spironolactone carries unacceptably high risk of life-threatening
hyperkalemia (K+ >6.0) without prior potassium optimization or dietary
counseling. An MRA alternative (eplerenone) or cautious initiation with intensive
monitoring might be considered later, but immediate addition is the riskiest
choice among options.
● Distractor Analysis:
○ A: Incorrect (this is appropriate). Beta-blockers are foundational HFrEF
therapy. Metoprolol succinate is evidence-based for EF <40%, improving
survival and reducing hospitalizations. Starting low and titrating is
standard.
○ B: Incorrect (this is appropriate). SGLT2 inhibitors are now foundational
therapy for HFrEF (EF ≤40%) regardless of diabetes status. Empagliflozin
reduces CV death and HF hospitalization (EMPEROR-Reduced).
Continuation is mandatory, not contraindicated.
○ D: Incorrect (this is appropriate). Sacubitril/valsartan (ARNI) is preferred
over ACE-I/ARB for HFrEF (PARADIGM-HF trial). However, he must be off
lisinopril for 36 hours before initiation to avoid angioedema. This is an
indicated therapy, not contraindicated, though requires washout period.
CASE STUDY 2 (Questions 4-6):
A 54-year-old female with morbid obesity (BMI 48 kg/m²), severe obstructive sleep
apnea (non-adherent to CPAP), type 2 diabetes (on metformin and semaglutide), and
hypertension presents with worsening right knee pain and swelling. She reports two
years of progressive activity-related pain, morning stiffness <30 minutes, and a
"grinding" sensation. Recent x-ray shows joint space narrowing, osteophytes, and
subchondral sclerosis in the medial compartment. She requests "stronger pain
medicine" as acetaminophen 3g daily is no longer effective. Current BP 138/86 mmHg,
heart rate 88 bpm. She reports no GI symptoms but has a family history of pephc ulcer
disease (father). She works as a cashier requiring standing 8 hours/day.
University of Texas at Arlington | Comprehensive
Review & Verified Guide
Section 1: Complex Chronic Disease Management (Questions 1-25)
CASE STUDY 1 (Questions 1-3):
A 68-year-old African American male with uncontrolled Type 2 diabetes mellitus
(diagnosed 12 years ago), Stage 3b CKD (eGFR 38 mL/min/1.73m², urine
albumin-to-creatinine ratio 285 mg/g), and hypertension presents for follow-up. Current
medications: metformin 1000mg BID, glipizide 10mg daily, lisinopril 20mg daily,
amlodipine 5mg daily. Labs today: HbA1c 9.2%, potassium 5.1 mEq/L, creatinine 1.9
mg/dL. He reports polyuria, nocturia x4 nightly, and occasional mild dyspnea with
exertion. BMI 34 kg/m². BP 148/88 mmHg. Fundoscopic exam reveals moderate
non-proliferative diabetic retinopathy.
Q1: What is the most appropriate NEXT step in adjusting his antihyperglycemic
regimen?
A) Continue metformin but reduce to 500mg BID due to eGFR <45 mL/min/1.73m².
B) Discontinue glipizide and initiate empagliflozin 10mg daily.
C) Add insulin glargine 10 units at bedtime and continue current oral agents.
D) Discontinue metformin and initiate combination therapy with dulaglutide 0.75mg
weekly and basal insulin.
Correct Answer: B
Complete Solution:
, ● Concept: Renoprotective diabetes management in moderate-to-advanced CKD
with albuminuria.
● Guideline: ADA Standards of Care 2024; KDIGO 2022 Diabetes Guideline. SGLT2
inhibitors are first-line for T2DM with CKD (eGFR ≥20) independent of HbA1c or
metformin use due to proven kidney and cardiovascular protection.
● Justification: Empagliflozin is FDA-approved for eGFR down to 20
mL/min/1.73m². It reduces progression of albuminuria and ESRD risk. Glipizide
provides minimal benefit and carries hypoglycemia risk in CKD. The patient's
HbA1c is significantly above target (通常 <7-8% individualized), but SGLT2i offers
organ protection beyond glucose lowering.
● Distractor Analysis:
○ A: Incorrect. While metformin requires dose reduction when eGFR 30-45,
and discontinuation if <30, this option misses the opportunity to initiate
guideline-directed therapy (SGLT2i) that addresses both glucose control
and kidney protection.
○ C: Incorrect. Adding basal insulin without first maximizing
organ-protective oral agents is premature. Insulin addresses
hyperglycemia but offers no renal protection. Risk of hypoglycemia is high
in CKD without kidney-protective strategy.
○ D: Incorrect. Discontinuing metformin is unnecessary at eGFR 38
(contraindicated only if <30). While GLP-1 RA is appropriate, initiating
basal insulin alongside it without first trying SGLT2i (which is specifically
indicated for albuminuric CKD) overtreats glycemia while undertreating
nephropathy.
Q2: Two months later, the patient returns. He is tolerating empagliflozin well but his BP
remains 146/86 mmHg. Potassium is now 5.3 mEq/L. eGFR is stable at 39. You note
mild lower extremity edema. Which modification to his antihypertensive regimen is
most appropriate?
