NR 603 Week 4 APEA Predictor Exam Study Guide
(2026/2027 Update) | Questions & Answers With
Rationales – Chamberlain University
1. A 45-year-old patient with a history of hypertension and type 2 diabetes presents with acute
onset of severe, tearing chest pain that radiates to the back. Blood pressure is 210/130 mm Hg in
the right arm and 180/110 mm Hg in the left arm. Which of the following diagnostic tests is most
appropriate to confirm the suspected diagnosis?
A. CT angiography of the chest with intravenous contrast
B. Transthoracic echocardiogram
C. Ventilation-perfusion scan
D. Coronary angiography
Answer: A
Rationale: The presentation is classic for aortic dissection, and CT angiography is the gold standard for
diagnosis. Transthoracic echocardiogram may be used but is less sensitive. V/Q scan is for pulmonary
embolism. Coronary angiography is for coronary artery disease.
2. A patient with chronic kidney disease stage 4 (eGFR 25 mL/min/1.73m²) is found to have a
serum potassium of 6.2 mEq/L, ECG showing peaked T waves. Which of the following
interventions should be administered first?
A. Intravenous calcium gluconate
B. Oral sodium polystyrene sulfonate
C. Intravenous insulin and dextrose
D. Intravenous sodium bicarbonate
Answer: A
Rationale: Calcium gluconate is given first to stabilize the cardiac membrane in life-threatening
hyperkalemia with ECG changes. Insulin and dextrose shift potassium intracellularly but take longer.
Sodium polystyrene is a slower-acting GI exchange. Bicarbonate is less effective in CKD.
3. A 30-year-old patient presents with acute onset of dyspnea, pleuritic chest pain, and hemoptysis.
D-dimer is elevated. CT pulmonary angiography shows a filling defect in the right main
pulmonary artery. The patient has no contraindications to anticoagulation. Which of the following
is the most appropriate initial anticoagulant?
A. Unfractionated heparin continuous infusion
B. Low molecular weight heparin (LMWH) subcutaneous
C. Warfarin with a target INR of 2-3
D. Direct oral anticoagulant (DOAC) such as rivaroxaban
Answer: A
Page 1
,Rationale: For acute PE with hemodynamic instability or large clot burden, unfractionated heparin is preferred due to its
short half-life and reversibility. LMWH or DOAC may be used for stable patients. Warfarin requires bridging and is not
initial therapy.
4. A patient with suspected meningitis undergoes lumbar puncture. CSF results: opening pressure
300 mm H2O, WBC 1200/mm³ (80% neutrophils), glucose 25 mg/dL (serum glucose 100 mg/dL),
protein 150 mg/dL. Which of the following is the most likely causative organism?
A. Streptococcus pneumoniae
B. Neisseria meningitidis
C. Listeria monocytogenes
D. Cryptococcus neoformans
Answer: A
Rationale: The CSF findings (elevated pressure, neutrophilic pleocytosis, low glucose, high protein) are
classic for bacterial meningitis. S. pneumoniae is the most common cause in adults. N. meningitidis is
more common in adolescents/young adults. Listeria is seen in immunocompromised or elderly.
Cryptococcus has lymphocytic predominance.
5. A patient with chronic obstructive pulmonary disease (COPD) presents with acute dyspnea,
wheezing, and a productive cough with purulent sputum. Chest X-ray shows no infiltrate. Which of
the following is the most appropriate initial antibiotic therapy?
A. Azithromycin 500 mg orally on day 1, then 250 mg daily for 4 days
B. Amoxicillin-clavulanate 875/125 mg twice daily for 5 days
C. Levofloxacin 750 mg daily for 5 days
D. Trimethoprim-sulfamethoxazole DS twice daily for 7 days
Answer: B
Rationale: For acute exacerbation of COPD with purulent sputum and no pneumonia,
amoxicillin-clavulanate is first-line per GOLD guidelines. Azithromycin is an alternative but less
effective for H. influenzae. Levofloxacin is reserved for severe or resistant cases. TMP-SMX is not
recommended due to resistance.
