CLINICAL DECISION-MAKING EXAM PRACTICE
QUESTIONS AND CORRECT ANSWERS (VERIFIED
ANSWERS) PLUS RATIONALES 2026 Q&A | INSTANT
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SECTION I: DIAGNOSTIC REASONING & DIFFERENTIAL DIAGNOSIS (Qs 1–15)
1. A 65-year-old patient with hypertension and diabetes presents with new-
onset fatigue, muscle weakness, and a serum potassium of 5.8 mEq/L. He is on
lisinopril, hydrochlorothiazide, metformin, and ibuprofen for arthritis. Which
medication is the MOST likely contributor to this hyperkalemia, and what is the
appropriate clinical decision?
• A) Metformin – discontinue immediately
• B) Ibuprofen – discontinue and consider acetaminophen; lisinopril also
contributes via reduced aldosterone
• C) Hydrochlorothiazide – increase the dose
• D) Lisinopril alone – no action needed
Correct Answer: B
Rationale: Both ACE inhibitors (lisinopril) and NSAIDs (ibuprofen) can cause
hyperkalemia. NSAIDs reduce renal blood flow (afferent arteriolar constriction),
while ACE inhibitors reduce aldosterone. The combination synergistically increases
potassium. The clinical decision is to discontinue the NSAID, monitor potassium,
and consider an alternative analgesic. NSAIDs are also nephrotoxic.
2. A 72-year-old patient presents with a new, non-productive cough, fatigue, and
an INR of 6.5 (target 2.5). He has been on warfarin for 3 years and was started
,on amiodarone 2 weeks ago for atrial fibrillation. What is the MOST appropriate
clinical decision?
• A) Continue warfarin and amiodarone at the same doses
• B) Hold warfarin, reduce the amiodarone dose, and check INR tomorrow
• C) Hold warfarin, consider low-dose Vitamin K (1-2 mg oral) if no bleeding,
and reduce the warfarin dose upon restarting because amiodarone inhibits
warfarin metabolism
• D) Stop amiodarone permanently
Correct Answer: C
*Rationale: Amiodarone inhibits CYP2C9 (the enzyme that metabolizes S-
warfarin), causing a significant INR rise within 1-2 weeks of initiation. The correct
clinical decision is to hold warfarin, consider low-dose Vitamin K for an INR >5
without bleeding, and reduce the warfarin dose by 30-50% when restarting.
Amiodarone should not be stopped abruptly.*
3. A 60-year-old patient with Type 2 diabetes and CKD (eGFR 40) is on metformin
and glipizide. She presents with confusion, dizziness, and a blood glucose of 45
mg/dL. Which clinical decision is MOST appropriate for managing her
hypoglycemia and preventing recurrence?
• A) Increase the glipizide dose to improve glucose control
• B) Discontinue metformin due to CKD
• C) Administer IV dextrose, and consider deprescribing glipizide
(sulfonylurea) due to high hypoglycemia risk in CKD
• D) Add a third agent
Correct Answer: C
Rationale: Sulfonylureas (glipizide, glyburide) accumulate in renal impairment and
cause severe hypoglycemia. The clinical decision is to treat the acute hypoglycemia
,and then deprescribe or significantly reduce the sulfonylurea. Metformin is safe at
eGFR >30 (with dose adjustment), but the sulfonylurea is the culprit here.
4. A 55-year-old patient on a high-intensity statin (atorvastatin 80 mg) reports
severe bilateral thigh pain and dark urine. Labs show a CK of 12,000 U/L. What is
the MOST appropriate clinical decision?
• A) Continue the statin and add CoQ10
• B) Switch to a lower dose of rosuvastatin
• C) Discontinue the statin immediately, assess for rhabdomyolysis, and
hospitalize for IV hydration
• D) Add fenofibrate to manage lipids
Correct Answer: C
*Rationale: A CK > 10x the upper limit of normal with muscle symptoms and dark
urine indicates rhabdomyolysis, a life-threatening condition that can cause acute
kidney injury. The statin must be immediately discontinued, and the patient
requires hospitalization for IV hydration and renal monitoring.*
5. A 68-year-old patient with heart failure with reduced ejection fraction (HFrEF)
is on sacubitril/valsartan, bisoprolol, and spironolactone. She presents with a
potassium of 6.1 mEq/L and worsening renal function (creatinine 2.0 mg/dL).
