NR 601 Midterm Exam Guide, Questions with
Answers and Rationales
SECTION I: CARDIOVASCULAR DISORDERS (Questions 1–20)
1. A 68-year-old male with hypertension has blood pressure readings of 150/92
mmHg on three separate occasions. He has no diabetes or chronic kidney
disease. According to the ACC/AHA 2017 guidelines, what is his blood
pressure goal?
A. < 150/90 mmHg
B. < 140/90 mmHg
C. < 130/80 mmHg
D. < 120/80 mmHg
Rationale: The ACC/AHA 2017 guidelines recommend a blood pressure goal of <
130/80 mmHg for all adults with hypertension, regardless of age or comorbidities.
This lower target is based on evidence showing reduced cardiovascular events with
more aggressive blood pressure control.
2. An 82-year-old female with heart failure with preserved ejection fraction
(HFpEF) reports worsening dyspnea and 3+ pitting edema. Her jugular
venous pressure is elevated at 12 cm. Which medication is most likely to
improve symptoms and reduce hospitalizations in HFpEF?
A. Digoxin
B. Spironolactone
C. Metoprolol
D. Hydralazine
Rationale: The TOPCAT trial demonstrated that spironolactone reduces
hospitalizations in patients with HFpEF. Digoxin and beta-blockers are primarily
used for heart failure with reduced ejection fraction (HFrEF). Spironolactone is a
mineralocorticoid receptor antagonist that helps manage volume overload and
improves outcomes.
,3. A 75-year-old male on warfarin for atrial fibrillation has an INR of 1.2. He
admits to missing several doses. What is the most appropriate next step?
A. Increase warfarin dose by 50%
B. Give vitamin K 10 mg orally
C. Resume warfarin at the same dose and recheck INR in 1 week
D. Switch to apixaban immediately
Rationale: A subtherapeutic INR due to missed doses is managed by resuming the
usual warfarin dose and rechecking the INR in approximately one week. Vitamin
K is indicated for high INR with bleeding, not for subtherapeutic levels. Increasing
the dose abruptly could lead to over-anticoagulation.
4. A 79-year-old male has a new diagnosis of atrial fibrillation. His CHA₂DS₂-
VASc score is 4. Which anticoagulant is preferred?
A. Aspirin 81 mg daily
B. Warfarin
C. Apixaban
D. No anticoagulation
Rationale: For patients with atrial fibrillation and a CHA₂DS₂-VASc score ≥ 2 in
males (or ≥ 3 in females), oral anticoagulation is indicated. Direct oral
anticoagulants (DOACs) such as apixaban are preferred over warfarin due to fewer
drug interactions, no need for INR monitoring, and lower risk of intracranial
hemorrhage.
5. A 73-year-old male with hypertension has a blood pressure of 144/86 mmHg
on lisinopril 10 mg daily. He has no comorbidities. What is the next step in
management?
A. Continue current dose (at goal)
B. Increase lisinopril to 20 mg daily
C. Add hydrochlorothiazide 12.5 mg daily
D. Switch to amlodipine
Rationale: The ACC/AHA goal is < 130/80 mmHg. This patient is not at goal, so
the next step is to increase the ACE inhibitor dose before adding a second agent.
,ACE inhibitors should be titrated to maximum tolerated doses before combination
therapy is considered.
6. An 84-year-old female with HFpEF has dyspnea on exertion and fatigue.
Which medication is first-line for symptom management?
A. Diuretics (furosemide)
B. Spironolactone
C. Digoxin
D. Carvedilol
Rationale: Loop diuretics such as furosemide are first-line for managing volume
overload symptoms in HFpEF. Spironolactone reduces hospitalizations but is not
first-line for acute symptom management. Digoxin and beta-blockers are primarily
used in HFrEF.
7. A 78-year-old male on warfarin for a mechanical mitral valve has an INR of
4.6. He has no bleeding. What is the appropriate management?
A. Hold warfarin for 1 day and recheck
B. Administer vitamin K 2.5 mg orally
C. Hold warfarin and give vitamin K 1–2.5 mg orally
D. Administer fresh frozen plasma
Rationale: For an INR of 4.5–10 without bleeding, the appropriate management is
to hold warfarin and administer low-dose oral vitamin K (1–2.5 mg). Patients with
mechanical valves require cautious correction to avoid thrombotic complications.
