NR603 Week 4 APEA Predictor Exam Review
Latest 2026/2027 Update | 100 Questions & Answers with Concise Explanations
Family Nurse Practitioner Board Preparation | APEA Predictor Review
1. A 64-year-old male with a history of hypertension and type 2 diabetes presents with exertional chest
pressure radiating to his left jaw, relieved by rest. His ECG shows no acute changes. Which is the most
appropriate next step?
A. Initiate immediate heparin infusion
B. Order an exercise stress test
C. Prescribe sublingual nitroglycerin and refer for cardiology evaluation
D. Obtain a chest radiograph only
Correct Answer: C. Prescribe sublingual nitroglycerin and refer for cardiology evaluation
Explanation: This presentation is consistent with stable angina. The appropriate primary care step is to
provide sublingual nitroglycerin for acute episodes and refer to cardiology for further evaluation, including
possible stress testing or coronary angiography. Immediate heparin is indicated for ACS, not stable angina.
Exercise stress testing requires appropriate risk stratification first. A chest radiograph alone would not
address the underlying coronary concern.
2. A 72-year-old woman with hypertension is started on lisinopril 10 mg daily. Two weeks later she
reports a dry, persistent cough. Which is the best management step?
A. Add codeine cough syrup to suppress the cough
B. Continue lisinopril and reassure the patient
C. Switch to an angiotensin receptor blocker such as losartan
D. Stop all antihypertensives immediately
Correct Answer: C. Switch to an angiotensin receptor blocker such as losartan
Explanation: A persistent dry cough is a well-known class effect of ACE inhibitors due to bradykinin
accumulation. The appropriate management is to switch to an ARB, which provides equivalent blood
pressure and renal protective benefits without causing cough. Adding cough suppressants does not address
the underlying cause. Continuing lisinopril despite the cough is inappropriate. Stopping all antihypertensives
is not indicated.
3. A 58-year-old man presents with progressive dyspnea on exertion, bilateral ankle edema, and
orthopnea. On exam, you note an S3 gallop, JVD, and crackles at both lung bases. Which diagnosis is
most likely?
A. Pulmonary embolism
B. Congestive heart failure
C. Liver cirrhosis
D. Nephrotic syndrome
Correct Answer: B. Congestive heart failure
Explanation: The triad of dyspnea on exertion, orthopnea, and bilateral ankle edema combined with an S3
gallop, JVD, and bibasilar crackles is classic for congestive heart failure. Pulmonary embolism typically
presents acutely without S3 or JVD. Cirrhosis and nephrotic syndrome cause edema but not S3 or pulmonary
crackles from cardiac failure.
,4. A 67-year-old male with newly diagnosed heart failure with reduced ejection fraction (HFrEF, EF
35%) is stable on furosemide. Which additional medication class has been shown to reduce mortality in
this condition?
A. Calcium channel blockers
B. Beta-blockers such as carvedilol
C. Loop diuretics alone
D. Alpha-1 blockers
Correct Answer: B. Beta-blockers such as carvedilol
Explanation: Beta-blockers such as carvedilol, metoprolol succinate, and bisoprolol are guideline-directed
medical therapy for HFrEF and significantly reduce morbidity and mortality. ACE inhibitors or ARBs and
aldosterone antagonists are also foundational. Calcium channel blockers can worsen heart failure. Diuretics
relieve symptoms but do not improve survival. Alpha-1 blockers are not indicated for HFrEF.
5. A 55-year-old woman with known atrial fibrillation, hypertension, and diabetes presents for a routine
visit. Her CHA2DS2-VASc score is 4. Which is the most appropriate management?
A. Aspirin 81 mg daily
B. No anticoagulation needed
C. Warfarin or a direct oral anticoagulant (DOAC)
D. Clopidogrel plus aspirin
Correct Answer: C. Warfarin or a direct oral anticoagulant (DOAC)
Explanation: A CHA2DS2-VASc score of 4 indicates high stroke risk in atrial fibrillation, and oral
anticoagulation with warfarin or a DOAC (e.g., apixaban, rivaroxaban) is strongly recommended. Aspirin
alone is not sufficient for stroke prevention in high-risk AF patients. Dual antiplatelet therapy is not
guideline-directed for AF stroke prophylaxis.
