NR 667 CHAMBERLAIN CEA FINAL EXAM
(LATEST UPDATE WITH CORRECTLY
ANSWERED QUESTIONS 100% GUARANTEED
PASS..
1. A 45-year-old patient with a history of well-controlled hypertension and type 2 diabetes presents
with a two-week history of progressive dyspnea on exertion, orthopnea, and paroxysmal nocturnal
dyspnea. Vital signs: BP 148/92, HR 98, RR 22, SpO2 94% on room air. Lung exam reveals
bilateral crackles up to the mid-scapulae. Jugular venous pressure is elevated at 10 cm H2O. An
echocardiogram shows left ventricular ejection fraction of 40% with global hypokinesis. Which of
the following pharmacologic interventions has been shown to reduce mortality in this patient
population and should be initiated as first-line therapy?
A. Initiate metoprolol tartrate 25 mg twice daily and titrate as tolerated
B. Initiate lisinopril 5 mg daily and titrate to target dose
C. Initiate furosemide 40 mg daily for symptom relief
D. Initiate digoxin 0.125 mg daily for rate control
Answer: B
Rationale: In patients with heart failure with reduced ejection fraction (HFrEF), angiotensin-converting
enzyme inhibitors (ACEi) like lisinopril are first-line therapy proven to reduce mortality and morbidity.
Beta-blockers (e.g., metoprolol succinate, not tartrate) are also recommended but should be initiated
after the patient is euvolemic and stable. Furosemide provides symptom relief but does not reduce
mortality. Digoxin is third-line for symptom control and does not improve survival.
2. A 30-year-old patient with no significant medical history presents with acute onset of severe,
sharp right lower quadrant abdominal pain that began 12 hours ago, associated with nausea and
anorexia. Temperature is 38.5°C, HR 100, BP 120/80. Abdominal exam reveals guarding and
rebound tenderness at McBurney's point. White blood cell count is 15,000/µL with left shift. A CT
scan of the abdomen shows a distended appendix with surrounding fat stranding and a 1.5 cm
appendicolith. Which of the following is the most appropriate next step in management?
A. Administer intravenous antibiotics and schedule appendectomy within 24 hours
B. Initiate bowel rest and intravenous fluids, and observe for 48 hours
C. Perform immediate laparoscopic appendectomy without antibiotics
D. Obtain a surgical consultation for urgent appendectomy and start broad-spectrum antibiotics
Answer: D
Rationale: For acute appendicitis with evidence of obstruction (appendicolith) and signs of peritoneal
irritation, urgent surgical consultation is indicated. Broad-spectrum antibiotics should be started
preoperatively to reduce infectious complications. Delaying surgery beyond 24 hours increases the risk
of perforation. Observation is inappropriate. Antibiotics alone are insufficient for an obstructing
appendicolith. Immediate surgery without antibiotics increases infection risk.
Page 1
,3. A 55-year-old patient with a history of chronic obstructive pulmonary disease (COPD) presents
with a three-day history of increasing dyspnea, cough with purulent sputum, and fever. Vital signs:
BP 130/80, HR 100, RR 24, SpO2 88% on room air. Arterial blood gas on room air shows pH 7.32,
PaCO2 55 mmHg, PaO2 55 mmHg, HCO3- 28 mEq/L. Chest X-ray shows no infiltrate. Which of
the following is the most appropriate initial management?
A. Initiate noninvasive positive pressure ventilation (NIPPV) and administer bronchodilators and corticosteroids
B. Intubate and initiate mechanical ventilation immediately
C. Administer high-flow oxygen via non-rebreather mask and obtain sputum culture
D. Start intravenous antibiotics and monitor oxygen saturation
Answer: A
Rationale: This patient presents with acute hypercapnic respiratory failure due to COPD exacerbation.
