NR601 Week 3 Questions With Answers and Explanations
Primary Care of the Maturing and Aged Family Practicum | Cardiovascular Unit 2 | 600 Original Practice Questions
Question 1. A patient has palpitations and an ECG showing no discrete P waves with irregularly irregular R-R
intervals. Which diagnosis best fits these findings?
A. Atrial fibrillation
B. Atrial flutter with fixed conduction
C. Sinus arrhythmia
D. Ventricular bigeminy
Correct Answer: A. Atrial fibrillation
Explanation: Atrial fibrillation produces chaotic atrial activation, so organized P waves are absent. Variable conduction through the AV
node creates irregularly irregular ventricular intervals. Atrial flutter more often shows organized flutter waves, while sinus arrhythmia
retains sinus P waves. Ventricular bigeminy consists of alternating sinus beats and PVCs rather than continuously irregular atrial activity.
Question 2. Which ECG feature is most characteristic of atrial fibrillation?
A. Regular narrow-complex tachycardia with visible P waves
B. Sawtooth flutter waves with a fixed ventricular pattern
C. Premature wide QRS complexes after normal sinus beats
D. Irregularly irregular ventricular response with absent discrete P waves
Correct Answer: D. Irregularly irregular ventricular response with absent discrete P waves
Explanation: The hallmark ECG pattern of atrial fibrillation is an irregularly irregular ventricular rhythm without consistent P waves. The
atria depolarize rapidly and disorganizedly, producing a fibrillatory baseline. A regular narrow tachycardia suggests another
supraventricular rhythm, and sawtooth waves favor atrial flutter. Premature wide complexes occurring intermittently are more consistent
with PVCs.
Question 3. A patient reports brief episodes of palpitations twice each week, but the office ECG is normal. Which
test is most useful to document a suspected intermittent atrial arrhythmia?
A. Ambulatory ECG monitoring
B. Routine chest radiography
C. Carotid ultrasonography
D. Resting ankle-brachial index
Correct Answer: A. Ambulatory ECG monitoring
Explanation: Intermittent symptoms may not occur during a short office ECG, so ambulatory monitoring improves the chance of capturing
the rhythm. A Holter monitor is useful for frequent symptoms, while longer event or patch monitoring can help when episodes are less
frequent. Chest radiography does not directly document the cardiac rhythm. Carotid studies and ankle-brachial measurements evaluate
vascular disease rather than episodic arrhythmia.
Question 4. After newly confirming atrial fibrillation, which study is commonly obtained to assess chamber size,
ventricular function, and structural heart disease?
A. Exercise ankle pressure testing
B. Transthoracic echocardiography
C. Noncontrast head CT
D. Pulmonary function testing
Correct Answer: B. Transthoracic echocardiography
Explanation: Transthoracic echocardiography helps evaluate left atrial size, ventricular function, and structural or valvular abnormalities
in atrial fibrillation. These findings influence management and may reveal contributors such as valvular disease or cardiomyopathy. A
head CT is reserved for suspected neurologic events rather than routine AF assessment. Vascular exercise testing and pulmonary
function studies do not provide the needed structural cardiac information.
Page 1
,NR601 Week 3 - Questions With Answers and Explanations
Question 5. Which laboratory evaluation is especially appropriate when atrial fibrillation is newly diagnosed without
an obvious precipitating cause?
A. Serum amylase only
B. Rheumatoid factor only
C. Thyroid function testing
D. Fecal occult blood testing only
Correct Answer: C. Thyroid function testing
Explanation: Hyperthyroidism can precipitate atrial fibrillation, so thyroid testing is an important part of the initial evaluation. Electrolytes,
renal function, blood counts, and other studies may also be appropriate according to the clinical picture. Amylase and rheumatoid factor
are not routine tests for an otherwise unexplained atrial arrhythmia. Fecal occult blood testing does not identify a cause of atrial fibrillation.
Question 6. A patient with atrial fibrillation has hypotension, acute pulmonary edema, and altered mentation. What
is the most appropriate immediate treatment?
