NURS 6531 Final Exam – Advanced Practice
Care of Adults | Comprehensive Practice
Examination (Week 11, Latest Version)
SECTION 1: CARDIOVASCULAR DISORDERS (Q1-Q15)
Q1: A 58-year-old African American male presents for initial evaluation of hypertension.
His blood pressure readings over three separate visits average 152/94 mmHg. He has no
diabetes, chronic kidney disease, or cardiovascular disease. According to JNC 8
guidelines, which of the following is the most appropriate initial pharmacologic therapy?
A. Lisinopril 10 mg daily
B. Amlodipine 5 mg daily
C. Chlorthalidone 12.5 mg daily [CORRECT]
D. Metoprolol succinate 50 mg daily
Correct Answer: C
Rationale: JNC 8 guidelines recommend thiazide-type diuretics (including
chlorthalidone) or calcium channel blockers as first-line therapy for African American
patients with hypertension, either alone or in combination. ACE inhibitors are less
effective as monotherapy in African American populations. Beta-blockers are not
recommended as first-line agents unless there is a compelling indication such as
coronary artery disease or heart failure.
Q2: A 62-year-old woman with hypertension, type 2 diabetes, and hyperlipidemia
presents for routine follow-up. Her current medications include lisinopril 20 mg daily,
metformin 1000 mg BID, and atorvastatin 40 mg daily. BP today is 138/86 mmHg.
Laboratory testing reveals serum creatinine 1.3 mg/dL (eGFR 52 mL/min/1.73m²) and
potassium 5.3 mEq/L. Which of the following is the most appropriate next step in
management?
A. Discontinue lisinopril and start amlodipine 5 mg daily [CORRECT]
B. Add hydrochlorothiazide 25 mg daily
,C. Increase lisinopril to 40 mg daily
D. Add spironolactone 25 mg daily
Correct Answer: A
Rationale: This patient has developed hyperkalemia and declining renal function while
on an ACE inhibitor. In the setting of CKD with potassium elevation, discontinuing the
ACE inhibitor and initiating a calcium channel blocker is appropriate. Adding a thiazide
diuretic would be ineffective with an eGFR below 30-50 mL/min. Increasing lisinopril or
adding spironolactone would worsen hyperkalemia.
Q3: A 55-year-old man presents with intermittent chest pain that occurs with exertion
and resolves with rest. He describes the pain as substernal pressure radiating to his left
arm. His father had a myocardial infarction at age 52. Vitals: BP 128/78, HR 72, BMI 31.
Fasting lipid panel: LDL 165 mg/dL, HDL 35 mg/dL, triglycerides 180 mg/dL. According
to ACC/AHA guidelines, which of the following is the most appropriate statin intensity
for this patient?
A. Low-intensity statin therapy
B. Moderate-intensity statin therapy
C. High-intensity statin therapy [CORRECT]
D. No statin therapy indicated
Correct Answer: C
Rationale: This patient presents with classic symptoms of stable angina, indicating
clinical atherosclerotic cardiovascular disease (ASCVD). ACC/AHA guidelines recommend
high-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg) for all
patients with clinical ASCVD. High-intensity statins reduce LDL by ≥50% and provide the
greatest cardiovascular event reduction.
Q4: A 72-year-old woman with heart failure with reduced ejection fraction (HFrEF, EF
30%) presents with increasing dyspnea on exertion, orthopnea, and bilateral lower
extremity edema. Current medications include lisinopril 10 mg BID, carvedilol 12.5 mg
BID, and furosemide 40 mg daily. Vitals: BP 108/68, HR 64, O2 sat 94% on room air.
,Examination reveals JVD, crackles at lung bases, and 2+ pitting edema. Which of the
following medications should be added to improve mortality?
A. Digoxin 0.125 mg daily
B. Spironolactone 25 mg daily [CORRECT]
C. Amlodipine 5 mg daily
D. Isosorbide dinitrate 20 mg TID
Correct Answer: B
Rationale: Mineralocorticoid receptor antagonists (spironolactone or eplerenone) are
indicated in patients with HFrEF (EF ≤35%) and NYHA class II-IV symptoms despite
optimal medical therapy with ACE inhibitors/ARBs and beta-blockers. The RALES trial
demonstrated mortality reduction with spironolactone. Digoxin provides symptom relief
but no mortality benefit. Calcium channel blockers (except amlodipine for specific
indications) are generally avoided in HFrEF. Hydralazine/isosorbide is indicated in select
populations.
Q5: A 67-year-old man with a history of atrial fibrillation (CHADS2-VASc score = 4)
presents for anticoagulation management. He has been taking warfarin 5 mg daily with
variable INR readings. He asks about switching to a direct oral anticoagulant (DOAC).
Which of the following is a contraindication to DOAC therapy?