NIPPV is the first-line intervention for patients with acute-on-chronic hypercapnia without
contraindications, as it reduces intubation rates and mortality. Bronchodilators and corticosteroids are
essential to treat the exacerbation. Intubation is reserved for failure of NIPPV or severe acidosis (pH
<7.25). High-flow oxygen can worsen hypercapnia by blunting hypoxic drive. Antibiotics are indicated
but not the immediate priority.
4. A 65-year-old patient with a history of atrial fibrillation on warfarin therapy presents with a
two-hour history of acute onset of left-sided weakness, facial droop, and slurred speech. Last
known well was 1 hour ago. Vital signs: BP 180/100, HR 80 irregularly irregular, INR 2.5. CT head
shows no hemorrhage. Which of the following is the most appropriate management?
A. Administer intravenous alteplase within 3 hours of symptom onset
B. Administer intravenous alteplase after reversing warfarin with vitamin K and fresh frozen plasma
C. Do not administer alteplase; consider mechanical thrombectomy if large vessel occlusion is present
D. Start aspirin 325 mg and monitor for 24 hours
Answer: C
Rationale: Patients on warfarin with INR >1.7 are contraindicated for intravenous alteplase due to
increased bleeding risk. This patient's INR is 2.5, so alteplase is not an option. However, if a large vessel
occlusion is suspected, mechanical thrombectomy may be performed within 6-24 hours of onset based on
perfusion imaging. Aspirin is not indicated in the acute setting when thrombectomy is possible.
Reversing warfarin for alteplase is not recommended due to time constraints and risk.
5. A 40-year-old patient with a history of recurrent urinary tract infections presents with acute
onset of left flank pain, fever, and chills. Urinalysis shows pyuria and bacteriuria. CT abdomen
reveals a 7 mm obstructing stone at the left ureterovesical junction with mild hydronephrosis.
Serum creatinine is 1.2 mg/dL. Which of the following is the most appropriate initial step in
management?
A. Start intravenous antibiotics and schedule urgent ureteroscopy with stone extraction
B. Start intravenous antibiotics and place a percutaneous nephrostomy tube
C. Start intravenous antibiotics and place a ureteral stent
D. Start intravenous antibiotics and observe for spontaneous stone passage
Answer: C
Rationale: This patient has an obstructing ureteral stone with signs of infection (fever, pyuria), which
constitutes a urologic emergency. Urgent decompression of the obstructed kidney is required to prevent
Page 2
,urosepsis. Ureteral stent placement is the preferred method for decompression when the stone is in the
distal ureter. Percutaneous nephrostomy is an alternative if stent placement fails. Urgent stone
extraction is not indicated as the first step; decompression and antibiotics are priorities. Observation is
inappropriate in the setting of infection.
6. A 28-year-old patient presents with a three-week history of fatigue, weight gain, cold intolerance,
and constipation. Vital signs: BP 110/70, HR 55, RR 14, afebrile. Physical exam reveals dry skin,
nonpitting edema in the lower extremities, and a diffusely enlarged thyroid gland. Laboratory
studies show TSH 25 mIU/L (normal 0.5-4.5), free T4 0.6 ng/dL (normal 0.8-1.8), and positive
thyroid peroxidase antibodies. Which of the following is the most appropriate initial
pharmacotherapy?
A. Levothyroxine 25 mcg daily, with dose titration based on TSH every 6-8 weeks
B. Levothyroxine 100 mcg daily, with dose adjustment based on clinical response
C. Methimazole 10 mg three times daily
D. Liothyronine 25 mcg twice daily
Answer: A
Rationale: This patient has primary hypothyroidism due to Hashimoto's thyroiditis. Levothyroxine is the
standard replacement therapy. A starting dose of 25-50 mcg daily is appropriate for young, healthy
patients without cardiac disease. Higher starting doses (e.g., 100 mcg) may cause tachyarrhythmias,
especially in older patients. Methimazole is used for hyperthyroidism, not hypothyroidism. Liothyronine
(T3) is not first-line due to short half-life and potential for cardiac side effects; levothyroxine is
preferred.