6. A patient with cirrhosis and ascites develops fever, abdominal pain, and altered mental status.
Paracentesis reveals ascitic fluid PMN count of 500 cells/µL. Which of the following is the most
appropriate initial empiric antibiotic regimen?
A. Ceftriaxone 2 g IV daily
B. Ciprofloxacin 400 mg IV twice daily
C. Piperacillin-tazobactam 4.5 g IV every 6 hours
D. Vancomycin plus gentamicin
Answer: A
Rationale: Spontaneous bacterial peritonitis (SBP) is diagnosed with PMN count >250 cells/µL.
Ceftriaxone is first-line empiric therapy as it covers common pathogens (E. coli, Klebsiella, S.
pneumoniae). Ciprofloxacin may be used if no recent quinolone exposure. Piperacillin-tazobactam is for
nosocomial peritonitis. Vancomycin is not needed without MRSA risk.
Page 2
,7. A patient with acute pancreatitis has a Ranson score of 4 at 48 hours. Which of the following
best predicts a severe course?
A. Age >55 years
B. Hematocrit drop >10 points
C. Serum calcium <8 mg/dL
D. LDH >350 IU/L
Answer: C
Rationale: Hypocalcemia (serum calcium <8 mg/dL) is a marker of severe pancreatitis and indicates
saponification of fat necrosis. Age >55, hematocrit drop, and elevated LDH are all components of
Ranson criteria but hypocalcemia specifically correlates with worse prognosis.
8. A patient with systemic lupus erythematosus (SLE) presents with acute onset of confusion,
seizures, and fever. CSF shows mild lymphocytic pleocytosis and elevated protein. Which of the
following is the most likely diagnosis?
A. CNS lupus (lupus cerebritis)
B. Infectious meningitis
C. Posterior reversible encephalopathy syndrome (PRES)
D. Cerebral venous sinus thrombosis
Answer: A
Rationale: In a patient with SLE, acute neuropsychiatric symptoms with CSF lymphocytic pleocytosis and
elevated protein suggest CNS lupus. Infectious meningitis must be ruled out but is less likely without
typical CSF findings. PRES is associated with hypertension and immunosuppressants. Cerebral venous
sinus thrombosis presents with headache and papilledema.
9. A patient with diabetic ketoacidosis (DKA) has a serum potassium of 3.2 mEq/L on admission.
Which of the following is the most appropriate management?
A. Start insulin infusion immediately and recheck potassium in 2 hours
B. Administer potassium 20-30 mEq/h IV before starting insulin infusion
C. Give sodium bicarbonate to correct acidosis first
D. Hold insulin until potassium is >4.0 mEq/L
Answer: B
Rationale: In DKA with hypokalemia on admission, potassium must be replaced before starting insulin to
avoid life-threatening hypokalemia as insulin drives potassium into cells. Insulin can be started after
potassium is >3.3 mEq/L. Bicarbonate is not recommended unless severe acidosis (pH <7.0). Holding
insulin delays treatment.
10. A patient with acute kidney injury (AKI) has a fractional excretion of sodium (FENa) of 0.5%
and urine osmolality of 500 mOsm/kg. Which of the following is the most likely cause?
A. Acute tubular necrosis (ATN)
B. Prerenal azotemia
C. Acute interstitial nephritis
D. Glomerulonephritis
Page 3
, Answer: B
Rationale: A low FENa (<1%) and high urine osmolality (>400 mOsm/kg) indicate intact tubular
function, consistent with prerenal azotemia (e.g., volume depletion). ATN typically has FENa >2% and
isothenuria. Interstitial nephritis and glomerulonephritis usually have higher FENa.
11. A 45-year-old patient with a history of hypertension and type 2 diabetes presents with acute
onset of severe, tearing chest pain radiating to the back. Blood pressure is 210/120 mm Hg in the
right arm and 180/100 mm Hg in the left arm. Which of the following is the most appropriate
initial diagnostic test?
