NUR 676 Final Exam Advanced Practice
Nursing Comprehensive Review Official
Practice Exam Actual Exam 2026/2027 with
Detailed Rationales | Complete Exam-Style
Questions | Pass Guaranteed – A+ Graded
══════════════════════════════════════
SECTION 1: ADVANCED HEALTH ASSESSMENT & DIAGNOSTIC REASONING Q1 –
Q15
══════════════════════════════════════
Question 1 of 90
A 58-year-old male presents with progressive dyspnea on exertion, orthopnea, and bilateral
lower extremity edema. On physical exam, jugular venous pressure is elevated to 8 cm H2O,
an S3 gallop is auscultated at the apex, and hepatojugular reflux is positive. Chest X-ray
shows cardiomegaly and pulmonary vascular congestion. BNP is 850 pg/mL. Which
diagnostic finding on echocardiography would most strongly support a diagnosis of heart
failure with preserved ejection fraction?
A. Left ventricular ejection fraction of 35% with regional wall motion abnormalities
B. Severe mitral regurgitation with a dilated left atrium
C. Left ventricular ejection fraction of 58% with elevated E/e' ratio and left atrial enlargement
✓ CORRECT
D. Dilated cardiomyopathy with an LV end-diastolic dimension of 65 mm
Correct Answer: C
Rationale: Heart failure with preserved ejection fraction (HFpEF) is defined by an LVEF ≥50%
with evidence of diastolic dysfunction, typically demonstrated by an elevated E/e' ratio (>14)
and left atrial enlargement on echocardiography. Option A describes heart failure with
reduced ejection fraction (HFrEF), which is a distinct hemodynamic phenotype with different
therapeutic implications. The E/e' ratio is a key noninvasive marker of elevated left
ventricular filling pressures in HFpEF.
Question 2 of 90
A 42-year-old female presents with a 3-month history of intermittent palpitations, heat
intolerance, and a 12-pound unintentional weight loss. She has a fine tremor, lid lag, and a
,diffusely enlarged, non-tender thyroid gland. TSH is 0.01 mIU/L, free T4 is 2.8 ng/dL, and T3 is
280 ng/dL. Which physical exam finding would most specifically distinguish Graves disease
from other causes of thyrotoxicosis?
A. A thyroid bruit audible over the upper poles
B. Exophthalmos and periorbital edema ✓ CORRECT
C. A solitary, firm nodule palpable in the right lobe
D. Tenderness with palpation of the thyroid gland
Correct Answer: B
Rationale: Exophthalmos and periorbital edema are pathognomonic for Graves disease, an
autoimmune disorder mediated by TSH receptor-stimulating antibodies. A thyroid bruit can
occur in any cause of hyperthyroidism with increased vascular flow, while a solitary nodule
suggests toxic adenoma and tenderness suggests subacute thyroiditis. Recognition of these
distinguishing features prevents unnecessary imaging and directs antibody testing.
Question 3 of 90
A 67-year-old male with a 40 pack-year smoking history presents with a new, persistent cough
and hemoptysis. Chest CT reveals a 3.5 cm spiculated mass in the left upper lobe with
enlarged hilar lymph nodes. PET-CT shows an SUVmax of 14.2 in the mass and 8.5 in the
mediastinal lymph nodes. Bronchoscopy with biopsy is planned. Which pre-procedure
assessment is most critical to evaluate before proceeding with transbronchial needle
aspiration of the mediastinal lymph nodes?
A. Pulmonary function tests with diffusion capacity
B. Six-minute walk test
C. Coagulation studies and platelet count ✓ CORRECT
D. Endobronchial ultrasound staging with EBUS-TBNA
Correct Answer: C
Rationale: Coagulation studies and platelet count are essential before any invasive biopsy
procedure to assess bleeding risk, particularly for transbronchial needle aspiration where
vascular injury is a significant concern. While EBUS-TBNA is the planned procedure itself, not
a pre-procedure assessment, and PFTs are important for surgical candidacy but not for the
safety of the biopsy. Unrecognized coagulopathy can lead to life-threatening hemorrhage
during bronchoscopy.
Question 4 of 90
A 29-year-old female presents with recurrent episodes of sharp, pleuritic chest pain radiating
to the left shoulder, worsened by deep inspiration and lying supine, and relieved by sitting
forward. She recently recovered from an upper respiratory infection. On exam, a friction rub is
audible at the left lower sternal border. ECG shows diffuse ST-segment elevation and
,PR-segment depression. Which additional finding on echocardiography would most
significantly alter management?