A. Schedule an outpatient Holter monitor
B. Begin lifestyle counseling and reassess next month
C. Synchronized electrical cardioversion
D. Give aspirin and observe without rhythm treatment
Correct Answer: C. Synchronized electrical cardioversion
Explanation: Hemodynamic instability attributable to atrial fibrillation requires urgent synchronized cardioversion. Hypotension, acute
heart failure, ischemic discomfort, or shock are warning signs that rate observation alone is unsafe. Ambulatory monitoring is for
diagnostic clarification in stable patients, not an unstable emergency. Aspirin does not correct the unstable rhythm and is not an adequate
substitute for indicated anticoagulation.
Question 7. A hemodynamically stable patient with atrial fibrillation and rapid ventricular response has preserved
left ventricular systolic function. Which medication class is a reasonable initial option for ventricular rate control?
A. A fibrinolytic agent
B. A beta blocker or nondihydropyridine calcium channel blocker
C. A loop diuretic as the only rate-control therapy
D. A nitrate as the primary rhythm-control drug
Correct Answer: B. A beta blocker or nondihydropyridine calcium channel blocker
Explanation: Beta blockers and nondihydropyridine calcium channel blockers are commonly used for acute or chronic ventricular rate
control when clinically appropriate. The choice depends on blood pressure, ventricular function, comorbidities, and concurrent
medications. Fibrinolytics do not provide routine rate control for atrial fibrillation. Diuretics and nitrates may treat other cardiovascular
problems but do not serve as primary rate-control drugs.
Question 8. Which rate-control medication should generally be avoided in atrial fibrillation when the patient has
decompensated heart failure with markedly reduced ejection fraction?
A. A carefully selected beta blocker after stabilization
B. Digoxin in selected patients
C. An anticoagulant when stroke prevention is indicated
D. Diltiazem
Correct Answer: D. Diltiazem
Explanation: Diltiazem has negative inotropic effects and is generally avoided in decompensated heart failure with reduced ejection
fraction. Digoxin can be useful for rate control in selected patients with reduced systolic function, although it requires individualized
monitoring. Beta blockers may be used when the patient is clinically stable and appropriately selected. Anticoagulation addresses
thromboembolic risk rather than ventricular rate and may still be indicated.
Page 2
,NR601 Week 3 - Questions With Answers and Explanations
Question 9. For most patients with nonvalvular atrial fibrillation who need oral anticoagulation, which strategy is
generally preferred?
A. A direct oral anticoagulant when no contraindication is present
B. Aspirin alone regardless of stroke risk
C. Dual antiplatelet therapy in place of anticoagulation
D. No therapy because paroxysmal AF carries no stroke risk
Correct Answer: A. A direct oral anticoagulant when no contraindication is present
Explanation: Current AF guidance generally prefers a direct oral anticoagulant over warfarin when anticoagulation is indicated and no
specific exception applies. Aspirin is not an equivalent substitute for stroke prevention in eligible patients with atrial fibrillation. Paroxysmal
AF still carries thromboembolic risk, so stroke prevention is based on risk rather than the rhythm pattern alone. Antiplatelet combinations
also do not replace indicated anticoagulation in routine AF care.
Question 10. A patient with atrial fibrillation also has a mechanical prosthetic heart valve. Which anticoagulation
approach is appropriate?
A. Aspirin alone
B. No antithrombotic therapy
C. A direct oral anticoagulant as the preferred replacement for warfarin
D. Warfarin-based anticoagulation
Correct Answer: D. Warfarin-based anticoagulation
Explanation: Mechanical prosthetic valves remain an important setting in which warfarin is used rather than a direct oral anticoagulant.
Anticoagulation intensity depends on the valve type and other risk factors. Aspirin alone does not provide adequate protection against
valve-related thrombosis and embolism. The presence of atrial fibrillation further reinforces the need for appropriate anticoagulant
management.
Question 11. A patient with atrial fibrillation has moderate-to-severe rheumatic mitral stenosis. Which anticoagulant
is generally preferred for stroke prevention?
A. Warfarin
B. Apixaban as the routine first choice
C. Clopidogrel alone
D. Aspirin alone
Correct Answer: A. Warfarin
Explanation: Rheumatic mitral stenosis with atrial fibrillation is a key exception to the general preference for direct oral anticoagulants.
Warfarin remains the standard oral anticoagulant in this setting. Antiplatelet drugs do not provide equivalent prevention of cardioembolic
stroke. The valvular diagnosis therefore materially changes the anticoagulation choice.