A. Electrocardiogram (ECG) and cardiac troponin levels
B. Computed tomography angiography (CTA) of the chest
C. Transesophageal echocardiogram (TEE)
D. Chest X-ray and D-dimer
Answer: B
Rationale: Given the clinical presentation of severe tearing chest pain with a significant blood pressure
differential between arms, aortic dissection is highly suspected. CTA of the chest is the imaging modality
of choice for diagnosis due to its high sensitivity and specificity for detecting dissection. While ECG and
troponin are important to rule out myocardial infarction, they are not diagnostic for dissection. TEE is
an alternative but is less readily available and more invasive. Chest X-ray and D-dimer lack sufficient
specificity.
12. In the management of a patient with acute ischemic stroke within 4.5 hours of symptom onset,
which of the following factors is an absolute contraindication to intravenous thrombolysis with
alteplase?
A. History of intracranial hemorrhage
B. Blood glucose level of 180 mg/dL
C. Systolic blood pressure of 175 mm Hg
D. Seizure at onset with postictal neurological deficits
Answer: A
Rationale: A prior history of intracranial hemorrhage is an absolute contraindication to IV thrombolysis
due to the high risk of recurrent bleeding. Blood glucose >400 mg/dL is a relative contraindication, but
180 mg/dL is acceptable. Systolic BP >185 mm Hg requires lowering before treatment, but 175 mm Hg
is not an absolute contraindication. Seizure at onset is a relative contraindication if deficits are due to
postictal state, but if the clinician is confident the deficits are from stroke, thrombolysis may still be
considered.
13. A patient with chronic heart failure with reduced ejection fraction (HFrEF) is on optimal
medical therapy including an ACE inhibitor, beta-blocker, and spironolactone. Despite this, the
patient remains symptomatic with NYHA class III symptoms. Which of the following medication
adjustments is most likely to improve outcomes?
A. Add hydralazine and isosorbide dinitrate
B. Switch from ACE inhibitor to angiotensin receptor blocker
C. Increase beta-blocker to maximum tolerated dose
Page 4
(2026/2027 Update) | Questions & Answers With
Rationales – Chamberlain University
1. A 45-year-old patient with a history of hypertension and type 2 diabetes presents with acute
onset of severe, tearing chest pain that radiates to the back. Blood pressure is 210/130 mm Hg in
the right arm and 180/110 mm Hg in the left arm. Which of the following diagnostic tests is most
appropriate to confirm the suspected diagnosis?
A. CT angiography of the chest with intravenous contrast
B. Transthoracic echocardiogram
C. Ventilation-perfusion scan
D. Coronary angiography
Answer: A
Rationale: The presentation is classic for aortic dissection, and CT angiography is the gold standard for
diagnosis. Transthoracic echocardiogram may be used but is less sensitive. V/Q scan is for pulmonary
embolism. Coronary angiography is for coronary artery disease.
2. A patient with chronic kidney disease stage 4 (eGFR 25 mL/min/1.73m²) is found to have a
serum potassium of 6.2 mEq/L, ECG showing peaked T waves. Which of the following
interventions should be administered first?
A. Intravenous calcium gluconate
B. Oral sodium polystyrene sulfonate
C. Intravenous insulin and dextrose
D. Intravenous sodium bicarbonate
Answer: A
Rationale: Calcium gluconate is given first to stabilize the cardiac membrane in life-threatening
hyperkalemia with ECG changes. Insulin and dextrose shift potassium intracellularly but take longer.
Sodium polystyrene is a slower-acting GI exchange. Bicarbonate is less effective in CKD.
3. A 30-year-old patient presents with acute onset of dyspnea, pleuritic chest pain, and hemoptysis.
D-dimer is elevated. CT pulmonary angiography shows a filling defect in the right main
pulmonary artery. The patient has no contraindications to anticoagulation. Which of the following
is the most appropriate initial anticoagulant?