A. A large pericardial effusion with right ventricular diastolic collapse ✓ CORRECT
B. Mild tricuspid regurgitation
C. Normal left ventricular ejection fraction
D. Small pericardial effusion without hemodynamic compromise
Correct Answer: A
Rationale: A large pericardial effusion with right ventricular diastolic collapse indicates
cardiac tamponade, a life-threatening emergency requiring urgent pericardiocentesis. While
acute pericarditis is often self-limited, the presence of hemodynamic compromise from
tamponade fundamentally changes management from NSAIDs and colchicine to immediate
drainage. Small effusions without hemodynamic compromise are managed conservatively.
Question 5 of 90
A 55-year-old African American male with hypertension and type 2 diabetes presents for a
routine follow-up. His home blood pressure log shows readings consistently between
142-148/88-92 mmHg over the past month. Current medications include metformin 1000 mg
BID and lisinopril 20 mg daily. Laboratory studies show a serum creatinine of 1.1 mg/dL,
potassium 4.2 mEq/L, and urine albumin-to-creatinine ratio of 45 mg/g. According to current
ACC/AHA and ADA guidelines, which medication adjustment is most appropriate?
A. Increase lisinopril to 40 mg daily
B. Add amlodipine 5 mg daily ✓ CORRECT
C. Switch lisinopril to losartan 50 mg daily
D. Add hydrochlorothiazide 25 mg daily
Correct Answer: B
Rationale: Current guidelines recommend initiating combination therapy when blood pressure
is >20/10 mmHg above goal, and for patients with diabetes and albuminuria, an ACE inhibitor
or ARB is first-line; adding a dihydropyridine calcium channel blocker like amlodipine is the
preferred second agent. Increasing lisinopril alone may not achieve goal and risks
hyperkalemia, while switching to losartan offers no advantage over lisinopril in this context.
Thiazide diuretics are less preferred in diabetes due to metabolic effects.
Question 6 of 90
A 38-year-old female presents with a 6-week history of progressive fatigue, arthralgias, and a
malar rash that worsens with sun exposure. Laboratory studies reveal a positive ANA at
1:640 speckled pattern, anti-dsDNA antibodies, and low complement levels. She has no active
renal or CNS involvement. Which additional laboratory finding would most specifically
, support a diagnosis of systemic lupus erythematosus rather than another connective tissue
disease?
A. Elevated rheumatoid factor
B. Positive anti-SSA/Ro antibodies
C. Positive anti-Smith antibodies ✓ CORRECT
D. Elevated C-reactive protein
Correct Answer: C
Rationale: Anti-Smith antibodies are highly specific for systemic lupus erythematosus and are
included in the SLICC classification criteria, making them more diagnostically specific than
anti-SSA/Ro antibodies, which are also seen in Sjögren syndrome. Rheumatoid factor is
nonspecific and can be elevated in multiple autoimmune conditions, while CRP is often
paradoxically normal in active SLE due to type I interferon effects. High specificity prevents
misdiagnosis and inappropriate treatment.
Question 7 of 90
A 71-year-old female with a history of atrial fibrillation on apixaban presents after a fall from
standing height. She struck her occiput and experienced a brief loss of consciousness. On
arrival, she is alert and oriented with a GCS of 15. Her initial non-contrast head CT is negative
for acute hemorrhage. Which finding would most strongly indicate the need for repeat
imaging within 6 hours?
A. A history of prior ischemic stroke
B. Age greater than 65 years
C. Anticoagulation with a direct oral anticoagulant
D. A GCS score that decreases by 2 points within 2 hours ✓ CORRECT
Correct Answer: D
Rationale: A declining GCS score is the most sensitive clinical indicator of delayed
intracranial hemorrhage in anticoagulated patients with minor head trauma, necessitating
urgent repeat imaging. While age over 65 and anticoagulation use are risk factors for delayed
hemorrhage, they alone do not mandate repeat imaging if the patient remains neurologically
intact. Clinical deterioration, not demographic risk factors, drives the decision for emergent
re-evaluation.