7. A 50-year-old patient with a history of cirrhosis secondary to nonalcoholic fatty liver disease
presents with acute onset of hematemesis and melena. Vital signs: BP 85/50, HR 120, RR 22, SpO2
95% on room air. Abdominal exam reveals mild ascites. Laboratory studies show hemoglobin 7.0
g/dL, platelets 80,000/µL, INR 1.8. Which of the following is the most appropriate initial
intervention?
A. Perform emergency upper endoscopy with variceal band ligation
B. Administer intravenous octreotide and start a proton pump inhibitor infusion
C. Administer intravenous ceftriaxone and initiate vasopressor support
D. Transfuse packed red blood cells to maintain hemoglobin >9 g/dL
Answer: A
Rationale: In a patient with cirrhosis and suspected variceal hemorrhage, the initial management
includes hemodynamic resuscitation and urgent upper endoscopy (within 12 hours) for variceal band
ligation, which is the definitive therapy. Octreotide and antibiotics (ceftriaxone) are adjunctive but not
the first priority. Vasopressors may be needed for hypotension but do not replace endoscopy.
Transfusion should target hemoglobin of 7-8 g/dL; a higher threshold may increase portal pressure.
Page 3
, 8. A 35-year-old patient with a history of systemic lupus erythematosus (SLE) presents with acute
onset of pleuritic chest pain, dyspnea, and fever. Vital signs: BP 120/80, HR 110, RR 24, SpO2 96%
on room air. ECG shows diffuse ST-segment elevation in all leads except aVR, with PR depression.
Chest X-ray shows an enlarged cardiac silhouette. Which of the following is the most likely
diagnosis?
A. Acute pericarditis
B. Acute myocardial infarction
C. Pulmonary embolism
D. Pneumothorax
Answer: A
Rationale: The combination of pleuritic chest pain, fever, diffuse ST-segment elevation with PR
depression, and enlarged cardiac silhouette (suggesting pericardial effusion) is classic for acute
pericarditis, especially in a patient with SLE, a known cause. Myocardial infarction typically shows
localized ST elevation in a coronary distribution. Pulmonary embolism may cause sinus tachycardia but
not diffuse ST elevation. Pneumothorax would show hyperresonance and absent breath sounds, not ST
changes.
9. A 60-year-old patient with a history of type 2 diabetes mellitus and hypertension presents with a
two-week history of progressive swelling in the lower extremities and foamy urine. Vital signs: BP
160/95, HR 80, RR 16. Laboratory studies show serum creatinine 1.4 mg/dL, albumin 2.8 g/dL, and
urine protein-to-creatinine ratio 4.5 g/g. Renal ultrasound shows normal-sized kidneys. Which of
the following is the most likely underlying pathology?
A. Diabetic nephropathy with nodular glomerulosclerosis
B. Minimal change disease
C. Focal segmental glomerulosclerosis
D. Membranous nephropathy
Answer: A
Rationale: This patient with long-standing diabetes and hypertension presents with nephrotic-range
proteinuria, hypoalbuminemia, and renal impairment. The most common cause is diabetic nephropathy,
characterized by nodular glomerulosclerosis (Kimmelstiel-Wilson nodules) on biopsy. Minimal change
disease typically presents with acute nephrotic syndrome without renal impairment or hypertension.
Focal segmental glomerulosclerosis can occur but is less common in diabetes. Membranous nephropathy
is an autoimmune cause not typically associated with diabetes.
10. A 25-year-old patient presents with a two-day history of watery diarrhea, abdominal cramps,
and vomiting. He recently returned from a camping trip where he drank untreated lake water.
Vital signs: BP 100/70, HR 110, RR 18, temperature 38.2°C. Stool culture grows motile, curved
gram-negative rods. Which of the following is the most appropriate antibiotic therapy?
A. Azithromycin 500 mg orally once daily for three days
B. Ciprofloxacin 500 mg orally twice daily for five days
C. Metronidazole 500 mg orally three times daily for seven days
D. No antibiotic therapy; supportive care with oral rehydration
Answer: A
Page 4
(LATEST UPDATE WITH CORRECTLY
ANSWERED QUESTIONS 100% GUARANTEED
PASS..