What is the FIRST clinical decision to make?
• A) Increase the sacubitril/valsartan dose
• B) Hold spironolactone and reduce the sacubitril/valsartan dose; monitor
potassium and renal function
• C) Add sodium polystyrene sulfonate
• D) Start a loop diuretic
, Correct Answer: B
Rationale: The combination of an ARNI/ACEi/ARB with a mineralocorticoid
receptor antagonist (spironolactone) significantly increases the risk of
hyperkalemia and acute kidney injury. The clinical decision is to hold the
spironolactone, reduce the ARNI dose, and monitor closely. Sodium polystyrene
can be used but is not the first step.
6. A 62-year-old patient with COPD and asthma overlap is prescribed a beta-
blocker (metoprolol) for heart failure. Which clinical decision is MOST
appropriate regarding beta-blocker selection?
• A) Avoid beta-blockers entirely due to asthma
• B) Use a cardioselective beta-1 blocker (metoprolol or bisoprolol) at a low
dose and titrate slowly; it is safe in COPD
• C) Use a non-selective beta-blocker (propranolol)
• D) Use a high dose immediately
Correct Answer: B
*Rationale: Cardioselective beta-1 blockers (metoprolol, bisoprolol) are preferred
in patients with COPD/asthma because they have less bronchospastic effect. They
are not contraindicated and have a mortality benefit in heart failure. Non-selective
agents (propranolol) are avoided. Low dose and slow titration are essential.*
7. A 75-year-old patient with dementia and agitation is on quetiapine 25 mg at
bedtime. The patient develops a new-onset shuffling gait and rigidity. What is
the MOST appropriate clinical decision?
• A) Increase quetiapine to 50 mg
• B) Add benztropine
• C) Consider reducing or deprescribing quetiapine; these are extrapyramidal
side effects (EPS) from dopamine blockade
QUESTIONS AND CORRECT ANSWERS (VERIFIED
ANSWERS) PLUS RATIONALES 2026 Q&A | INSTANT
DOWNLOAD PDF
SECTION I: DIAGNOSTIC REASONING & DIFFERENTIAL DIAGNOSIS (Qs 1–15)
1. A 65-year-old patient with hypertension and diabetes presents with new-
onset fatigue, muscle weakness, and a serum potassium of 5.8 mEq/L. He is on
lisinopril, hydrochlorothiazide, metformin, and ibuprofen for arthritis. Which
medication is the MOST likely contributor to this hyperkalemia, and what is the
appropriate clinical decision?
• A) Metformin – discontinue immediately
• B) Ibuprofen – discontinue and consider acetaminophen; lisinopril also
contributes via reduced aldosterone
• C) Hydrochlorothiazide – increase the dose
• D) Lisinopril alone – no action needed
Correct Answer: B
Rationale: Both ACE inhibitors (lisinopril) and NSAIDs (ibuprofen) can cause
hyperkalemia. NSAIDs reduce renal blood flow (afferent arteriolar constriction),
while ACE inhibitors reduce aldosterone. The combination synergistically increases
potassium. The clinical decision is to discontinue the NSAID, monitor potassium,
and consider an alternative analgesic. NSAIDs are also nephrotoxic.
2. A 72-year-old patient presents with a new, non-productive cough, fatigue, and
an INR of 6.5 (target 2.5). He has been on warfarin for 3 years and was started
,on amiodarone 2 weeks ago for atrial fibrillation. What is the MOST appropriate
clinical decision?
• A) Continue warfarin and amiodarone at the same doses
• B) Hold warfarin, reduce the amiodarone dose, and check INR tomorrow
• C) Hold warfarin, consider low-dose Vitamin K (1-2 mg oral) if no bleeding,
and reduce the warfarin dose upon restarting because amiodarone inhibits
warfarin metabolism
• D) Stop amiodarone permanently
Correct Answer: C
*Rationale: Amiodarone inhibits CYP2C9 (the enzyme that metabolizes S-
warfarin), causing a significant INR rise within 1-2 weeks of initiation. The correct
clinical decision is to hold warfarin, consider low-dose Vitamin K for an INR >5
without bleeding, and reduce the warfarin dose by 30-50% when restarting.
