NURS6540 Final Exam | NURS 6540 / NRNP 6540 Advanced Practice Care of Frail
Elders | Actual Q&A with Rationale | Walden University
1. An 84-year-old woman with multimorbidity (HFpEF, CKD stage 3b, type 2 diabetes,
osteoarthritis, and depression) is admitted from home after a fall. She was found on the
floor for 12 hours. Admission labs: Cr 2.8 (baseline 1.5), K+ 5.9, troponin 0.12 ng/mL, Hb
10.2 g/dL. She is on lisinopril 20 mg, furosemide 40 mg BID, metformin 1000 mg BID,
sertraline 100 mg, and ibuprofen 600 mg TID PRN. On exam, she is confused, with right
hip tenderness and ecchymosis. BP 80/50, HR 105, RR 22. Which is the highest priority
action?
A. Obtain a stat ECG and hold lisinopril, furosemide, and metformin
B. Order a CT head and hold ibuprofen only
C. Start IV normal saline bolus and obtain a stat hip X-ray
D. Administer insulin and dextrose for hyperkalemia
Correct Answer: A
Rationale: This patient presents with AKI, hyperkalemia, hypotension, and possible
rhabdomyolysis (prolonged immobility) with acute coronary syndrome. The ECG is
needed to rule out life-threatening hyperkalemia. Holding the ACEi (hyperkalemia),
diuretic (hypotension), and metformin (AKI) addresses acute risks. While fluid
resuscitation is needed, the immediate priority is cardiac assessment and stopping
offending medications. Option C is important but secondary to assessing for
hyperkalemic arrhythmia.
2. A 79-year-old man with advanced Alzheimer’s disease, hypertension, and BPH is
brought to the clinic by his daughter, who is the primary caregiver. She reports he has
become more agitated over the past week, hitting her during care. He is on donepezil 10
mg, lisinopril 10 mg, and tamsulosin 0.4 mg. The daughter is tearful and says she "can't
do this anymore." Which is the most appropriate initial intervention?
A. Increase donepezil to 15 mg to improve cognition
B. Start quetiapine 25 mg at bedtime for agitation
C. Assess for underlying causes of agitation (pain, infection, constipation)
D. Recommend placement in a memory care facility
Correct Answer: C
Rationale: Agitation in dementia often has a reversible cause (delirium, pain, UTI,
constipation). Pharmacologic intervention should not be first-line. Addressing caregiver
distress is important, but the priority is to assess for modifiable triggers. Referral to
social work and respite care is also needed, but the clinical assessment comes first.
,3. An 88-year-old woman with severe COPD, osteoporosis, and recurrent falls is
admitted after a mechanical fall. She is on tiotropium, alendronate, and cholecalciferol.
She is independent with a walker. Which intervention is most likely to prevent future
falls?
A. Replace alendronate with denosumab
B. Add a home safety evaluation and physical therapy
C. Switch from tiotropium to a LABA/LAMA combination
D. Prescribe a calcium supplement
Correct Answer: B
Rationale: Multifactorial fall prevention (home safety, PT for gait and balance) is most
effective. While bone health medications reduce fracture risk, they do not prevent falls.
Option C may improve COPD but not directly address falls.
4. A 92-year-old man with advanced dementia, dysphagia, and recurrent aspiration
pneumonia is admitted from a nursing home. He has a POLST form indicating "comfort
measures only" and "do not hospitalize." The family requests IV antibiotics and a feeding
tube. What is the best course of action?
A. Honor the POLST and provide comfort care
B. Initiate IV antibiotics and consult a speech therapist for feeding tube
C. Transfer to the ICU for closer monitoring
D. Ask the nursing home to accept the patient back with hospice
Correct Answer: A
Rationale: POLST is a legally binding medical order. The patient's documented wishes
for comfort care must be honored. The family's request does not override the POLST.
An ethics consultation may be helpful for family support, but the immediate action is to
adhere to the POLST.
5. A 76-year-old woman with HFrEF, CKD stage 4 (eGFR 22), and type 2 diabetes is on
furosemide 80 mg BID, lisinopril 20 mg, carvedilol 25 mg BID, and insulin glargine. She
presents with worsening dyspnea, JVD, and 3+ pitting edema. BP 90/60, HR 55. She is
euvolemic on exam? Actually, she is volume overloaded but hypotensive. Which
medication adjustment is most appropriate?