A. Unfractionated heparin continuous infusion
B. Low molecular weight heparin (LMWH) subcutaneous
C. Warfarin with a target INR of 2-3
D. Direct oral anticoagulant (DOAC) such as rivaroxaban
Answer: A
Page 1
,Rationale: For acute PE with hemodynamic instability or large clot burden, unfractionated heparin is preferred due to its
short half-life and reversibility. LMWH or DOAC may be used for stable patients. Warfarin requires bridging and is not
initial therapy.
4. A patient with suspected meningitis undergoes lumbar puncture. CSF results: opening pressure
300 mm H2O, WBC 1200/mm³ (80% neutrophils), glucose 25 mg/dL (serum glucose 100 mg/dL),
protein 150 mg/dL. Which of the following is the most likely causative organism?
A. Streptococcus pneumoniae
B. Neisseria meningitidis
C. Listeria monocytogenes
D. Cryptococcus neoformans
Answer: A
Rationale: The CSF findings (elevated pressure, neutrophilic pleocytosis, low glucose, high protein) are
classic for bacterial meningitis. S. pneumoniae is the most common cause in adults. N. meningitidis is
more common in adolescents/young adults. Listeria is seen in immunocompromised or elderly.
Cryptococcus has lymphocytic predominance.
5. A patient with chronic obstructive pulmonary disease (COPD) presents with acute dyspnea,
wheezing, and a productive cough with purulent sputum. Chest X-ray shows no infiltrate. Which of
the following is the most appropriate initial antibiotic therapy?
A. Azithromycin 500 mg orally on day 1, then 250 mg daily for 4 days
B. Amoxicillin-clavulanate 875/125 mg twice daily for 5 days
C. Levofloxacin 750 mg daily for 5 days
D. Trimethoprim-sulfamethoxazole DS twice daily for 7 days
Answer: B
Rationale: For acute exacerbation of COPD with purulent sputum and no pneumonia,
amoxicillin-clavulanate is first-line per GOLD guidelines. Azithromycin is an alternative but less
effective for H. influenzae. Levofloxacin is reserved for severe or resistant cases. TMP-SMX is not
recommended due to resistance.
6. A patient with cirrhosis and ascites develops fever, abdominal pain, and altered mental status.
Paracentesis reveals ascitic fluid PMN count of 500 cells/µL. Which of the following is the most
appropriate initial empiric antibiotic regimen?
A. Ceftriaxone 2 g IV daily
B. Ciprofloxacin 400 mg IV twice daily
C. Piperacillin-tazobactam 4.5 g IV every 6 hours
D. Vancomycin plus gentamicin
Answer: A
Rationale: Spontaneous bacterial peritonitis (SBP) is diagnosed with PMN count >250 cells/µL.
Ceftriaxone is first-line empiric therapy as it covers common pathogens (E. coli, Klebsiella, S.
pneumoniae). Ciprofloxacin may be used if no recent quinolone exposure. Piperacillin-tazobactam is for
nosocomial peritonitis. Vancomycin is not needed without MRSA risk.
Page 2
,7. A patient with acute pancreatitis has a Ranson score of 4 at 48 hours. Which of the following
best predicts a severe course?
A. Age >55 years
B. Hematocrit drop >10 points
C. Serum calcium <8 mg/dL
D. LDH >350 IU/L
Answer: C
Rationale: Hypocalcemia (serum calcium <8 mg/dL) is a marker of severe pancreatitis and indicates
saponification of fat necrosis. Age >55, hematocrit drop, and elevated LDH are all components of
Ranson criteria but hypocalcemia specifically correlates with worse prognosis.
8. A patient with systemic lupus erythematosus (SLE) presents with acute onset of confusion,
seizures, and fever. CSF shows mild lymphocytic pleocytosis and elevated protein. Which of the
following is the most likely diagnosis?
A. CNS lupus (lupus cerebritis)
B. Infectious meningitis
C. Posterior reversible encephalopathy syndrome (PRES)
D. Cerebral venous sinus thrombosis
Answer: A
Rationale: In a patient with SLE, acute neuropsychiatric symptoms with CSF lymphocytic pleocytosis and
elevated protein suggest CNS lupus. Infectious meningitis must be ruled out but is less likely without
typical CSF findings. PRES is associated with hypertension and immunosuppressants. Cerebral venous
sinus thrombosis presents with headache and papilledema.