Amiodarone should not be stopped abruptly.*
3. A 60-year-old patient with Type 2 diabetes and CKD (eGFR 40) is on metformin
and glipizide. She presents with confusion, dizziness, and a blood glucose of 45
mg/dL. Which clinical decision is MOST appropriate for managing her
hypoglycemia and preventing recurrence?
• A) Increase the glipizide dose to improve glucose control
• B) Discontinue metformin due to CKD
• C) Administer IV dextrose, and consider deprescribing glipizide
(sulfonylurea) due to high hypoglycemia risk in CKD
• D) Add a third agent
Correct Answer: C
Rationale: Sulfonylureas (glipizide, glyburide) accumulate in renal impairment and
cause severe hypoglycemia. The clinical decision is to treat the acute hypoglycemia
,and then deprescribe or significantly reduce the sulfonylurea. Metformin is safe at
eGFR >30 (with dose adjustment), but the sulfonylurea is the culprit here.
4. A 55-year-old patient on a high-intensity statin (atorvastatin 80 mg) reports
severe bilateral thigh pain and dark urine. Labs show a CK of 12,000 U/L. What is
the MOST appropriate clinical decision?
• A) Continue the statin and add CoQ10
• B) Switch to a lower dose of rosuvastatin
• C) Discontinue the statin immediately, assess for rhabdomyolysis, and
hospitalize for IV hydration
• D) Add fenofibrate to manage lipids
Correct Answer: C
*Rationale: A CK > 10x the upper limit of normal with muscle symptoms and dark
urine indicates rhabdomyolysis, a life-threatening condition that can cause acute
kidney injury. The statin must be immediately discontinued, and the patient
requires hospitalization for IV hydration and renal monitoring.*
5. A 68-year-old patient with heart failure with reduced ejection fraction (HFrEF)
is on sacubitril/valsartan, bisoprolol, and spironolactone. She presents with a
potassium of 6.1 mEq/L and worsening renal function (creatinine 2.0 mg/dL).
What is the FIRST clinical decision to make?
• A) Increase the sacubitril/valsartan dose
• B) Hold spironolactone and reduce the sacubitril/valsartan dose; monitor
potassium and renal function
• C) Add sodium polystyrene sulfonate
• D) Start a loop diuretic
, Correct Answer: B
Rationale: The combination of an ARNI/ACEi/ARB with a mineralocorticoid
receptor antagonist (spironolactone) significantly increases the risk of
hyperkalemia and acute kidney injury. The clinical decision is to hold the
spironolactone, reduce the ARNI dose, and monitor closely. Sodium polystyrene
can be used but is not the first step.
6. A 62-year-old patient with COPD and asthma overlap is prescribed a beta-
blocker (metoprolol) for heart failure. Which clinical decision is MOST
appropriate regarding beta-blocker selection?
• A) Avoid beta-blockers entirely due to asthma
• B) Use a cardioselective beta-1 blocker (metoprolol or bisoprolol) at a low
dose and titrate slowly; it is safe in COPD
• C) Use a non-selective beta-blocker (propranolol)
• D) Use a high dose immediately
Correct Answer: B
*Rationale: Cardioselective beta-1 blockers (metoprolol, bisoprolol) are preferred
in patients with COPD/asthma because they have less bronchospastic effect. They
are not contraindicated and have a mortality benefit in heart failure. Non-selective
agents (propranolol) are avoided. Low dose and slow titration are essential.*
7. A 75-year-old patient with dementia and agitation is on quetiapine 25 mg at
bedtime. The patient develops a new-onset shuffling gait and rigidity. What is
the MOST appropriate clinical decision?
• A) Increase quetiapine to 50 mg
• B) Add benztropine
• C) Consider reducing or deprescribing quetiapine; these are extrapyramidal
side effects (EPS) from dopamine blockade