A. Increase furosemide to 100 mg BID
B. Hold carvedilol and increase lisinopril
C. Hold lisinopril and decrease furosemide to 40 mg BID
D. Add spironolactone 12.5 mg daily
Correct Answer: C
Rationale: Hypotension in the setting of volume overload suggests excessive
vasodilation from ACEi or beta-blocker effect. Holding lisinopril can improve blood
, pressure while continuing diuresis. Decreasing furosemide may worsen congestion, but
the hypotension is more immediately dangerous. Carvedilol may be contributing to
bradycardia and hypotension, but holding lisinopril is the first step. Adding
spironolactone is contraindicated with hyperkalemia risk.
6. An 80-year-old man with Parkinson’s disease, depression, and chronic constipation
is on carbidopa-levodopa 25/100 mg TID, sertraline 100 mg, and polyethylene glycol. He
reports worsening tremor and gait instability. Which medication is most likely
contributing to his motor symptoms?
A. Carbidopa-levodopa
B. Sertraline
C. Polyethylene glycol
D. None
Correct Answer: B
Rationale: SSRIs (sertraline) can worsen Parkinsonism in some patients, causing tremor
and gait instability. Carbidopa-levodopa should improve motor symptoms.
Polyethylene glycol does not affect motor function.
7. A 91-year-old woman with atrial fibrillation, hypertension, and osteoporosis is on
warfarin, amlodipine, and alendronate. She develops a hip fracture after a fall. Her INR is
4.8. She is scheduled for urgent surgery. Which reversal agent is most appropriate?
A. Vitamin K 10 mg IV
B. Fresh frozen plasma
C. Prothrombin complex concentrate (PCC)
D. Hold warfarin and wait 24 hours
Correct Answer: C
Rationale: For urgent surgery with INR > 4.0, PCC is preferred for rapid reversal with
minimal volume. Vitamin K IV takes 12-24 hours. FFP has volume overload risk. Waiting is
not appropriate for urgent surgery.
8. An 85-year-old man with advanced dementia, hypertension, and BPH is brought to
the ED by his wife, who reports he has been "seeing things" and is more confused. He is
on lisinopril, tamsulosin, and donepezil. Urinalysis shows pyuria and bacteriuria. What is
the most likely cause of his hallucinations?
A. Donepezil toxicity
B. Lisinopril-induced cough
C. Delirium due to urinary tract infection
Elders | Actual Q&A with Rationale | Walden University
1. An 84-year-old woman with multimorbidity (HFpEF, CKD stage 3b, type 2 diabetes,
osteoarthritis, and depression) is admitted from home after a fall. She was found on the
floor for 12 hours. Admission labs: Cr 2.8 (baseline 1.5), K+ 5.9, troponin 0.12 ng/mL, Hb
10.2 g/dL. She is on lisinopril 20 mg, furosemide 40 mg BID, metformin 1000 mg BID,
sertraline 100 mg, and ibuprofen 600 mg TID PRN. On exam, she is confused, with right
hip tenderness and ecchymosis. BP 80/50, HR 105, RR 22. Which is the highest priority
action?
A. Obtain a stat ECG and hold lisinopril, furosemide, and metformin
B. Order a CT head and hold ibuprofen only
C. Start IV normal saline bolus and obtain a stat hip X-ray
D. Administer insulin and dextrose for hyperkalemia
Correct Answer: A
Rationale: This patient presents with AKI, hyperkalemia, hypotension, and possible
rhabdomyolysis (prolonged immobility) with acute coronary syndrome. The ECG is
needed to rule out life-threatening hyperkalemia. Holding the ACEi (hyperkalemia),
diuretic (hypotension), and metformin (AKI) addresses acute risks. While fluid
resuscitation is needed, the immediate priority is cardiac assessment and stopping
offending medications. Option C is important but secondary to assessing for
hyperkalemic arrhythmia.
2. A 79-year-old man with advanced Alzheimer’s disease, hypertension, and BPH is
brought to the clinic by his daughter, who is the primary caregiver. She reports he has
become more agitated over the past week, hitting her during care. He is on donepezil 10
mg, lisinopril 10 mg, and tamsulosin 0.4 mg. The daughter is tearful and says she "can't
do this anymore." Which is the most appropriate initial intervention?
A. Increase donepezil to 15 mg to improve cognition
B. Start quetiapine 25 mg at bedtime for agitation
C. Assess for underlying causes of agitation (pain, infection, constipation)
D. Recommend placement in a memory care facility
Correct Answer: C
Rationale: Agitation in dementia often has a reversible cause (delirium, pain, UTI,
constipation). Pharmacologic intervention should not be first-line. Addressing caregiver
distress is important, but the priority is to assess for modifiable triggers. Referral to
social work and respite care is also needed, but the clinical assessment comes first.
