NR667 FNP CAPSTONE – WEEK 2
FULL LENGTH PRACTICE EXAM
150 Questions | 100% Correct | With Full
Rationales
Most-Tested • Most-Difficult • REAL EXAM Topics
Clinical Content: Cardiology | Pulmonology | Endocrinology | GI | Neurology
Women's Health | MSK | Mental Health | Peds | Derm | ID | Renal | Pharmacology | Ethics/NP Role
HOW TO USE THIS EXAM
Each question includes: (1) Topic label (2) Clinical vignette stem (3) Five answer choices A-E (4)
Checkmark + highlighted correct answer (5) Detailed rationale explaining why the answer is correct
and distractors are wrong.
All 150 questions are HIGH-YIELD and represent the MOST TESTED, MOST DIFFICULT clinical
concepts tested on the NR667 FNP Capstone examination.
SECTION 1: CARDIOLOGY & HYPERTENSION
Question 1 [ Hypertension – First-Line Therapy ]
A 58-year-old Black male presents with newly diagnosed Stage 2 hypertension (BP 158/96
mmHg), no diabetes, no CKD. According to JNC/ACC/AHA 2017 guidelines, which
antihypertensive regimen is MOST appropriate as initial therapy?
A. ACE inhibitor monotherapy
B. Thiazide diuretic monotherapy
✓ C. Thiazide diuretic plus calcium channel blocker (CCB)
D. Beta-blocker monotherapy
E. ARB plus beta-blocker
CORRECT ANSWER: C. Thiazide diuretic plus calcium channel blocker (CCB)
,RATIONALE: For Black patients with Stage 2 HTN (BP >=20/10 above goal), ACC/AHA 2017
recommends initiating combination therapy. In Black patients WITHOUT diabetes or CKD, thiazide
diuretics and CCBs are preferred over ACE inhibitors/ARBs as first-line agents, as these drug classes
have demonstrated superior BP lowering in this population. ACE inhibitors alone are LESS effective
in Black patients due to lower renin levels. Beta-blockers are NOT first-line unless there is a
compelling indication (CAD, HFrEF).
Question 2 [ Hypertension – Compelling Indications ]
A 62-year-old woman has HTN, HFrEF (EF 35%), and diabetes. Which antihypertensive
combination addresses ALL compelling indications?
A. Amlodipine + HCTZ
✓ B. ACE inhibitor + beta-blocker + loop diuretic
C. ARB + CCB + thiazide
D. Beta-blocker + alpha-blocker
E. Clonidine + spironolactone
CORRECT ANSWER: B. ACE inhibitor + beta-blocker + loop diuretic
RATIONALE: Compelling indications drive drug selection: HFrEF mandates ACE inhibitor/ARB +
beta-blocker (carvedilol, metoprolol succinate, bisoprolol) + diuretic (loop preferred in HF). Diabetes
adds benefit of ACE/ARB for renoprotection. Loop diuretics (furosemide) manage fluid overload in HF
better than thiazides. This triple combination addresses HF, diabetes, and HTN simultaneously.
Question 3 [ Hypertension – Hypertensive Urgency vs. Emergency ]
A 55-year-old male presents with BP 210/120 mmHg, headache, and no evidence of end-
organ damage. The MOST appropriate management is:
A. IV labetalol and ICU admission
✓ B. Oral antihypertensive with gradual BP reduction over 24-48 hours and close follow-up
C. Immediate BP reduction to <120/80 mmHg within 1 hour
D. Observation only; recheck BP in 1 week
E. IV nitroprusside infusion
CORRECT ANSWER: B. Oral antihypertensive with gradual BP reduction over 24-48 hours
and close follow-up
,RATIONALE: Hypertensive urgency (severely elevated BP WITHOUT acute end-organ damage) is
managed with oral agents and gradual reduction over 24-48 hours. Rapid BP reduction risks cerebral
hypoperfusion, stroke, and MI. Hypertensive emergency (with end-organ damage: encephalopathy,
AKI, aortic dissection, ACS) requires IV therapy with controlled reduction. The patient has NO end-
organ damage — urgency, not emergency.