Question 12. Which statement about aspirin for stroke prevention in atrial fibrillation is most accurate?
A. Aspirin is preferred to anticoagulation whenever the patient is older than 75
B. Aspirin is not an adequate alternative to indicated oral anticoagulation
C. Aspirin eliminates the need to assess thromboembolic risk
D. Aspirin and anticoagulants have equivalent stroke-prevention efficacy in AF
Correct Answer: B. Aspirin is not an adequate alternative to indicated oral anticoagulation
Explanation: Aspirin is not considered an adequate substitute when oral anticoagulation is indicated for atrial fibrillation. Stroke risk
should be estimated using a validated approach and balanced with bleeding risk and patient factors. Older age generally increases
thromboembolic risk rather than automatically favoring aspirin. Anticoagulants reduce cardioembolic stroke more effectively than
antiplatelet therapy in appropriate patients.
Page 3
, NR601 Week 3 - Questions With Answers and Explanations
Question 13. A stable patient has atrial fibrillation of more than 48 hours' duration and elective cardioversion is
planned. Which approach best reduces pericardioversion thromboembolic risk?
A. Immediate elective cardioversion without anticoagulation assessment
B. Aspirin for one dose immediately before cardioversion only
C. Delay all treatment for six months regardless of symptoms
D. Therapeutic anticoagulation before cardioversion or imaging to exclude atrial thrombus, followed by appropriate
post-cardioversion anticoagulation
Correct Answer: D. Therapeutic anticoagulation before cardioversion or imaging to exclude atrial thrombus, followed by
appropriate post-cardioversion anticoagulation
Explanation: Atrial fibrillation lasting at least 48 hours or of uncertain duration can permit atrial thrombus formation. Elective cardioversion
therefore requires an anticoagulation strategy or imaging-based exclusion of thrombus according to current guidance. Anticoagulation is
generally continued for at least four weeks after cardioversion because atrial mechanical recovery may lag behind electrical recovery. A
single aspirin dose does not provide adequate protection in this setting.
Question 14. After cardioversion of atrial fibrillation lasting at least 48 hours, how long is anticoagulation generally
continued at minimum unless a specific circumstance changes the plan?
A. 24 hours only
B. 3 days only
C. At least 4 weeks
D. Anticoagulation is always stopped immediately after sinus rhythm returns
Correct Answer: C. At least 4 weeks
Explanation: Anticoagulation is generally continued for at least four weeks after cardioversion when AF has lasted at least 48 hours or its
duration is uncertain. Restoration of sinus rhythm does not immediately normalize atrial mechanical function. Longer-term anticoagulation
is then based on the patient's ongoing thromboembolic risk rather than cardioversion success alone. Stopping anticoagulation
immediately can leave a vulnerable period for embolic events.
Question 15. Transesophageal echocardiography before planned cardioversion reveals a left atrial appendage
thrombus. What is the best next step?
A. Defer cardioversion and provide therapeutic anticoagulation
B. Proceed immediately because the thrombus is already identified
C. Switch to aspirin only
D. Perform an exercise stress test instead of treating the thrombus
Correct Answer: A. Defer cardioversion and provide therapeutic anticoagulation
Explanation: An identified left atrial or appendage thrombus increases the risk of embolization with cardioversion. Cardioversion is
therefore deferred while therapeutic anticoagulation is established and follow-up management is arranged. Aspirin alone is insufficient
treatment for this cardioembolic risk. Exercise testing does not resolve the thrombus or make immediate cardioversion safe.
Question 16. In the CHA2DS2-VASc score, which condition contributes one point under the letter C?
A. Chronic cough
B. Cataract
C. Clinical heart failure or left ventricular dysfunction
D. Celiac disease
Correct Answer: C. Clinical heart failure or left ventricular dysfunction
Explanation: The C in CHA2DS2-VASc refers to clinical heart failure or left ventricular dysfunction. This factor contributes to estimated
thromboembolic risk in atrial fibrillation. Chronic cough, cataract, and celiac disease are not components of this score. Risk scoring should
still be integrated with clinical judgment and current guideline thresholds.
Page 4
Primary Care of the Maturing and Aged Family Practicum | Cardiovascular Unit 2 | 600 Original Practice Questions
Question 1. A patient has palpitations and an ECG showing no discrete P waves with irregularly irregular R-R
intervals. Which diagnosis best fits these findings?