6. A 48-year-old male has a fasting LDL of 178 mg/dL, HDL of 38 mg/dL, and triglycerides of 210
mg/dL. He has no other cardiovascular risk factors. His 10-year ASCVD risk is 6%. What is the most
appropriate initial management?
A. Initiate high-intensity statin therapy immediately
B. Prescribe niacin for HDL raising
C. Recommend therapeutic lifestyle changes and reassess in 3 months
D. Initiate fibrate therapy for triglycerides
Correct Answer: C. Recommend therapeutic lifestyle changes and reassess in 3 months
Explanation: Per ACC/AHA guidelines, for a patient with borderline ASCVD risk (5-7.5%) without clinical
ASCVD or other high-risk conditions, therapeutic lifestyle changes are the first-line intervention. High-intensity
statins are reserved for high-risk patients or LDL over 190 mg/dL with clinical ASCVD. Niacin is not first-line.
Fibrates are reserved for severe hypertriglyceridemia (>500 mg/dL) or high-risk patients.
7. A 70-year-old woman with stage 2 hypertension and type 2 diabetes presents for follow-up. Her
blood pressure today is 158/94 mmHg despite lifestyle modifications. Which antihypertensive class is
most appropriate as initial therapy?
A. Beta-blocker
B. Loop diuretic
C. ACE inhibitor or ARB
D. Alpha-2 agonist
Correct Answer: C. ACE inhibitor or ARB
, Explanation: For patients with hypertension and diabetes, ACE inhibitors or ARBs are the preferred first-line
agents due to their renoprotective benefits and outcomes data in reducing diabetic nephropathy progression.
Beta-blockers and loop diuretics are not first-line. Alpha-2 agonists such as clonidine are generally not
preferred as initial therapy.
8. A patient with hypertension is found to have a potassium level of 2.9 mEq/L after starting
hydrochlorothiazide. Which is the most appropriate next step?
A. Add spironolactone
B. Switch to a loop diuretic
C. Supplement potassium and consider adding an ACE inhibitor or ARB
D. Stop all diuretics permanently
Correct Answer: C. Supplement potassium and consider adding an ACE inhibitor or ARB
Explanation: Thiazide diuretics commonly cause hypokalemia. The appropriate step is to replete potassium
and consider adding a potassium-sparing agent such as an ACE inhibitor or ARB, which also provides
cardiovascular benefit. Spironolactone could be added, but combining it with ACE inhibitor requires
monitoring for hyperkalemia. Switching to loop diuretics would worsen hypokalemia. Stopping diuretics
abruptly is not the preferred approach.
9. A 60-year-old male smoker presents with a resting ECG showing a normal sinus rhythm with left
bundle branch block (LBBB). He denies chest pain. This finding is most consistent with which
condition?
A. Benign early repolarization
B. Wolff-Parkinson-White syndrome
C. Structural heart disease or ischemic cardiomyopathy
D. Athlete's heart
Correct Answer: C. Structural heart disease or ischemic cardiomyopathy
Explanation: New or existing LBBB in a symptomatic or high-risk patient is associated with underlying
structural heart disease, ischemic cardiomyopathy, or conduction system disease and warrants further
evaluation including echocardiography. WPW presents with a delta wave and short PR interval. Benign early
repolarization and athlete's heart do not explain LBBB.
10. A 66-year-old man with no cardiac history presents to the clinic with a pulse of 110 bpm that is
irregularly irregular. An ECG reveals absence of P waves and an irregular ventricular response. What is
the most likely diagnosis?
A. Sinus tachycardia
B. Atrial flutter
C. Atrial fibrillation
D. Multifocal atrial tachycardia
Correct Answer: C. Atrial fibrillation
Explanation: Irregularly irregular rhythm with no discernible P waves on ECG is the hallmark of atrial
fibrillation. Atrial flutter typically shows a regular sawtooth flutter wave pattern. Sinus tachycardia has normal
P waves. Multifocal atrial tachycardia shows at least three distinct P-wave morphologies and is often seen in
COPD patients.
11. A 75-year-old woman with HFrEF and CKD stage 3 has a potassium of 5.8 mEq/L. She is currently
on lisinopril and spironolactone. Which medication should be discontinued first?