Question 4 [ Heart Failure – Classification & Management ]
A patient with HFrEF (EF 30%) is euvolemic on current therapy. Which medication has the
STRONGEST mortality benefit in this patient?
A. Digoxin
B. Isosorbide dinitrate + hydralazine
✓ C. Sacubitril/valsartan (Entresto) replacing ACE inhibitor
D. Ivabradine
E. Spironolactone alone
CORRECT ANSWER: C. Sacubitril/valsartan (Entresto) replacing ACE inhibitor
RATIONALE: PARADIGM-HF trial demonstrated sacubitril/valsartan (ARNI) reduced cardiovascular
death and HF hospitalization by 20% compared to enalapril in HFrEF. Current ACC/AHA guidelines
recommend transitioning stable HFrEF patients from ACE inhibitor/ARB to sacubitril/valsartan to
further reduce mortality. Must wait 36 hours after last ACE inhibitor dose before starting to prevent
angioedema. Digoxin reduces hospitalizations but NOT mortality.
Question 5 [ Atrial Fibrillation – Anticoagulation ]
A 72-year-old woman with nonvalvular atrial fibrillation has a CHA2DS2-VASc score of 4.
She has no contraindications. Which anticoagulation strategy is MOST appropriate?
A. Aspirin 325mg daily
B. Aspirin + clopidogrel
✓ C. Warfarin with INR target 2.0-3.0 OR a DOAC (rivaroxaban, apixaban, dabigatran)
D. No anticoagulation — rate control only
E. Aspirin 81mg + warfarin
CORRECT ANSWER: C. Warfarin with INR target 2.0-3.0 OR a DOAC (rivaroxaban, apixaban,
dabigatran)
, RATIONALE: CHA2DS2-VASc >= 2 in females (score >=3 overall) warrants anticoagulation. DOACs
are preferred over warfarin for nonvalvular AF due to: predictable dosing, no INR monitoring, fewer
drug interactions, lower intracranial hemorrhage rates (RE-LY, ROCKET-AF, ARISTOTLE trials).
Aspirin alone is INADEQUATE — provides much less stroke protection than anticoagulants with
similar bleeding risk. Valvular AF (mechanical valves, rheumatic mitral stenosis) requires warfarin.
Question 6 [ Atrial Fibrillation – Rate vs. Rhythm Control ]
A 68-year-old male with persistent AF, mild symptoms (palpitations only), HTN, and EF
50% asks about treatment strategy. Based on AFFIRM trial data, the BEST initial approach
is:
A. Immediate electrical cardioversion without anticoagulation
✓ B. Rate control with beta-blocker or CCB plus anticoagulation
C. Amiodarone for rhythm control before anticoagulation
D. Ablation as first-line therapy
E. Rate control only; anticoagulation not needed at EF 50%
CORRECT ANSWER: B. Rate control with beta-blocker or CCB plus anticoagulation
RATIONALE: AFFIRM trial showed rate control is equivalent to rhythm control for mortality in
persistent AF patients. Rate control (HR <80 bpm at rest) with beta-blocker (metoprolol, atenolol) or
non-DHP CCB (diltiazem, verapamil) is first-line for most patients. Anticoagulation is based on
CHA2DS2-VASc score regardless of rate vs. rhythm strategy. Rhythm control is preferred for
younger, symptomatic patients or those with HFrEF who fail rate control.
