1
Barkley ENP-C Diagnostic Readiness Test (DRT) #4 – 100
Board-Style Questions & Detailed Rationales
Welcome to the Barkley Emergency Nurse Practitioner (ENP-C) Diagnostic Readiness Test (DRT) #4. This
comprehensive test bank contains 100 multiple-choice questions designed to mirror the content and difficulty of
the American Academy of Nurse Practitioners (AANP) ENP-C certification exam. Each question includes a clinical
vignette, four answer options, the correct answer, and a detailed, evidence-based rationale. Domains covered
include: cardiovascular, respiratory, trauma, neurology, infectious disease, toxicology, environmental,
abdominal, endocrine, obstetric/gynecologic, pediatric, psychiatric, and professional/legal issues.
SECTION 1 – CARDIOVASCULAR EMERGENCIES (Questions 1–15)
Q1. A 62-year-old male with a history of hypertension presents with acute onset
of severe, tearing chest pain radiating to the back. BP is 160/90 in the right arm
and 110/70 in the left arm. What is the most appropriate next diagnostic test?
A) ECG
B) Chest X-ray
C) CT angiography of the chest
D) Transthoracic echocardiogram
: Correct Answer : C
Rationale: The presentation is classic for acute aortic dissection. CT angiography is
the gold standard and should be obtained emergently. ECG and chest X-ray are
nonspecific. Echocardiography may detect an intimal flap but is not the first-line
study.
Q2. A 55-year-old male with a history of coronary artery disease presents with
substernal chest pressure that occurs with exertion and is relieved by rest. He has
no ECG changes. Troponin is normal. What is the most appropriate initial
diagnostic test?
A) Exercise stress test
B) Coronary angiography
C) CT coronary angiography
D) Resting echocardiogram
pg. 1
,2
: Correct Answer : A
Rationale: The patient has stable angina. For a patient with an interpretable ECG
who can exercise, an exercise stress test is the appropriate first-line non-invasive
test to detect inducible ischemia.
Q3. A 70-year-old female presents with acute pulmonary edema. BP is 180/100
mmHg. Which medication is most appropriate to reduce preload and afterload?
A) Metoprolol
B) Digoxin
C) Dobutamine
D) Nitroglycerin
: Correct Answer : D
Rationale: IV nitroglycerin is a venodilator (reduces preload) and also dilates
arteries (reduces afterload) at higher doses. It is first-line for acute pulmonary
edema with hypertension.
Q4. A 45-year-old male presents with palpitations. ECG shows a narrow-complex
tachycardia at 190 bpm. He is hemodynamically stable. After vagal maneuvers
fail, what is the next appropriate intervention?
A) Synchronized cardioversion
B) IV adenosine
C) IV metoprolol
D) IV amiodarone
: Correct Answer : B
Rationale: For stable SVT, vagal maneuvers are first-line. If they fail, IV adenosine
(6 mg rapid push, then 12 mg if needed) is the next step. Cardioversion is for
unstable patients.
Q5. A 68-year-old male with heart failure and reduced ejection fraction (HFrEF) is
on lisinopril, carvedilol, and furosemide. He now develops acute worsening
dyspnea and 3+ pitting edema. What is the most appropriate next step?
A) Increase furosemide
B) Add spironolactone
pg. 2
,3
C) Increase carvedilol
D) Add digoxin
: Correct Answer : A
Rationale: Acute fluid overload is treated with increased loop diuretic dose.
Spironolactone is for chronic management. Beta-blocker uptitration should not be
done during acute decompensation.
Q6. A 30-year-old female presents with syncope during exercise. ECG shows a QTc
of 520 ms. What is the most likely diagnosis?
A) Hypertrophic cardiomyopathy
B) Brugada syndrome
C) Long QT syndrome
D) Wolff-Parkinson-White (WPW) syndrome
: Correct Answer : C
Rationale: A QTc >470 ms in females (>450 ms in males) is diagnostic of long QT
syndrome. Exertional syncope is a common presentation. Beta-blockers are
first-line treatment.
Q7. A 50-year-old male presents with acute onset of palpitations and
lightheadedness. ECG shows a wide QRS complex tachycardia. He is hypotensive
with a BP of 85/50 mmHg. What is the most appropriate immediate intervention?