1. A 45-year-old patient with a history of well-controlled hypertension and type 2 diabetes presents
with a two-week history of progressive dyspnea on exertion, orthopnea, and paroxysmal nocturnal
dyspnea. Vital signs: BP 148/92, HR 98, RR 22, SpO2 94% on room air. Lung exam reveals
bilateral crackles up to the mid-scapulae. Jugular venous pressure is elevated at 10 cm H2O. An
echocardiogram shows left ventricular ejection fraction of 40% with global hypokinesis. Which of
the following pharmacologic interventions has been shown to reduce mortality in this patient
population and should be initiated as first-line therapy?
A. Initiate metoprolol tartrate 25 mg twice daily and titrate as tolerated
B. Initiate lisinopril 5 mg daily and titrate to target dose
C. Initiate furosemide 40 mg daily for symptom relief
D. Initiate digoxin 0.125 mg daily for rate control
Answer: B
Rationale: In patients with heart failure with reduced ejection fraction (HFrEF), angiotensin-converting
enzyme inhibitors (ACEi) like lisinopril are first-line therapy proven to reduce mortality and morbidity.
Beta-blockers (e.g., metoprolol succinate, not tartrate) are also recommended but should be initiated
after the patient is euvolemic and stable. Furosemide provides symptom relief but does not reduce
mortality. Digoxin is third-line for symptom control and does not improve survival.
2. A 30-year-old patient with no significant medical history presents with acute onset of severe,
sharp right lower quadrant abdominal pain that began 12 hours ago, associated with nausea and
anorexia. Temperature is 38.5°C, HR 100, BP 120/80. Abdominal exam reveals guarding and
rebound tenderness at McBurney's point. White blood cell count is 15,000/µL with left shift. A CT
scan of the abdomen shows a distended appendix with surrounding fat stranding and a 1.5 cm
appendicolith. Which of the following is the most appropriate next step in management?
A. Administer intravenous antibiotics and schedule appendectomy within 24 hours
B. Initiate bowel rest and intravenous fluids, and observe for 48 hours
C. Perform immediate laparoscopic appendectomy without antibiotics
D. Obtain a surgical consultation for urgent appendectomy and start broad-spectrum antibiotics
Answer: D
Rationale: For acute appendicitis with evidence of obstruction (appendicolith) and signs of peritoneal
irritation, urgent surgical consultation is indicated. Broad-spectrum antibiotics should be started
preoperatively to reduce infectious complications. Delaying surgery beyond 24 hours increases the risk
of perforation. Observation is inappropriate. Antibiotics alone are insufficient for an obstructing
appendicolith. Immediate surgery without antibiotics increases infection risk.
Page 1
,3. A 55-year-old patient with a history of chronic obstructive pulmonary disease (COPD) presents
with a three-day history of increasing dyspnea, cough with purulent sputum, and fever. Vital signs:
BP 130/80, HR 100, RR 24, SpO2 88% on room air. Arterial blood gas on room air shows pH 7.32,
PaCO2 55 mmHg, PaO2 55 mmHg, HCO3- 28 mEq/L. Chest X-ray shows no infiltrate. Which of
the following is the most appropriate initial management?
A. Initiate noninvasive positive pressure ventilation (NIPPV) and administer bronchodilators and corticosteroids
B. Intubate and initiate mechanical ventilation immediately
C. Administer high-flow oxygen via non-rebreather mask and obtain sputum culture
D. Start intravenous antibiotics and monitor oxygen saturation
Answer: A
Rationale: This patient presents with acute hypercapnic respiratory failure due to COPD exacerbation.
NIPPV is the first-line intervention for patients with acute-on-chronic hypercapnia without
contraindications, as it reduces intubation rates and mortality. Bronchodilators and corticosteroids are
essential to treat the exacerbation. Intubation is reserved for failure of NIPPV or severe acidosis (pH
<7.25). High-flow oxygen can worsen hypercapnia by blunting hypoxic drive. Antibiotics are indicated
but not the immediate priority.