Latest 2026/2027 Update | 100 Questions & Answers with Concise Explanations
Family Nurse Practitioner Board Preparation | APEA Predictor Review
1. A 64-year-old male with a history of hypertension and type 2 diabetes presents with exertional chest
pressure radiating to his left jaw, relieved by rest. His ECG shows no acute changes. Which is the most
appropriate next step?
A. Initiate immediate heparin infusion
B. Order an exercise stress test
C. Prescribe sublingual nitroglycerin and refer for cardiology evaluation
D. Obtain a chest radiograph only
Correct Answer: C. Prescribe sublingual nitroglycerin and refer for cardiology evaluation
Explanation: This presentation is consistent with stable angina. The appropriate primary care step is to
provide sublingual nitroglycerin for acute episodes and refer to cardiology for further evaluation, including
possible stress testing or coronary angiography. Immediate heparin is indicated for ACS, not stable angina.
Exercise stress testing requires appropriate risk stratification first. A chest radiograph alone would not
address the underlying coronary concern.
2. A 72-year-old woman with hypertension is started on lisinopril 10 mg daily. Two weeks later she
reports a dry, persistent cough. Which is the best management step?
A. Add codeine cough syrup to suppress the cough
B. Continue lisinopril and reassure the patient
C. Switch to an angiotensin receptor blocker such as losartan
D. Stop all antihypertensives immediately
Correct Answer: C. Switch to an angiotensin receptor blocker such as losartan
Explanation: A persistent dry cough is a well-known class effect of ACE inhibitors due to bradykinin
accumulation. The appropriate management is to switch to an ARB, which provides equivalent blood
pressure and renal protective benefits without causing cough. Adding cough suppressants does not address
the underlying cause. Continuing lisinopril despite the cough is inappropriate. Stopping all antihypertensives
is not indicated.
3. A 58-year-old man presents with progressive dyspnea on exertion, bilateral ankle edema, and
orthopnea. On exam, you note an S3 gallop, JVD, and crackles at both lung bases. Which diagnosis is
most likely?
A. Pulmonary embolism
B. Congestive heart failure
C. Liver cirrhosis
D. Nephrotic syndrome
Correct Answer: B. Congestive heart failure
Explanation: The triad of dyspnea on exertion, orthopnea, and bilateral ankle edema combined with an S3
gallop, JVD, and bibasilar crackles is classic for congestive heart failure. Pulmonary embolism typically
presents acutely without S3 or JVD. Cirrhosis and nephrotic syndrome cause edema but not S3 or pulmonary
crackles from cardiac failure.
,4. A 67-year-old male with newly diagnosed heart failure with reduced ejection fraction (HFrEF, EF
35%) is stable on furosemide. Which additional medication class has been shown to reduce mortality in
this condition?
A. Calcium channel blockers
B. Beta-blockers such as carvedilol
C. Loop diuretics alone
D. Alpha-1 blockers
Correct Answer: B. Beta-blockers such as carvedilol
Explanation: Beta-blockers such as carvedilol, metoprolol succinate, and bisoprolol are guideline-directed
medical therapy for HFrEF and significantly reduce morbidity and mortality. ACE inhibitors or ARBs and
aldosterone antagonists are also foundational. Calcium channel blockers can worsen heart failure. Diuretics
relieve symptoms but do not improve survival. Alpha-1 blockers are not indicated for HFrEF.
5. A 55-year-old woman with known atrial fibrillation, hypertension, and diabetes presents for a routine
visit. Her CHA2DS2-VASc score is 4. Which is the most appropriate management?
A. Aspirin 81 mg daily
B. No anticoagulation needed
C. Warfarin or a direct oral anticoagulant (DOAC)
D. Clopidogrel plus aspirin
Correct Answer: C. Warfarin or a direct oral anticoagulant (DOAC)
Explanation: A CHA2DS2-VASc score of 4 indicates high stroke risk in atrial fibrillation, and oral
anticoagulation with warfarin or a DOAC (e.g., apixaban, rivaroxaban) is strongly recommended. Aspirin
alone is not sufficient for stroke prevention in high-risk AF patients. Dual antiplatelet therapy is not
guideline-directed for AF stroke prophylaxis.