A) IV amiodarone
B) IV adenosine
C) IV lidocaine
D) Synchronized cardioversion
: Correct Answer : D
Rationale: Wide-complex tachycardia (presumed ventricular tachycardia) with
hypotension is unstable and requires immediate synchronized cardioversion
(starting at 100-200 J biphasic).
Q8. A 72-year-old male with a history of atrial fibrillation is on warfarin. His INR is
4.5, and he has no bleeding. What is the most appropriate next step?
A) Administer vitamin K 10 mg IV
B) Hold warfarin and recheck INR in 1-2 days
pg. 3
, 4
C) Give fresh frozen plasma
D) Increase warfarin dose
: Correct Answer : B
Rationale: For INR 4.5-9 without bleeding, hold warfarin and recheck INR in 1-2
days. Low-dose oral vitamin K (1-2.5 mg) may be used for higher INR or high
bleeding risk. Fresh frozen plasma is for life-threatening bleeding.
Q9. A patient with a known abdominal aortic aneurysm (AAA) presents with
sudden onset of severe back pain and hypotension. What is the most appropriate
next step?
A) Emergency surgical consultation
B) Abdominal CT with contrast
C) Abdominal ultrasound
D) Abdominal X-ray
: Correct Answer : A
Rationale: Suspected ruptured AAA requires immediate surgical consultation.
Unstable patients should go directly to the operating room; CT may be obtained if
the patient is stable.
Q10. A 55-year-old male presents with chest pain and ST depression in leads
V3-V5. Troponin is elevated. What is the most appropriate diagnosis and
immediate management?
A) STEMI; transfer for primary PCI
B) Unstable angina; admission and observation
C) NSTEMI; admission and start antiplatelet/anticoagulation
D) Pericarditis; NSAIDs
: Correct Answer : C
Rationale: Elevated troponin with ST depression is diagnostic of NSTEMI.
Treatment includes aspirin, heparin (or enoxaparin), P2Y12 inhibitor, and
admission for risk stratification.
Q11. A 65-year-old male with a history of heart failure is admitted with acute
pulmonary edema. His BP is 100/60 mmHg. Which vasoactive medication is most
appropriate?
pg. 4
Barkley ENP-C Diagnostic Readiness Test (DRT) #4 – 100
Board-Style Questions & Detailed Rationales
Welcome to the Barkley Emergency Nurse Practitioner (ENP-C) Diagnostic Readiness Test (DRT) #4. This
comprehensive test bank contains 100 multiple-choice questions designed to mirror the content and difficulty of
the American Academy of Nurse Practitioners (AANP) ENP-C certification exam. Each question includes a clinical
vignette, four answer options, the correct answer, and a detailed, evidence-based rationale. Domains covered
include: cardiovascular, respiratory, trauma, neurology, infectious disease, toxicology, environmental,
abdominal, endocrine, obstetric/gynecologic, pediatric, psychiatric, and professional/legal issues.
SECTION 1 – CARDIOVASCULAR EMERGENCIES (Questions 1–15)
Q1. A 62-year-old male with a history of hypertension presents with acute onset
of severe, tearing chest pain radiating to the back. BP is 160/90 in the right arm
and 110/70 in the left arm. What is the most appropriate next diagnostic test?
A) ECG
B) Chest X-ray
C) CT angiography of the chest
D) Transthoracic echocardiogram
: Correct Answer : C
Rationale: The presentation is classic for acute aortic dissection. CT angiography is
the gold standard and should be obtained emergently. ECG and chest X-ray are
nonspecific. Echocardiography may detect an intimal flap but is not the first-line
study.
Q2. A 55-year-old male with a history of coronary artery disease presents with
substernal chest pressure that occurs with exertion and is relieved by rest. He has
no ECG changes. Troponin is normal. What is the most appropriate initial
diagnostic test?
A) Exercise stress test
B) Coronary angiography
C) CT coronary angiography
D) Resting echocardiogram
pg. 1
,2
: Correct Answer : A
Rationale: The patient has stable angina. For a patient with an interpretable ECG
who can exercise, an exercise stress test is the appropriate first-line non-invasive
test to detect inducible ischemia.
Q3. A 70-year-old female presents with acute pulmonary edema. BP is 180/100
mmHg. Which medication is most appropriate to reduce preload and afterload?
