,NSG555/NSG 555 Exam 3 Nurse Practitioners in
Primary Care II | Wilkes | 26/27 Updated (PDF)
1. A 58-year-old male with hypertension reports substernal chest pressure when walking uphill that
resolves with rest. His ECG is normal. What is the most appropriate next step?
A) Coronary angiography
B) Stress testing (exercise treadmill or nuclear)
C) Prescribe nitroglycerin and discharge
D) Repeat ECG in 1 hour
Correct Answer: Stress testing (exercise treadmill or nuclear)
Rationale: Classic stable angina requires risk stratification. A normal resting ECG does not rule out
coronary artery disease (CAD). Stress testing assesses for inducible ischemia and guides further
management. Coronary angiography is reserved for patients with high-risk features or positive stress
tests.
2. A 72-year-old female has a new murmur, mid-systolic click, and late systolic murmur at the apex.
These findings suggest:
A) Aortic stenosis
B) Mitral valve prolapse
C) Mitral stenosis
D) Tricuspid regurgitation
Correct Answer: Mitral valve prolapse
Rationale: A mid-systolic click followed by a late systolic murmur at the apex is classic for mitral valve
prolapse (MVP). MVP is the most common cause of mitral regurgitation. Aortic stenosis presents with
a systolic ejection murmur at the right upper sternal border. Mitral stenosis presents with a diastolic
rumble at the apex.
3. A 62-year-old patient with hypertension and type 2 diabetes has a blood pressure of 148/88 mmHg
on lisinopril 20 mg daily. Which medication should be added next according to ACC/AHA guidelines?
A) Hydrochlorothiazide
B) Amlodipine
C) Metoprolol
,D) Clonidine
Correct Answer: Amlodipine
Rationale: ACC/AHA guidelines recommend adding a calcium channel blocker (amlodipine) or a
thiazide diuretic if blood pressure remains above goal on an ACE inhibitor. Amlodipine is preferred in
patients with diabetes due to its neutral metabolic effects.
4. A 68-year-old female with heart failure with reduced ejection fraction (HFrEF) is on optimal medical
therapy but remains symptomatic. Her ECG shows QRS duration of 160 ms with LBBB morphology.
Which intervention is most appropriate?
A) Increase diuretic dose
B) Cardiac resynchronization therapy (CRT)
C) Implantable cardioverter-defibrillator (ICD)
D) Refer for heart transplant evaluation
Correct Answer: Cardiac resynchronization therapy (CRT)
Rationale: CRT is indicated for patients with HFrEF (EF ≤35%), NYHA class II-IV symptoms, and QRS
≥150 ms with LBBB morphology. CRT improves symptoms, reduces hospitalizations, and reduces
mortality in these patients. An ICD is for sudden cardiac death prevention but does not address
dyssynchrony.
5. A 55-year-old male with a history of myocardial infarction presents with progressive dyspnea on
exertion and orthopnea. Echocardiogram reveals an ejection fraction of 30%. According to guideline-
directed medical therapy, which medication should be initiated to reduce mortality?
A) Digoxin
B) Hydralazine and isosorbide dinitrate
C) Sacubitril/valsartan
D) Ivabradine
Correct Answer: Sacubitril/valsartan
Rationale: Sacubitril/valsartan (Entresto) has been shown to reduce mortality and hospitalizations in
patients with HFrEF and is recommended in place of an ACE inhibitor or ARB in eligible patients.
Digoxin reduces symptoms but not mortality. Ivabradine is indicated for heart rate control.
6. A 72-year-old male with atrial fibrillation has a CHA₂DS₂-VASc score of 5. Which anticoagulation
strategy is most appropriate?
, A) Aspirin 81 mg daily
B) Aspirin and clopidogrel
C) Warfarin with target INR 2.0-3.0
D) Direct oral anticoagulant (DOAC)
Correct Answer: Direct oral anticoagulant (DOAC)
Rationale: Patients with a CHA₂DS₂-VASc score ≥2 in males or ≥3 in females should receive oral
anticoagulation. DOACs (apixaban, rivaroxaban, dabigatran, edoxaban) are preferred over warfarin
for non-valvular atrial fibrillation due to comparable efficacy, lower bleeding risk, and no need for
routine INR monitoring.
7. A 65-year-old female on apixaban for atrial fibrillation presents with a left-sided stroke. Which
action is most appropriate regarding her anticoagulation?
A) Continue apixaban
B) Hold apixaban and consider reversal agent
C) Switch to warfarin
D) Add aspirin
Correct Answer: Hold apixaban and consider reversal agent
Rationale: In acute stroke on anticoagulation, the medication should be held, and reversal should be
considered if the patient is a candidate for thrombolysis or if there is significant bleeding. Andexanet
alfa is the reversal agent for apixaban and rivaroxaban.
8. A 58-year-old male with peripheral artery disease complains of right calf pain when walking one
block that resolves with rest. What is the most appropriate initial diagnostic test?
A) Ankle-brachial index (ABI)
B) Lower extremity Doppler ultrasound
C) CT angiography of the lower extremities
D) Magnetic resonance angiography
Correct Answer: Ankle-brachial index (ABI)
Rationale: ABI is the initial non-invasive test for diagnosing peripheral artery disease. An ABI <0.90 is
consistent with PAD. Doppler ultrasound can assess for stenosis but is not first-line. CT and MR
angiography are reserved for pre-procedural planning.