6. A 48-year-old male has a fasting LDL of 178 mg/dL, HDL of 38 mg/dL, and triglycerides of 210
mg/dL. He has no other cardiovascular risk factors. His 10-year ASCVD risk is 6%. What is the most
appropriate initial management?
A. Initiate high-intensity statin therapy immediately
B. Prescribe niacin for HDL raising
C. Recommend therapeutic lifestyle changes and reassess in 3 months
D. Initiate fibrate therapy for triglycerides
Correct Answer: C. Recommend therapeutic lifestyle changes and reassess in 3 months
Explanation: Per ACC/AHA guidelines, for a patient with borderline ASCVD risk (5-7.5%) without clinical
ASCVD or other high-risk conditions, therapeutic lifestyle changes are the first-line intervention. High-intensity
statins are reserved for high-risk patients or LDL over 190 mg/dL with clinical ASCVD. Niacin is not first-line.
Fibrates are reserved for severe hypertriglyceridemia (>500 mg/dL) or high-risk patients.
7. A 70-year-old woman with stage 2 hypertension and type 2 diabetes presents for follow-up. Her
blood pressure today is 158/94 mmHg despite lifestyle modifications. Which antihypertensive class is
most appropriate as initial therapy?
A. Beta-blocker
B. Loop diuretic
C. ACE inhibitor or ARB
D. Alpha-2 agonist
Correct Answer: C. ACE inhibitor or ARB
, Explanation: For patients with hypertension and diabetes, ACE inhibitors or ARBs are the preferred first-line
agents due to their renoprotective benefits and outcomes data in reducing diabetic nephropathy progression.
Beta-blockers and loop diuretics are not first-line. Alpha-2 agonists such as clonidine are generally not
preferred as initial therapy.
8. A patient with hypertension is found to have a potassium level of 2.9 mEq/L after starting
hydrochlorothiazide. Which is the most appropriate next step?
A. Add spironolactone
B. Switch to a loop diuretic
C. Supplement potassium and consider adding an ACE inhibitor or ARB
D. Stop all diuretics permanently
Correct Answer: C. Supplement potassium and consider adding an ACE inhibitor or ARB
Explanation: Thiazide diuretics commonly cause hypokalemia. The appropriate step is to replete potassium
and consider adding a potassium-sparing agent such as an ACE inhibitor or ARB, which also provides
cardiovascular benefit. Spironolactone could be added, but combining it with ACE inhibitor requires
monitoring for hyperkalemia. Switching to loop diuretics would worsen hypokalemia. Stopping diuretics
abruptly is not the preferred approach.
9. A 60-year-old male smoker presents with a resting ECG showing a normal sinus rhythm with left
bundle branch block (LBBB). He denies chest pain. This finding is most consistent with which
condition?
A. Benign early repolarization
B. Wolff-Parkinson-White syndrome
C. Structural heart disease or ischemic cardiomyopathy
D. Athlete's heart
Correct Answer: C. Structural heart disease or ischemic cardiomyopathy
Explanation: New or existing LBBB in a symptomatic or high-risk patient is associated with underlying
structural heart disease, ischemic cardiomyopathy, or conduction system disease and warrants further
evaluation including echocardiography. WPW presents with a delta wave and short PR interval. Benign early
repolarization and athlete's heart do not explain LBBB.
10. A 66-year-old man with no cardiac history presents to the clinic with a pulse of 110 bpm that is
irregularly irregular. An ECG reveals absence of P waves and an irregular ventricular response. What is
the most likely diagnosis?
A. Sinus tachycardia
B. Atrial flutter
C. Atrial fibrillation
D. Multifocal atrial tachycardia
Correct Answer: C. Atrial fibrillation
Explanation: Irregularly irregular rhythm with no discernible P waves on ECG is the hallmark of atrial
fibrillation. Atrial flutter typically shows a regular sawtooth flutter wave pattern. Sinus tachycardia has normal
P waves. Multifocal atrial tachycardia shows at least three distinct P-wave morphologies and is often seen in
COPD patients.
11. A 75-year-old woman with HFrEF and CKD stage 3 has a potassium of 5.8 mEq/L. She is currently
on lisinopril and spironolactone. Which medication should be discontinued first?