Question 7 [ Coronary Artery Disease – Stable Angina ]
A 64-year-old male with stable angina on aspirin 81mg and metoprolol succinate
continues to have angina 2-3x/week with moderate exertion. His BP is 138/82, HR 68. The
BEST next step is:
✓ A. Add long-acting nitrate (isosorbide mononitrate)
B. Switch metoprolol to amlodipine
C. Add ranolazine
D. Refer for immediate coronary angiography
E. Add sublingual nitroglycerin PRN only
CORRECT ANSWER: A. Add long-acting nitrate (isosorbide mononitrate)
FULL LENGTH PRACTICE EXAM
150 Questions | 100% Correct | With Full
Rationales
Most-Tested • Most-Difficult • REAL EXAM Topics
Clinical Content: Cardiology | Pulmonology | Endocrinology | GI | Neurology
Women's Health | MSK | Mental Health | Peds | Derm | ID | Renal | Pharmacology | Ethics/NP Role
HOW TO USE THIS EXAM
Each question includes: (1) Topic label (2) Clinical vignette stem (3) Five answer choices A-E (4)
Checkmark + highlighted correct answer (5) Detailed rationale explaining why the answer is correct
and distractors are wrong.
All 150 questions are HIGH-YIELD and represent the MOST TESTED, MOST DIFFICULT clinical
concepts tested on the NR667 FNP Capstone examination.
SECTION 1: CARDIOLOGY & HYPERTENSION
Question 1 [ Hypertension – First-Line Therapy ]
A 58-year-old Black male presents with newly diagnosed Stage 2 hypertension (BP 158/96
mmHg), no diabetes, no CKD. According to JNC/ACC/AHA 2017 guidelines, which
antihypertensive regimen is MOST appropriate as initial therapy?
A. ACE inhibitor monotherapy
B. Thiazide diuretic monotherapy
✓ C. Thiazide diuretic plus calcium channel blocker (CCB)
D. Beta-blocker monotherapy
E. ARB plus beta-blocker
CORRECT ANSWER: C. Thiazide diuretic plus calcium channel blocker (CCB)
,RATIONALE: For Black patients with Stage 2 HTN (BP >=20/10 above goal), ACC/AHA 2017
recommends initiating combination therapy. In Black patients WITHOUT diabetes or CKD, thiazide
diuretics and CCBs are preferred over ACE inhibitors/ARBs as first-line agents, as these drug classes
have demonstrated superior BP lowering in this population. ACE inhibitors alone are LESS effective
in Black patients due to lower renin levels. Beta-blockers are NOT first-line unless there is a
compelling indication (CAD, HFrEF).
Question 2 [ Hypertension – Compelling Indications ]
A 62-year-old woman has HTN, HFrEF (EF 35%), and diabetes. Which antihypertensive
combination addresses ALL compelling indications?
A. Amlodipine + HCTZ
✓ B. ACE inhibitor + beta-blocker + loop diuretic
C. ARB + CCB + thiazide
D. Beta-blocker + alpha-blocker
E. Clonidine + spironolactone
CORRECT ANSWER: B. ACE inhibitor + beta-blocker + loop diuretic
RATIONALE: Compelling indications drive drug selection: HFrEF mandates ACE inhibitor/ARB +
beta-blocker (carvedilol, metoprolol succinate, bisoprolol) + diuretic (loop preferred in HF). Diabetes
adds benefit of ACE/ARB for renoprotection. Loop diuretics (furosemide) manage fluid overload in HF
better than thiazides. This triple combination addresses HF, diabetes, and HTN simultaneously.
Question 3 [ Hypertension – Hypertensive Urgency vs. Emergency ]
A 55-year-old male presents with BP 210/120 mmHg, headache, and no evidence of end-
organ damage. The MOST appropriate management is:
A. IV labetalol and ICU admission
✓ B. Oral antihypertensive with gradual BP reduction over 24-48 hours and close follow-up
C. Immediate BP reduction to <120/80 mmHg within 1 hour
D. Observation only; recheck BP in 1 week
E. IV nitroprusside infusion
CORRECT ANSWER: B. Oral antihypertensive with gradual BP reduction over 24-48 hours
and close follow-up
,RATIONALE: Hypertensive urgency (severely elevated BP WITHOUT acute end-organ damage) is
managed with oral agents and gradual reduction over 24-48 hours. Rapid BP reduction risks cerebral
hypoperfusion, stroke, and MI. Hypertensive emergency (with end-organ damage: encephalopathy,
AKI, aortic dissection, ACS) requires IV therapy with controlled reduction. The patient has NO end-
organ damage — urgency, not emergency.