A) Metoprolol
B) Digoxin
C) Dobutamine
D) Nitroglycerin
: Correct Answer : D
Rationale: IV nitroglycerin is a venodilator (reduces preload) and also dilates
arteries (reduces afterload) at higher doses. It is first-line for acute pulmonary
edema with hypertension.
Q4. A 45-year-old male presents with palpitations. ECG shows a narrow-complex
tachycardia at 190 bpm. He is hemodynamically stable. After vagal maneuvers
fail, what is the next appropriate intervention?
A) Synchronized cardioversion
B) IV adenosine
C) IV metoprolol
D) IV amiodarone
: Correct Answer : B
Rationale: For stable SVT, vagal maneuvers are first-line. If they fail, IV adenosine
(6 mg rapid push, then 12 mg if needed) is the next step. Cardioversion is for
unstable patients.
Q5. A 68-year-old male with heart failure and reduced ejection fraction (HFrEF) is
on lisinopril, carvedilol, and furosemide. He now develops acute worsening
dyspnea and 3+ pitting edema. What is the most appropriate next step?
A) Increase furosemide
B) Add spironolactone
pg. 2
,3
C) Increase carvedilol
D) Add digoxin
: Correct Answer : A
Rationale: Acute fluid overload is treated with increased loop diuretic dose.
Spironolactone is for chronic management. Beta-blocker uptitration should not be
done during acute decompensation.
Q6. A 30-year-old female presents with syncope during exercise. ECG shows a QTc
of 520 ms. What is the most likely diagnosis?
A) Hypertrophic cardiomyopathy
B) Brugada syndrome
C) Long QT syndrome
D) Wolff-Parkinson-White (WPW) syndrome
: Correct Answer : C
Rationale: A QTc >470 ms in females (>450 ms in males) is diagnostic of long QT
syndrome. Exertional syncope is a common presentation. Beta-blockers are
first-line treatment.
Q7. A 50-year-old male presents with acute onset of palpitations and
lightheadedness. ECG shows a wide QRS complex tachycardia. He is hypotensive
with a BP of 85/50 mmHg. What is the most appropriate immediate intervention?
A) IV amiodarone
B) IV adenosine
C) IV lidocaine
D) Synchronized cardioversion
: Correct Answer : D
Rationale: Wide-complex tachycardia (presumed ventricular tachycardia) with
hypotension is unstable and requires immediate synchronized cardioversion
(starting at 100-200 J biphasic).
Q8. A 72-year-old male with a history of atrial fibrillation is on warfarin. His INR is
4.5, and he has no bleeding. What is the most appropriate next step?
A) Administer vitamin K 10 mg IV
B) Hold warfarin and recheck INR in 1-2 days
pg. 3
, 4
C) Give fresh frozen plasma
D) Increase warfarin dose
: Correct Answer : B
Rationale: For INR 4.5-9 without bleeding, hold warfarin and recheck INR in 1-2
days. Low-dose oral vitamin K (1-2.5 mg) may be used for higher INR or high
bleeding risk. Fresh frozen plasma is for life-threatening bleeding.
Q9. A patient with a known abdominal aortic aneurysm (AAA) presents with
sudden onset of severe back pain and hypotension. What is the most appropriate
next step?
A) Emergency surgical consultation
B) Abdominal CT with contrast
C) Abdominal ultrasound
D) Abdominal X-ray
: Correct Answer : A
Rationale: Suspected ruptured AAA requires immediate surgical consultation.
Unstable patients should go directly to the operating room; CT may be obtained if
the patient is stable.
Q10. A 55-year-old male presents with chest pain and ST depression in leads
V3-V5. Troponin is elevated. What is the most appropriate diagnosis and
immediate management?
A) STEMI; transfer for primary PCI
B) Unstable angina; admission and observation
C) NSTEMI; admission and start antiplatelet/anticoagulation
D) Pericarditis; NSAIDs
: Correct Answer : C
Rationale: Elevated troponin with ST depression is diagnostic of NSTEMI.
Treatment includes aspirin, heparin (or enoxaparin), P2Y12 inhibitor, and
admission for risk stratification.
Q11. A 65-year-old male with a history of heart failure is admitted with acute
pulmonary edema. His BP is 100/60 mmHg. Which vasoactive medication is most
appropriate?
pg. 4