Fresh frozen plasma is reserved for life-threatening bleeding.
8. A 76-year-old male has had stable angina for 3 months. He takes aspirin
and nitroglycerin as needed. What is the next step in management?
A. Add a beta-blocker (metoprolol)
B. Add a calcium channel blocker
C. Obtain a stress test for risk stratification
D. Proceed to cardiac catheterization immediately
, Rationale: After initiating antiplatelet therapy, stress testing helps determine the
need for revascularization in patients with stable angina. Beta-blockers and
calcium channel blockers are used for symptom management but do not replace the
need for risk stratification.
9. A 55-year-old Caucasian male was referred to a cardiologist and is now
following up. He thinks his medication is causing a cough and sometimes he
has difficulty breathing. Which medication was most likely prescribed?
A. Amlodipine
B. Lisinopril
C. Metoprolol
D. Hydrochlorothiazide
Rationale: Lisinopril, an ACE inhibitor, is notorious for causing a dry, hacking
cough due to bradykinin accumulation, affecting 5–20% of patients. This side
effect is dose-independent and resolves upon discontinuation. Amlodipine causes
peripheral edema, metoprolol can cause bradycardia, and HCTZ can cause
electrolyte imbalances.
10. Which of the following is a normal physiological change in the aging
heart?
A. Decreased myocardial mass
B. Increased valve elasticity
C. Heart valve thickening and rigidity secondary to fibrosis and sclerosis
D. Decreased left ventricular wall thickness
Rationale: Age-related cardiac changes include valvular fibrosis and calcification
(sclerosis), leading to decreased compliance and potential murmurs. Myocardial
mass typically increases with age due to left ventricular hypertrophy, and valve
elasticity decreases rather than increases.
11. A 74-year-old female with HFrEF has an ejection fraction of 35% on
optimal medical therapy. Which additional medication reduces mortality in
HFrEF regardless of diabetes status?
Answers and Rationales
SECTION I: CARDIOVASCULAR DISORDERS (Questions 1–20)
1. A 68-year-old male with hypertension has blood pressure readings of 150/92
mmHg on three separate occasions. He has no diabetes or chronic kidney
disease. According to the ACC/AHA 2017 guidelines, what is his blood
pressure goal?
A. < 150/90 mmHg
B. < 140/90 mmHg
C. < 130/80 mmHg
D. < 120/80 mmHg
Rationale: The ACC/AHA 2017 guidelines recommend a blood pressure goal of <
130/80 mmHg for all adults with hypertension, regardless of age or comorbidities.
This lower target is based on evidence showing reduced cardiovascular events with
more aggressive blood pressure control.
2. An 82-year-old female with heart failure with preserved ejection fraction
(HFpEF) reports worsening dyspnea and 3+ pitting edema. Her jugular
venous pressure is elevated at 12 cm. Which medication is most likely to
improve symptoms and reduce hospitalizations in HFpEF?
A. Digoxin
B. Spironolactone
C. Metoprolol
D. Hydralazine
Rationale: The TOPCAT trial demonstrated that spironolactone reduces
hospitalizations in patients with HFpEF. Digoxin and beta-blockers are primarily
used for heart failure with reduced ejection fraction (HFrEF). Spironolactone is a
mineralocorticoid receptor antagonist that helps manage volume overload and
improves outcomes.
,3. A 75-year-old male on warfarin for atrial fibrillation has an INR of 1.2. He
admits to missing several doses. What is the most appropriate next step?
A. Increase warfarin dose by 50%
B. Give vitamin K 10 mg orally
C. Resume warfarin at the same dose and recheck INR in 1 week
D. Switch to apixaban immediately
Rationale: A subtherapeutic INR due to missed doses is managed by resuming the
usual warfarin dose and rechecking the INR in approximately one week. Vitamin
K is indicated for high INR with bleeding, not for subtherapeutic levels. Increasing
the dose abruptly could lead to over-anticoagulation.