Question 8 of 90
A 45-year-old male presents with epigastric pain radiating to the back, nausea, and vomiting
for 24 hours. He reports drinking 8-10 beers daily. On exam, he is febrile to 101.2°F,
tachycardic, and has epigastric tenderness with guarding. Serum lipase is 1,200 U/L. CT
abdomen with contrast shows peripancreatic fat stranding and a small amount of
Nursing Comprehensive Review Official
Practice Exam Actual Exam 2026/2027 with
Detailed Rationales | Complete Exam-Style
Questions | Pass Guaranteed – A+ Graded
══════════════════════════════════════
SECTION 1: ADVANCED HEALTH ASSESSMENT & DIAGNOSTIC REASONING Q1 –
Q15
══════════════════════════════════════
Question 1 of 90
A 58-year-old male presents with progressive dyspnea on exertion, orthopnea, and bilateral
lower extremity edema. On physical exam, jugular venous pressure is elevated to 8 cm H2O,
an S3 gallop is auscultated at the apex, and hepatojugular reflux is positive. Chest X-ray
shows cardiomegaly and pulmonary vascular congestion. BNP is 850 pg/mL. Which
diagnostic finding on echocardiography would most strongly support a diagnosis of heart
failure with preserved ejection fraction?
A. Left ventricular ejection fraction of 35% with regional wall motion abnormalities
B. Severe mitral regurgitation with a dilated left atrium
C. Left ventricular ejection fraction of 58% with elevated E/e' ratio and left atrial enlargement
✓ CORRECT
D. Dilated cardiomyopathy with an LV end-diastolic dimension of 65 mm
Correct Answer: C
Rationale: Heart failure with preserved ejection fraction (HFpEF) is defined by an LVEF ≥50%
with evidence of diastolic dysfunction, typically demonstrated by an elevated E/e' ratio (>14)
and left atrial enlargement on echocardiography. Option A describes heart failure with
reduced ejection fraction (HFrEF), which is a distinct hemodynamic phenotype with different
therapeutic implications. The E/e' ratio is a key noninvasive marker of elevated left
ventricular filling pressures in HFpEF.
Question 2 of 90
A 42-year-old female presents with a 3-month history of intermittent palpitations, heat
intolerance, and a 12-pound unintentional weight loss. She has a fine tremor, lid lag, and a
,diffusely enlarged, non-tender thyroid gland. TSH is 0.01 mIU/L, free T4 is 2.8 ng/dL, and T3 is
280 ng/dL. Which physical exam finding would most specifically distinguish Graves disease
from other causes of thyrotoxicosis?
A. A thyroid bruit audible over the upper poles
B. Exophthalmos and periorbital edema ✓ CORRECT
C. A solitary, firm nodule palpable in the right lobe
D. Tenderness with palpation of the thyroid gland
Correct Answer: B
Rationale: Exophthalmos and periorbital edema are pathognomonic for Graves disease, an
autoimmune disorder mediated by TSH receptor-stimulating antibodies. A thyroid bruit can
occur in any cause of hyperthyroidism with increased vascular flow, while a solitary nodule
suggests toxic adenoma and tenderness suggests subacute thyroiditis. Recognition of these
distinguishing features prevents unnecessary imaging and directs antibody testing.
Question 3 of 90
A 67-year-old male with a 40 pack-year smoking history presents with a new, persistent cough
and hemoptysis. Chest CT reveals a 3.5 cm spiculated mass in the left upper lobe with
enlarged hilar lymph nodes. PET-CT shows an SUVmax of 14.2 in the mass and 8.5 in the
mediastinal lymph nodes. Bronchoscopy with biopsy is planned. Which pre-procedure
assessment is most critical to evaluate before proceeding with transbronchial needle
aspiration of the mediastinal lymph nodes?
A. Pulmonary function tests with diffusion capacity
B. Six-minute walk test
C. Coagulation studies and platelet count ✓ CORRECT
D. Endobronchial ultrasound staging with EBUS-TBNA
Correct Answer: C
Rationale: Coagulation studies and platelet count are essential before any invasive biopsy
procedure to assess bleeding risk, particularly for transbronchial needle aspiration where
vascular injury is a significant concern. While EBUS-TBNA is the planned procedure itself, not
a pre-procedure assessment, and PFTs are important for surgical candidacy but not for the
safety of the biopsy. Unrecognized coagulopathy can lead to life-threatening hemorrhage
during bronchoscopy.
Question 4 of 90
A 29-year-old female presents with recurrent episodes of sharp, pleuritic chest pain radiating
to the left shoulder, worsened by deep inspiration and lying supine, and relieved by sitting
forward. She recently recovered from an upper respiratory infection. On exam, a friction rub is
audible at the left lower sternal border. ECG shows diffuse ST-segment elevation and
,PR-segment depression. Which additional finding on echocardiography would most
significantly alter management?