,3. An 88-year-old woman with severe COPD, osteoporosis, and recurrent falls is
admitted after a mechanical fall. She is on tiotropium, alendronate, and cholecalciferol.
She is independent with a walker. Which intervention is most likely to prevent future
falls?
A. Replace alendronate with denosumab
B. Add a home safety evaluation and physical therapy
C. Switch from tiotropium to a LABA/LAMA combination
D. Prescribe a calcium supplement
Correct Answer: B
Rationale: Multifactorial fall prevention (home safety, PT for gait and balance) is most
effective. While bone health medications reduce fracture risk, they do not prevent falls.
Option C may improve COPD but not directly address falls.
4. A 92-year-old man with advanced dementia, dysphagia, and recurrent aspiration
pneumonia is admitted from a nursing home. He has a POLST form indicating "comfort
measures only" and "do not hospitalize." The family requests IV antibiotics and a feeding
tube. What is the best course of action?
A. Honor the POLST and provide comfort care
B. Initiate IV antibiotics and consult a speech therapist for feeding tube
C. Transfer to the ICU for closer monitoring
D. Ask the nursing home to accept the patient back with hospice
Correct Answer: A
Rationale: POLST is a legally binding medical order. The patient's documented wishes
for comfort care must be honored. The family's request does not override the POLST.
An ethics consultation may be helpful for family support, but the immediate action is to
adhere to the POLST.
5. A 76-year-old woman with HFrEF, CKD stage 4 (eGFR 22), and type 2 diabetes is on
furosemide 80 mg BID, lisinopril 20 mg, carvedilol 25 mg BID, and insulin glargine. She
presents with worsening dyspnea, JVD, and 3+ pitting edema. BP 90/60, HR 55. She is
euvolemic on exam? Actually, she is volume overloaded but hypotensive. Which
medication adjustment is most appropriate?
A. Increase furosemide to 100 mg BID
B. Hold carvedilol and increase lisinopril
C. Hold lisinopril and decrease furosemide to 40 mg BID
D. Add spironolactone 12.5 mg daily
Correct Answer: C
Rationale: Hypotension in the setting of volume overload suggests excessive
vasodilation from ACEi or beta-blocker effect. Holding lisinopril can improve blood
, pressure while continuing diuresis. Decreasing furosemide may worsen congestion, but
the hypotension is more immediately dangerous. Carvedilol may be contributing to
bradycardia and hypotension, but holding lisinopril is the first step. Adding
spironolactone is contraindicated with hyperkalemia risk.
6. An 80-year-old man with Parkinson’s disease, depression, and chronic constipation
is on carbidopa-levodopa 25/100 mg TID, sertraline 100 mg, and polyethylene glycol. He
reports worsening tremor and gait instability. Which medication is most likely
contributing to his motor symptoms?
A. Carbidopa-levodopa
B. Sertraline
C. Polyethylene glycol
D. None
Correct Answer: B
Rationale: SSRIs (sertraline) can worsen Parkinsonism in some patients, causing tremor
and gait instability. Carbidopa-levodopa should improve motor symptoms.
Polyethylene glycol does not affect motor function.
7. A 91-year-old woman with atrial fibrillation, hypertension, and osteoporosis is on
warfarin, amlodipine, and alendronate. She develops a hip fracture after a fall. Her INR is
4.8. She is scheduled for urgent surgery. Which reversal agent is most appropriate?
A. Vitamin K 10 mg IV
B. Fresh frozen plasma
C. Prothrombin complex concentrate (PCC)
D. Hold warfarin and wait 24 hours
Correct Answer: C
Rationale: For urgent surgery with INR > 4.0, PCC is preferred for rapid reversal with
minimal volume. Vitamin K IV takes 12-24 hours. FFP has volume overload risk. Waiting is
not appropriate for urgent surgery.
8. An 85-year-old man with advanced dementia, hypertension, and BPH is brought to
the ED by his wife, who reports he has been "seeing things" and is more confused. He is
on lisinopril, tamsulosin, and donepezil. Urinalysis shows pyuria and bacteriuria. What is
the most likely cause of his hallucinations?
A. Donepezil toxicity
B. Lisinopril-induced cough
C. Delirium due to urinary tract infection