Primary Care II | Wilkes | 26/27 Updated (PDF)
1. A 58-year-old male with hypertension reports substernal chest pressure when walking uphill that
resolves with rest. His ECG is normal. What is the most appropriate next step?
A) Coronary angiography
B) Stress testing (exercise treadmill or nuclear)
C) Prescribe nitroglycerin and discharge
D) Repeat ECG in 1 hour
Correct Answer: Stress testing (exercise treadmill or nuclear)
Rationale: Classic stable angina requires risk stratification. A normal resting ECG does not rule out
coronary artery disease (CAD). Stress testing assesses for inducible ischemia and guides further
management. Coronary angiography is reserved for patients with high-risk features or positive stress
tests.
2. A 72-year-old female has a new murmur, mid-systolic click, and late systolic murmur at the apex.
These findings suggest:
A) Aortic stenosis
B) Mitral valve prolapse
C) Mitral stenosis
D) Tricuspid regurgitation
Correct Answer: Mitral valve prolapse
Rationale: A mid-systolic click followed by a late systolic murmur at the apex is classic for mitral valve
prolapse (MVP). MVP is the most common cause of mitral regurgitation. Aortic stenosis presents with
a systolic ejection murmur at the right upper sternal border. Mitral stenosis presents with a diastolic
rumble at the apex.
3. A 62-year-old patient with hypertension and type 2 diabetes has a blood pressure of 148/88 mmHg
on lisinopril 20 mg daily. Which medication should be added next according to ACC/AHA guidelines?
A) Hydrochlorothiazide
B) Amlodipine
C) Metoprolol
,D) Clonidine
Correct Answer: Amlodipine
Rationale: ACC/AHA guidelines recommend adding a calcium channel blocker (amlodipine) or a
thiazide diuretic if blood pressure remains above goal on an ACE inhibitor. Amlodipine is preferred in
patients with diabetes due to its neutral metabolic effects.
4. A 68-year-old female with heart failure with reduced ejection fraction (HFrEF) is on optimal medical
therapy but remains symptomatic. Her ECG shows QRS duration of 160 ms with LBBB morphology.
Which intervention is most appropriate?
A) Increase diuretic dose
B) Cardiac resynchronization therapy (CRT)
C) Implantable cardioverter-defibrillator (ICD)
D) Refer for heart transplant evaluation
Correct Answer: Cardiac resynchronization therapy (CRT)
Rationale: CRT is indicated for patients with HFrEF (EF ≤35%), NYHA class II-IV symptoms, and QRS
≥150 ms with LBBB morphology. CRT improves symptoms, reduces hospitalizations, and reduces
mortality in these patients. An ICD is for sudden cardiac death prevention but does not address
dyssynchrony.
5. A 55-year-old male with a history of myocardial infarction presents with progressive dyspnea on
exertion and orthopnea. Echocardiogram reveals an ejection fraction of 30%. According to guideline-
directed medical therapy, which medication should be initiated to reduce mortality?
A) Digoxin
B) Hydralazine and isosorbide dinitrate
C) Sacubitril/valsartan
D) Ivabradine
Correct Answer: Sacubitril/valsartan
Rationale: Sacubitril/valsartan (Entresto) has been shown to reduce mortality and hospitalizations in
patients with HFrEF and is recommended in place of an ACE inhibitor or ARB in eligible patients.
Digoxin reduces symptoms but not mortality. Ivabradine is indicated for heart rate control.
6. A 72-year-old male with atrial fibrillation has a CHA₂DS₂-VASc score of 5. Which anticoagulation
strategy is most appropriate?
, A) Aspirin 81 mg daily
B) Aspirin and clopidogrel
C) Warfarin with target INR 2.0-3.0
D) Direct oral anticoagulant (DOAC)
Correct Answer: Direct oral anticoagulant (DOAC)
Rationale: Patients with a CHA₂DS₂-VASc score ≥2 in males or ≥3 in females should receive oral
anticoagulation. DOACs (apixaban, rivaroxaban, dabigatran, edoxaban) are preferred over warfarin
for non-valvular atrial fibrillation due to comparable efficacy, lower bleeding risk, and no need for
routine INR monitoring.
7. A 65-year-old female on apixaban for atrial fibrillation presents with a left-sided stroke. Which
action is most appropriate regarding her anticoagulation?
A) Continue apixaban
B) Hold apixaban and consider reversal agent
C) Switch to warfarin
D) Add aspirin
Correct Answer: Hold apixaban and consider reversal agent
Rationale: In acute stroke on anticoagulation, the medication should be held, and reversal should be
considered if the patient is a candidate for thrombolysis or if there is significant bleeding. Andexanet
alfa is the reversal agent for apixaban and rivaroxaban.
8. A 58-year-old male with peripheral artery disease complains of right calf pain when walking one
block that resolves with rest. What is the most appropriate initial diagnostic test?
A) Ankle-brachial index (ABI)
B) Lower extremity Doppler ultrasound
C) CT angiography of the lower extremities
D) Magnetic resonance angiography
Correct Answer: Ankle-brachial index (ABI)
Rationale: ABI is the initial non-invasive test for diagnosing peripheral artery disease. An ABI <0.90 is
consistent with PAD. Doppler ultrasound can assess for stenosis but is not first-line. CT and MR
angiography are reserved for pre-procedural planning.