A. A large pericardial effusion with right ventricular diastolic collapse ✓ CORRECT
B. Mild tricuspid regurgitation
C. Normal left ventricular ejection fraction
D. Small pericardial effusion without hemodynamic compromise
Correct Answer: A
Rationale: A large pericardial effusion with right ventricular diastolic collapse indicates
cardiac tamponade, a life-threatening emergency requiring urgent pericardiocentesis. While
acute pericarditis is often self-limited, the presence of hemodynamic compromise from
tamponade fundamentally changes management from NSAIDs and colchicine to immediate
drainage. Small effusions without hemodynamic compromise are managed conservatively.
Question 5 of 90
A 55-year-old African American male with hypertension and type 2 diabetes presents for a
routine follow-up. His home blood pressure log shows readings consistently between
142-148/88-92 mmHg over the past month. Current medications include metformin 1000 mg
BID and lisinopril 20 mg daily. Laboratory studies show a serum creatinine of 1.1 mg/dL,
potassium 4.2 mEq/L, and urine albumin-to-creatinine ratio of 45 mg/g. According to current
ACC/AHA and ADA guidelines, which medication adjustment is most appropriate?
A. Increase lisinopril to 40 mg daily
B. Add amlodipine 5 mg daily ✓ CORRECT
C. Switch lisinopril to losartan 50 mg daily
D. Add hydrochlorothiazide 25 mg daily
Correct Answer: B
Rationale: Current guidelines recommend initiating combination therapy when blood pressure
is >20/10 mmHg above goal, and for patients with diabetes and albuminuria, an ACE inhibitor
or ARB is first-line; adding a dihydropyridine calcium channel blocker like amlodipine is the
preferred second agent. Increasing lisinopril alone may not achieve goal and risks
hyperkalemia, while switching to losartan offers no advantage over lisinopril in this context.
Thiazide diuretics are less preferred in diabetes due to metabolic effects.
Question 6 of 90
A 38-year-old female presents with a 6-week history of progressive fatigue, arthralgias, and a
malar rash that worsens with sun exposure. Laboratory studies reveal a positive ANA at
1:640 speckled pattern, anti-dsDNA antibodies, and low complement levels. She has no active
renal or CNS involvement. Which additional laboratory finding would most specifically
, support a diagnosis of systemic lupus erythematosus rather than another connective tissue
disease?
A. Elevated rheumatoid factor
B. Positive anti-SSA/Ro antibodies
C. Positive anti-Smith antibodies ✓ CORRECT
D. Elevated C-reactive protein
Correct Answer: C
Rationale: Anti-Smith antibodies are highly specific for systemic lupus erythematosus and are
included in the SLICC classification criteria, making them more diagnostically specific than
anti-SSA/Ro antibodies, which are also seen in Sjögren syndrome. Rheumatoid factor is
nonspecific and can be elevated in multiple autoimmune conditions, while CRP is often
paradoxically normal in active SLE due to type I interferon effects. High specificity prevents
misdiagnosis and inappropriate treatment.
Question 7 of 90
A 71-year-old female with a history of atrial fibrillation on apixaban presents after a fall from
standing height. She struck her occiput and experienced a brief loss of consciousness. On
arrival, she is alert and oriented with a GCS of 15. Her initial non-contrast head CT is negative
for acute hemorrhage. Which finding would most strongly indicate the need for repeat
imaging within 6 hours?
A. A history of prior ischemic stroke
B. Age greater than 65 years
C. Anticoagulation with a direct oral anticoagulant
D. A GCS score that decreases by 2 points within 2 hours ✓ CORRECT
Correct Answer: D
Rationale: A declining GCS score is the most sensitive clinical indicator of delayed
intracranial hemorrhage in anticoagulated patients with minor head trauma, necessitating
urgent repeat imaging. While age over 65 and anticoagulation use are risk factors for delayed
hemorrhage, they alone do not mandate repeat imaging if the patient remains neurologically
intact. Clinical deterioration, not demographic risk factors, drives the decision for emergent
re-evaluation.
Question 8 of 90
A 45-year-old male presents with epigastric pain radiating to the back, nausea, and vomiting
for 24 hours. He reports drinking 8-10 beers daily. On exam, he is febrile to 101.2°F,
tachycardic, and has epigastric tenderness with guarding. Serum lipase is 1,200 U/L. CT
abdomen with contrast shows peripancreatic fat stranding and a small amount of