4. A 79-year-old male has a new diagnosis of atrial fibrillation. His CHA₂DS₂-
VASc score is 4. Which anticoagulant is preferred?
A. Aspirin 81 mg daily
B. Warfarin
C. Apixaban
D. No anticoagulation
Rationale: For patients with atrial fibrillation and a CHA₂DS₂-VASc score ≥ 2 in
males (or ≥ 3 in females), oral anticoagulation is indicated. Direct oral
anticoagulants (DOACs) such as apixaban are preferred over warfarin due to fewer
drug interactions, no need for INR monitoring, and lower risk of intracranial
hemorrhage.
5. A 73-year-old male with hypertension has a blood pressure of 144/86 mmHg
on lisinopril 10 mg daily. He has no comorbidities. What is the next step in
management?
A. Continue current dose (at goal)
B. Increase lisinopril to 20 mg daily
C. Add hydrochlorothiazide 12.5 mg daily
D. Switch to amlodipine
Rationale: The ACC/AHA goal is < 130/80 mmHg. This patient is not at goal, so
the next step is to increase the ACE inhibitor dose before adding a second agent.
,ACE inhibitors should be titrated to maximum tolerated doses before combination
therapy is considered.
6. An 84-year-old female with HFpEF has dyspnea on exertion and fatigue.
Which medication is first-line for symptom management?
A. Diuretics (furosemide)
B. Spironolactone
C. Digoxin
D. Carvedilol
Rationale: Loop diuretics such as furosemide are first-line for managing volume
overload symptoms in HFpEF. Spironolactone reduces hospitalizations but is not
first-line for acute symptom management. Digoxin and beta-blockers are primarily
used in HFrEF.
7. A 78-year-old male on warfarin for a mechanical mitral valve has an INR of
4.6. He has no bleeding. What is the appropriate management?
A. Hold warfarin for 1 day and recheck
B. Administer vitamin K 2.5 mg orally
C. Hold warfarin and give vitamin K 1–2.5 mg orally
D. Administer fresh frozen plasma
Rationale: For an INR of 4.5–10 without bleeding, the appropriate management is
to hold warfarin and administer low-dose oral vitamin K (1–2.5 mg). Patients with
mechanical valves require cautious correction to avoid thrombotic complications.
Fresh frozen plasma is reserved for life-threatening bleeding.
8. A 76-year-old male has had stable angina for 3 months. He takes aspirin
and nitroglycerin as needed. What is the next step in management?
A. Add a beta-blocker (metoprolol)
B. Add a calcium channel blocker
C. Obtain a stress test for risk stratification
D. Proceed to cardiac catheterization immediately
, Rationale: After initiating antiplatelet therapy, stress testing helps determine the
need for revascularization in patients with stable angina. Beta-blockers and
calcium channel blockers are used for symptom management but do not replace the
need for risk stratification.
9. A 55-year-old Caucasian male was referred to a cardiologist and is now
following up. He thinks his medication is causing a cough and sometimes he
has difficulty breathing. Which medication was most likely prescribed?
A. Amlodipine
B. Lisinopril
C. Metoprolol
D. Hydrochlorothiazide
Rationale: Lisinopril, an ACE inhibitor, is notorious for causing a dry, hacking
cough due to bradykinin accumulation, affecting 5–20% of patients. This side
effect is dose-independent and resolves upon discontinuation. Amlodipine causes
peripheral edema, metoprolol can cause bradycardia, and HCTZ can cause
electrolyte imbalances.
10. Which of the following is a normal physiological change in the aging
heart?
A. Decreased myocardial mass
B. Increased valve elasticity
C. Heart valve thickening and rigidity secondary to fibrosis and sclerosis
D. Decreased left ventricular wall thickness
Rationale: Age-related cardiac changes include valvular fibrosis and calcification
(sclerosis), leading to decreased compliance and potential murmurs. Myocardial
mass typically increases with age due to left ventricular hypertrophy, and valve
elasticity decreases rather than increases.
11. A 74-year-old female with HFrEF has an ejection fraction of 35% on
optimal medical therapy. Which additional medication reduces mortality in
HFrEF regardless of diabetes status?