A. Age greater than 65 years
B. Creatinine clearance of 25 mL/min [CORRECT]
C. Concurrent use of metoprolol
D. History of hypertension
Correct Answer: B
Rationale: DOACs (apixaban, rivaroxaban, edoxaban, dabigatran) are contraindicated or
require dose adjustment in severe renal impairment. Creatinine clearance below 30
mL/min generally contraindicates dabigatran, while apixaban may be used with caution
down to 15 mL/min in some cases. At CrCl of 25 mL/min, most DOACs are
contraindicated, and warfarin or apixaban with dose adjustment would be preferred.
Age, concurrent beta-blocker use, and hypertension are not contraindications.
, Q6: A 60-year-old man presents with leg pain that occurs when walking two blocks and
is relieved by rest. He notes the pain is in his right calf and has been progressive over six
months. He has a 40-pack-year smoking history, hypertension, and hyperlipidemia.
Examination reveals diminished right dorsalis pedis and posterior tibial pulses, with cool,
hairless skin on the right lower extremity. Ankle-brachial index is 0.72. Which of the
following is the most appropriate initial management?
A. Refer for surgical revascularization
B. Start clopidogrel 75 mg daily [CORRECT]
C. Start warfarin therapy
D. Start amlodipine 5 mg daily
Correct Answer: B
Rationale: This patient presents with symptomatic peripheral arterial disease (PAD) with
claudication. Antiplatelet therapy with aspirin or clopidogrel is recommended to reduce
cardiovascular events in patients with symptomatic PAD. Surgical revascularization is
reserved for limb-threatening ischemia or disabling claudication unresponsive to
medical therapy. Anticoagulation is not indicated for PAD unless there is another
indication. Amlodipine does not treat the underlying pathology.
Q7: A 45-year-old woman presents with acute onset of unilateral leg swelling, pain, and
warmth following a transatlantic flight. She has no prior medical history. Examination
reveals left calf circumference 4 cm greater than right, with tenderness along the deep
venous system. Wells score is 3. Which of the following is the most appropriate next
step?
A. Obtain D-dimer testing [CORRECT]
B. Order venous duplex ultrasound
C. Start empiric anticoagulation
D. Apply compression stockings and observe
Correct Answer: A
Rationale: For patients with a moderate Wells score (2-6), D-dimer testing is the
recommended initial diagnostic step. A negative highly sensitive D-dimer effectively
rules out DVT, while a positive D-dimer requires confirmatory ultrasound. Starting
anticoagulation without diagnostic confirmation is inappropriate. Compression
Care of Adults | Comprehensive Practice
Examination (Week 11, Latest Version)
SECTION 1: CARDIOVASCULAR DISORDERS (Q1-Q15)
Q1: A 58-year-old African American male presents for initial evaluation of hypertension.
His blood pressure readings over three separate visits average 152/94 mmHg. He has no
diabetes, chronic kidney disease, or cardiovascular disease. According to JNC 8
guidelines, which of the following is the most appropriate initial pharmacologic therapy?
A. Lisinopril 10 mg daily
B. Amlodipine 5 mg daily
C. Chlorthalidone 12.5 mg daily [CORRECT]
D. Metoprolol succinate 50 mg daily
Correct Answer: C
Rationale: JNC 8 guidelines recommend thiazide-type diuretics (including
chlorthalidone) or calcium channel blockers as first-line therapy for African American
patients with hypertension, either alone or in combination. ACE inhibitors are less
effective as monotherapy in African American populations. Beta-blockers are not
recommended as first-line agents unless there is a compelling indication such as
coronary artery disease or heart failure.
Q2: A 62-year-old woman with hypertension, type 2 diabetes, and hyperlipidemia
presents for routine follow-up. Her current medications include lisinopril 20 mg daily,
metformin 1000 mg BID, and atorvastatin 40 mg daily. BP today is 138/86 mmHg.
Laboratory testing reveals serum creatinine 1.3 mg/dL (eGFR 52 mL/min/1.73m²) and
potassium 5.3 mEq/L. Which of the following is the most appropriate next step in
management?
A. Discontinue lisinopril and start amlodipine 5 mg daily [CORRECT]
B. Add hydrochlorothiazide 25 mg daily
,C. Increase lisinopril to 40 mg daily
D. Add spironolactone 25 mg daily
Correct Answer: A
Rationale: This patient has developed hyperkalemia and declining renal function while
on an ACE inhibitor. In the setting of CKD with potassium elevation, discontinuing the
ACE inhibitor and initiating a calcium channel blocker is appropriate. Adding a thiazide
diuretic would be ineffective with an eGFR below 30-50 mL/min. Increasing lisinopril or
adding spironolactone would worsen hyperkalemia.
Q3: A 55-year-old man presents with intermittent chest pain that occurs with exertion
and resolves with rest. He describes the pain as substernal pressure radiating to his left
arm. His father had a myocardial infarction at age 52. Vitals: BP 128/78, HR 72, BMI 31.