A) Increase lisinopril to 40mg daily to maximally reduce proteinuria.
B) Add hydrochlorothiazide 25mg daily for volume management and BP control.
C) Switch amlodipine to chlorthalidone 12.5mg daily and monitor potassium closely.
D) Add losartan 50mg daily for dual RAAS blockade in proteinuric CKD.
Correct Answer: C
Complete Solution:
● Concept: Refractory hypertension management in diabetic kidney disease with
hyperkalemia risk.
, ● Guideline: KDIGO 2021 Blood Pressure Guideline; ACC/AHA 2017 Hypertension
Guidelines. Thiazide-like diuretics are effective in Stage 3 CKD and help manage
volume status and hyperkalemia.
● Justification: The patient has volume-mediated hypertension (edema, nocturia)
and borderline hyperkalemia (5.3 mEq/L). Chlorthalidone provides better BP
reduction than HCTZ and increases renal potassium excretion. Switching from
amlodipine (which causes edema) addresses both volume status and AEs.
Potassium requires monitoring but exchanging a CCB for a thiazide addresses
both BP and metabolic concerns.
● Distractor Analysis:
○ A: Incorrect. Increasing ACE-I with potassium 5.3 mEq/L risks dangerous
hyperkalemia (>5.5). Additionally, the patient likely has volume overload
contributing to resistant hypertension; maximizing RAAS blockade without
addressing volume is ineffective and unsafe.
○ B: Incorrect. While thiazides are appropriate, adding HCTZ to amlodipine
preserves the edema-causing agent. Chlorthalidone is preferred over
HCTZ for superior outcomes data in CKD, and switching allows
discontinuation of the CCB responsible for edema.
○ D: Incorrect. Dual RAAS blockade (ACE-I + ARB) is contraindicated due to
increased risk of hyperkalemia, hypotension, and acute kidney injury
(ALTITUDE, VA NEPHRON-D trials). His potassium is already borderline
elevated.
Q3: Six months later, the patient develops progressive dyspnea on exertion and
orthopnea. Echocardiogram reveals EF 35-40%, left ventricular hypertrophy, moderate
diastolic dysfunction, and elevated filling pressures. Which medication adjustment is
CONTRAINDICATED at this time?
A) Initiation of metoprolol succinate 25mg daily for HFrEF cardioprotection.
B) Continuation of empagliflozin 10mg daily for heart failure risk reduction.
C) Addition of spironolactone 25mg daily for persistent albuminuria despite ACE-I
therapy.
D) Initiation of sacubitril/valsartan 49/51mg BID to reduce HF hospitalization risk.
Correct Answer: C
Complete Solution:
● Concept: Heart failure with reduced ejection fraction (HFrEF) pharmacology in
the context of hyperkalemia and moderate CKD.
, ● Guideline: ACC/AHA 2022 Heart Failure Guideline; EMPEROR-Reduced/DAPA-HF
trials. Mineralocorticoid receptor antagonists (MRA) require careful monitoring
but are not absolutely contraindicated; however, this specific patient has multiple
risk factors for severe hyperkalemia.
● Justification: While MRAs are guideline-directed therapy for HFrEF and
albuminuric CKD, this patient has baseline potassium 5.3 mEq/L on ACE-I alone.
Adding spironolactone carries unacceptably high risk of life-threatening
hyperkalemia (K+ >6.0) without prior potassium optimization or dietary
counseling. An MRA alternative (eplerenone) or cautious initiation with intensive
monitoring might be considered later, but immediate addition is the riskiest
choice among options.
● Distractor Analysis:
○ A: Incorrect (this is appropriate). Beta-blockers are foundational HFrEF
therapy. Metoprolol succinate is evidence-based for EF <40%, improving
survival and reducing hospitalizations. Starting low and titrating is
standard.
○ B: Incorrect (this is appropriate). SGLT2 inhibitors are now foundational
therapy for HFrEF (EF ≤40%) regardless of diabetes status. Empagliflozin
reduces CV death and HF hospitalization (EMPEROR-Reduced).
Continuation is mandatory, not contraindicated.
○ D: Incorrect (this is appropriate). Sacubitril/valsartan (ARNI) is preferred
over ACE-I/ARB for HFrEF (PARADIGM-HF trial). However, he must be off
lisinopril for 36 hours before initiation to avoid angioedema. This is an
indicated therapy, not contraindicated, though requires washout period.
CASE STUDY 2 (Questions 4-6):
A 54-year-old female with morbid obesity (BMI 48 kg/m²), severe obstructive sleep
apnea (non-adherent to CPAP), type 2 diabetes (on metformin and semaglutide), and
hypertension presents with worsening right knee pain and swelling. She reports two
years of progressive activity-related pain, morning stiffness <30 minutes, and a
"grinding" sensation. Recent x-ray shows joint space narrowing, osteophytes, and
subchondral sclerosis in the medial compartment. She requests "stronger pain
medicine" as acetaminophen 3g daily is no longer effective. Current BP 138/86 mmHg,
heart rate 88 bpm. She reports no GI symptoms but has a family history of pephc ulcer
disease (father). She works as a cashier requiring standing 8 hours/day.