4. A 65-year-old patient with a history of atrial fibrillation on warfarin therapy presents with a
two-hour history of acute onset of left-sided weakness, facial droop, and slurred speech. Last
known well was 1 hour ago. Vital signs: BP 180/100, HR 80 irregularly irregular, INR 2.5. CT head
shows no hemorrhage. Which of the following is the most appropriate management?
A. Administer intravenous alteplase within 3 hours of symptom onset
B. Administer intravenous alteplase after reversing warfarin with vitamin K and fresh frozen plasma
C. Do not administer alteplase; consider mechanical thrombectomy if large vessel occlusion is present
D. Start aspirin 325 mg and monitor for 24 hours
Answer: C
Rationale: Patients on warfarin with INR >1.7 are contraindicated for intravenous alteplase due to
increased bleeding risk. This patient's INR is 2.5, so alteplase is not an option. However, if a large vessel
occlusion is suspected, mechanical thrombectomy may be performed within 6-24 hours of onset based on
perfusion imaging. Aspirin is not indicated in the acute setting when thrombectomy is possible.
Reversing warfarin for alteplase is not recommended due to time constraints and risk.
5. A 40-year-old patient with a history of recurrent urinary tract infections presents with acute
onset of left flank pain, fever, and chills. Urinalysis shows pyuria and bacteriuria. CT abdomen
reveals a 7 mm obstructing stone at the left ureterovesical junction with mild hydronephrosis.
Serum creatinine is 1.2 mg/dL. Which of the following is the most appropriate initial step in
management?
A. Start intravenous antibiotics and schedule urgent ureteroscopy with stone extraction
B. Start intravenous antibiotics and place a percutaneous nephrostomy tube
C. Start intravenous antibiotics and place a ureteral stent
D. Start intravenous antibiotics and observe for spontaneous stone passage
Answer: C
Rationale: This patient has an obstructing ureteral stone with signs of infection (fever, pyuria), which
constitutes a urologic emergency. Urgent decompression of the obstructed kidney is required to prevent
Page 2
,urosepsis. Ureteral stent placement is the preferred method for decompression when the stone is in the
distal ureter. Percutaneous nephrostomy is an alternative if stent placement fails. Urgent stone
extraction is not indicated as the first step; decompression and antibiotics are priorities. Observation is
inappropriate in the setting of infection.
6. A 28-year-old patient presents with a three-week history of fatigue, weight gain, cold intolerance,
and constipation. Vital signs: BP 110/70, HR 55, RR 14, afebrile. Physical exam reveals dry skin,
nonpitting edema in the lower extremities, and a diffusely enlarged thyroid gland. Laboratory
studies show TSH 25 mIU/L (normal 0.5-4.5), free T4 0.6 ng/dL (normal 0.8-1.8), and positive
thyroid peroxidase antibodies. Which of the following is the most appropriate initial
pharmacotherapy?
A. Levothyroxine 25 mcg daily, with dose titration based on TSH every 6-8 weeks
B. Levothyroxine 100 mcg daily, with dose adjustment based on clinical response
C. Methimazole 10 mg three times daily
D. Liothyronine 25 mcg twice daily
Answer: A
Rationale: This patient has primary hypothyroidism due to Hashimoto's thyroiditis. Levothyroxine is the
standard replacement therapy. A starting dose of 25-50 mcg daily is appropriate for young, healthy
patients without cardiac disease. Higher starting doses (e.g., 100 mcg) may cause tachyarrhythmias,
especially in older patients. Methimazole is used for hyperthyroidism, not hypothyroidism. Liothyronine
(T3) is not first-line due to short half-life and potential for cardiac side effects; levothyroxine is
preferred.