Fasting lipid panel: LDL 165 mg/dL, HDL 35 mg/dL, triglycerides 180 mg/dL. According
to ACC/AHA guidelines, which of the following is the most appropriate statin intensity
for this patient?
A. Low-intensity statin therapy
B. Moderate-intensity statin therapy
C. High-intensity statin therapy [CORRECT]
D. No statin therapy indicated
Correct Answer: C
Rationale: This patient presents with classic symptoms of stable angina, indicating
clinical atherosclerotic cardiovascular disease (ASCVD). ACC/AHA guidelines recommend
high-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg) for all
patients with clinical ASCVD. High-intensity statins reduce LDL by ≥50% and provide the
greatest cardiovascular event reduction.
Q4: A 72-year-old woman with heart failure with reduced ejection fraction (HFrEF, EF
30%) presents with increasing dyspnea on exertion, orthopnea, and bilateral lower
extremity edema. Current medications include lisinopril 10 mg BID, carvedilol 12.5 mg
BID, and furosemide 40 mg daily. Vitals: BP 108/68, HR 64, O2 sat 94% on room air.
,Examination reveals JVD, crackles at lung bases, and 2+ pitting edema. Which of the
following medications should be added to improve mortality?
A. Digoxin 0.125 mg daily
B. Spironolactone 25 mg daily [CORRECT]
C. Amlodipine 5 mg daily
D. Isosorbide dinitrate 20 mg TID
Correct Answer: B
Rationale: Mineralocorticoid receptor antagonists (spironolactone or eplerenone) are
indicated in patients with HFrEF (EF ≤35%) and NYHA class II-IV symptoms despite
optimal medical therapy with ACE inhibitors/ARBs and beta-blockers. The RALES trial
demonstrated mortality reduction with spironolactone. Digoxin provides symptom relief
but no mortality benefit. Calcium channel blockers (except amlodipine for specific
indications) are generally avoided in HFrEF. Hydralazine/isosorbide is indicated in select
populations.
Q5: A 67-year-old man with a history of atrial fibrillation (CHADS2-VASc score = 4)
presents for anticoagulation management. He has been taking warfarin 5 mg daily with
variable INR readings. He asks about switching to a direct oral anticoagulant (DOAC).
Which of the following is a contraindication to DOAC therapy?
A. Age greater than 65 years
B. Creatinine clearance of 25 mL/min [CORRECT]
C. Concurrent use of metoprolol
D. History of hypertension
Correct Answer: B
Rationale: DOACs (apixaban, rivaroxaban, edoxaban, dabigatran) are contraindicated or
require dose adjustment in severe renal impairment. Creatinine clearance below 30
mL/min generally contraindicates dabigatran, while apixaban may be used with caution
down to 15 mL/min in some cases. At CrCl of 25 mL/min, most DOACs are
contraindicated, and warfarin or apixaban with dose adjustment would be preferred.
Age, concurrent beta-blocker use, and hypertension are not contraindications.
, Q6: A 60-year-old man presents with leg pain that occurs when walking two blocks and
is relieved by rest. He notes the pain is in his right calf and has been progressive over six
months. He has a 40-pack-year smoking history, hypertension, and hyperlipidemia.
Examination reveals diminished right dorsalis pedis and posterior tibial pulses, with cool,
hairless skin on the right lower extremity. Ankle-brachial index is 0.72. Which of the
following is the most appropriate initial management?
A. Refer for surgical revascularization
B. Start clopidogrel 75 mg daily [CORRECT]
C. Start warfarin therapy
D. Start amlodipine 5 mg daily
Correct Answer: B
Rationale: This patient presents with symptomatic peripheral arterial disease (PAD) with
claudication. Antiplatelet therapy with aspirin or clopidogrel is recommended to reduce
cardiovascular events in patients with symptomatic PAD. Surgical revascularization is
reserved for limb-threatening ischemia or disabling claudication unresponsive to
medical therapy. Anticoagulation is not indicated for PAD unless there is another
indication. Amlodipine does not treat the underlying pathology.
Q7: A 45-year-old woman presents with acute onset of unilateral leg swelling, pain, and
warmth following a transatlantic flight. She has no prior medical history. Examination
reveals left calf circumference 4 cm greater than right, with tenderness along the deep
venous system. Wells score is 3. Which of the following is the most appropriate next
step?
A. Obtain D-dimer testing [CORRECT]
B. Order venous duplex ultrasound
C. Start empiric anticoagulation
D. Apply compression stockings and observe
Correct Answer: A
Rationale: For patients with a moderate Wells score (2-6), D-dimer testing is the
recommended initial diagnostic step. A negative highly sensitive D-dimer effectively
rules out DVT, while a positive D-dimer requires confirmatory ultrasound. Starting
anticoagulation without diagnostic confirmation is inappropriate. Compression