9. A patient with diabetic ketoacidosis (DKA) has a serum potassium of 3.2 mEq/L on admission.
Which of the following is the most appropriate management?
A. Start insulin infusion immediately and recheck potassium in 2 hours
B. Administer potassium 20-30 mEq/h IV before starting insulin infusion
C. Give sodium bicarbonate to correct acidosis first
D. Hold insulin until potassium is >4.0 mEq/L
Answer: B
Rationale: In DKA with hypokalemia on admission, potassium must be replaced before starting insulin to
avoid life-threatening hypokalemia as insulin drives potassium into cells. Insulin can be started after
potassium is >3.3 mEq/L. Bicarbonate is not recommended unless severe acidosis (pH <7.0). Holding
insulin delays treatment.
10. A patient with acute kidney injury (AKI) has a fractional excretion of sodium (FENa) of 0.5%
and urine osmolality of 500 mOsm/kg. Which of the following is the most likely cause?
A. Acute tubular necrosis (ATN)
B. Prerenal azotemia
C. Acute interstitial nephritis
D. Glomerulonephritis
Page 3
, Answer: B
Rationale: A low FENa (<1%) and high urine osmolality (>400 mOsm/kg) indicate intact tubular
function, consistent with prerenal azotemia (e.g., volume depletion). ATN typically has FENa >2% and
isothenuria. Interstitial nephritis and glomerulonephritis usually have higher FENa.
11. A 45-year-old patient with a history of hypertension and type 2 diabetes presents with acute
onset of severe, tearing chest pain radiating to the back. Blood pressure is 210/120 mm Hg in the
right arm and 180/100 mm Hg in the left arm. Which of the following is the most appropriate
initial diagnostic test?
A. Electrocardiogram (ECG) and cardiac troponin levels
B. Computed tomography angiography (CTA) of the chest
C. Transesophageal echocardiogram (TEE)
D. Chest X-ray and D-dimer
Answer: B
Rationale: Given the clinical presentation of severe tearing chest pain with a significant blood pressure
differential between arms, aortic dissection is highly suspected. CTA of the chest is the imaging modality
of choice for diagnosis due to its high sensitivity and specificity for detecting dissection. While ECG and
troponin are important to rule out myocardial infarction, they are not diagnostic for dissection. TEE is
an alternative but is less readily available and more invasive. Chest X-ray and D-dimer lack sufficient
specificity.
12. In the management of a patient with acute ischemic stroke within 4.5 hours of symptom onset,
which of the following factors is an absolute contraindication to intravenous thrombolysis with
alteplase?
A. History of intracranial hemorrhage
B. Blood glucose level of 180 mg/dL
C. Systolic blood pressure of 175 mm Hg
D. Seizure at onset with postictal neurological deficits
Answer: A
Rationale: A prior history of intracranial hemorrhage is an absolute contraindication to IV thrombolysis
due to the high risk of recurrent bleeding. Blood glucose >400 mg/dL is a relative contraindication, but
180 mg/dL is acceptable. Systolic BP >185 mm Hg requires lowering before treatment, but 175 mm Hg
is not an absolute contraindication. Seizure at onset is a relative contraindication if deficits are due to
postictal state, but if the clinician is confident the deficits are from stroke, thrombolysis may still be
considered.
13. A patient with chronic heart failure with reduced ejection fraction (HFrEF) is on optimal
medical therapy including an ACE inhibitor, beta-blocker, and spironolactone. Despite this, the
patient remains symptomatic with NYHA class III symptoms. Which of the following medication
adjustments is most likely to improve outcomes?
A. Add hydralazine and isosorbide dinitrate
B. Switch from ACE inhibitor to angiotensin receptor blocker
C. Increase beta-blocker to maximum tolerated dose
Page 4