7. A 50-year-old patient with a history of cirrhosis secondary to nonalcoholic fatty liver disease
presents with acute onset of hematemesis and melena. Vital signs: BP 85/50, HR 120, RR 22, SpO2
95% on room air. Abdominal exam reveals mild ascites. Laboratory studies show hemoglobin 7.0
g/dL, platelets 80,000/µL, INR 1.8. Which of the following is the most appropriate initial
intervention?
A. Perform emergency upper endoscopy with variceal band ligation
B. Administer intravenous octreotide and start a proton pump inhibitor infusion
C. Administer intravenous ceftriaxone and initiate vasopressor support
D. Transfuse packed red blood cells to maintain hemoglobin >9 g/dL
Answer: A
Rationale: In a patient with cirrhosis and suspected variceal hemorrhage, the initial management
includes hemodynamic resuscitation and urgent upper endoscopy (within 12 hours) for variceal band
ligation, which is the definitive therapy. Octreotide and antibiotics (ceftriaxone) are adjunctive but not
the first priority. Vasopressors may be needed for hypotension but do not replace endoscopy.
Transfusion should target hemoglobin of 7-8 g/dL; a higher threshold may increase portal pressure.
Page 3
, 8. A 35-year-old patient with a history of systemic lupus erythematosus (SLE) presents with acute
onset of pleuritic chest pain, dyspnea, and fever. Vital signs: BP 120/80, HR 110, RR 24, SpO2 96%
on room air. ECG shows diffuse ST-segment elevation in all leads except aVR, with PR depression.
Chest X-ray shows an enlarged cardiac silhouette. Which of the following is the most likely
diagnosis?
A. Acute pericarditis
B. Acute myocardial infarction
C. Pulmonary embolism
D. Pneumothorax
Answer: A
Rationale: The combination of pleuritic chest pain, fever, diffuse ST-segment elevation with PR
depression, and enlarged cardiac silhouette (suggesting pericardial effusion) is classic for acute
pericarditis, especially in a patient with SLE, a known cause. Myocardial infarction typically shows
localized ST elevation in a coronary distribution. Pulmonary embolism may cause sinus tachycardia but
not diffuse ST elevation. Pneumothorax would show hyperresonance and absent breath sounds, not ST
changes.
9. A 60-year-old patient with a history of type 2 diabetes mellitus and hypertension presents with a
two-week history of progressive swelling in the lower extremities and foamy urine. Vital signs: BP
160/95, HR 80, RR 16. Laboratory studies show serum creatinine 1.4 mg/dL, albumin 2.8 g/dL, and
urine protein-to-creatinine ratio 4.5 g/g. Renal ultrasound shows normal-sized kidneys. Which of
the following is the most likely underlying pathology?
A. Diabetic nephropathy with nodular glomerulosclerosis
B. Minimal change disease
C. Focal segmental glomerulosclerosis
D. Membranous nephropathy
Answer: A
Rationale: This patient with long-standing diabetes and hypertension presents with nephrotic-range
proteinuria, hypoalbuminemia, and renal impairment. The most common cause is diabetic nephropathy,
characterized by nodular glomerulosclerosis (Kimmelstiel-Wilson nodules) on biopsy. Minimal change
disease typically presents with acute nephrotic syndrome without renal impairment or hypertension.
Focal segmental glomerulosclerosis can occur but is less common in diabetes. Membranous nephropathy
is an autoimmune cause not typically associated with diabetes.
10. A 25-year-old patient presents with a two-day history of watery diarrhea, abdominal cramps,
and vomiting. He recently returned from a camping trip where he drank untreated lake water.
Vital signs: BP 100/70, HR 110, RR 18, temperature 38.2°C. Stool culture grows motile, curved
gram-negative rods. Which of the following is the most appropriate antibiotic therapy?
A. Azithromycin 500 mg orally once daily for three days
B. Ciprofloxacin 500 mg orally twice daily for five days
C. Metronidazole 500 mg orally three times daily for seven days
D. No antibiotic therapy; supportive care with oral rehydration
Answer: A
Page 4