Question 4 [ Heart Failure – Classification & Management ]
A patient with HFrEF (EF 30%) is euvolemic on current therapy. Which medication has the
STRONGEST mortality benefit in this patient?
A. Digoxin
B. Isosorbide dinitrate + hydralazine
✓ C. Sacubitril/valsartan (Entresto) replacing ACE inhibitor
D. Ivabradine
E. Spironolactone alone
CORRECT ANSWER: C. Sacubitril/valsartan (Entresto) replacing ACE inhibitor
RATIONALE: PARADIGM-HF trial demonstrated sacubitril/valsartan (ARNI) reduced cardiovascular
death and HF hospitalization by 20% compared to enalapril in HFrEF. Current ACC/AHA guidelines
recommend transitioning stable HFrEF patients from ACE inhibitor/ARB to sacubitril/valsartan to
further reduce mortality. Must wait 36 hours after last ACE inhibitor dose before starting to prevent
angioedema. Digoxin reduces hospitalizations but NOT mortality.
Question 5 [ Atrial Fibrillation – Anticoagulation ]
A 72-year-old woman with nonvalvular atrial fibrillation has a CHA2DS2-VASc score of 4.
She has no contraindications. Which anticoagulation strategy is MOST appropriate?
A. Aspirin 325mg daily
B. Aspirin + clopidogrel
✓ C. Warfarin with INR target 2.0-3.0 OR a DOAC (rivaroxaban, apixaban, dabigatran)
D. No anticoagulation — rate control only
E. Aspirin 81mg + warfarin
CORRECT ANSWER: C. Warfarin with INR target 2.0-3.0 OR a DOAC (rivaroxaban, apixaban,
dabigatran)
, RATIONALE: CHA2DS2-VASc >= 2 in females (score >=3 overall) warrants anticoagulation. DOACs
are preferred over warfarin for nonvalvular AF due to: predictable dosing, no INR monitoring, fewer
drug interactions, lower intracranial hemorrhage rates (RE-LY, ROCKET-AF, ARISTOTLE trials).
Aspirin alone is INADEQUATE — provides much less stroke protection than anticoagulants with
similar bleeding risk. Valvular AF (mechanical valves, rheumatic mitral stenosis) requires warfarin.
Question 6 [ Atrial Fibrillation – Rate vs. Rhythm Control ]
A 68-year-old male with persistent AF, mild symptoms (palpitations only), HTN, and EF
50% asks about treatment strategy. Based on AFFIRM trial data, the BEST initial approach
is:
A. Immediate electrical cardioversion without anticoagulation
✓ B. Rate control with beta-blocker or CCB plus anticoagulation
C. Amiodarone for rhythm control before anticoagulation
D. Ablation as first-line therapy
E. Rate control only; anticoagulation not needed at EF 50%
CORRECT ANSWER: B. Rate control with beta-blocker or CCB plus anticoagulation
RATIONALE: AFFIRM trial showed rate control is equivalent to rhythm control for mortality in
persistent AF patients. Rate control (HR <80 bpm at rest) with beta-blocker (metoprolol, atenolol) or
non-DHP CCB (diltiazem, verapamil) is first-line for most patients. Anticoagulation is based on
CHA2DS2-VASc score regardless of rate vs. rhythm strategy. Rhythm control is preferred for
younger, symptomatic patients or those with HFrEF who fail rate control.
Question 7 [ Coronary Artery Disease – Stable Angina ]
A 64-year-old male with stable angina on aspirin 81mg and metoprolol succinate
continues to have angina 2-3x/week with moderate exertion. His BP is 138/82, HR 68. The
BEST next step is:
✓ A. Add long-acting nitrate (isosorbide mononitrate)
B. Switch metoprolol to amlodipine
C. Add ranolazine
D. Refer for immediate coronary angiography
E. Add sublingual nitroglycerin PRN only
CORRECT ANSWER: A. Add long-acting nitrate (isosorbide mononitrate)