A. Atrial fibrillation
B. Atrial flutter with fixed conduction
C. Sinus arrhythmia
D. Ventricular bigeminy
Correct Answer: A. Atrial fibrillation
Explanation: Atrial fibrillation produces chaotic atrial activation, so organized P waves are absent. Variable conduction through the AV
node creates irregularly irregular ventricular intervals. Atrial flutter more often shows organized flutter waves, while sinus arrhythmia
retains sinus P waves. Ventricular bigeminy consists of alternating sinus beats and PVCs rather than continuously irregular atrial activity.
Question 2. Which ECG feature is most characteristic of atrial fibrillation?
A. Regular narrow-complex tachycardia with visible P waves
B. Sawtooth flutter waves with a fixed ventricular pattern
C. Premature wide QRS complexes after normal sinus beats
D. Irregularly irregular ventricular response with absent discrete P waves
Correct Answer: D. Irregularly irregular ventricular response with absent discrete P waves
Explanation: The hallmark ECG pattern of atrial fibrillation is an irregularly irregular ventricular rhythm without consistent P waves. The
atria depolarize rapidly and disorganizedly, producing a fibrillatory baseline. A regular narrow tachycardia suggests another
supraventricular rhythm, and sawtooth waves favor atrial flutter. Premature wide complexes occurring intermittently are more consistent
with PVCs.
Question 3. A patient reports brief episodes of palpitations twice each week, but the office ECG is normal. Which
test is most useful to document a suspected intermittent atrial arrhythmia?
A. Ambulatory ECG monitoring
B. Routine chest radiography
C. Carotid ultrasonography
D. Resting ankle-brachial index
Correct Answer: A. Ambulatory ECG monitoring
Explanation: Intermittent symptoms may not occur during a short office ECG, so ambulatory monitoring improves the chance of capturing
the rhythm. A Holter monitor is useful for frequent symptoms, while longer event or patch monitoring can help when episodes are less
frequent. Chest radiography does not directly document the cardiac rhythm. Carotid studies and ankle-brachial measurements evaluate
vascular disease rather than episodic arrhythmia.
Question 4. After newly confirming atrial fibrillation, which study is commonly obtained to assess chamber size,
ventricular function, and structural heart disease?
A. Exercise ankle pressure testing
B. Transthoracic echocardiography
C. Noncontrast head CT
D. Pulmonary function testing
Correct Answer: B. Transthoracic echocardiography
Explanation: Transthoracic echocardiography helps evaluate left atrial size, ventricular function, and structural or valvular abnormalities
in atrial fibrillation. These findings influence management and may reveal contributors such as valvular disease or cardiomyopathy. A
head CT is reserved for suspected neurologic events rather than routine AF assessment. Vascular exercise testing and pulmonary
function studies do not provide the needed structural cardiac information.
Page 1
,NR601 Week 3 - Questions With Answers and Explanations
Question 5. Which laboratory evaluation is especially appropriate when atrial fibrillation is newly diagnosed without
an obvious precipitating cause?
A. Serum amylase only
B. Rheumatoid factor only
C. Thyroid function testing
D. Fecal occult blood testing only
Correct Answer: C. Thyroid function testing
Explanation: Hyperthyroidism can precipitate atrial fibrillation, so thyroid testing is an important part of the initial evaluation. Electrolytes,
renal function, blood counts, and other studies may also be appropriate according to the clinical picture. Amylase and rheumatoid factor
are not routine tests for an otherwise unexplained atrial arrhythmia. Fecal occult blood testing does not identify a cause of atrial fibrillation.
Question 6. A patient with atrial fibrillation has hypotension, acute pulmonary edema, and altered mentation. What
is the most appropriate immediate treatment?
A. Schedule an outpatient Holter monitor
B. Begin lifestyle counseling and reassess next month
C. Synchronized electrical cardioversion
D. Give aspirin and observe without rhythm treatment
Correct Answer: C. Synchronized electrical cardioversion
Explanation: Hemodynamic instability attributable to atrial fibrillation requires urgent synchronized cardioversion. Hypotension, acute
heart failure, ischemic discomfort, or shock are warning signs that rate observation alone is unsafe. Ambulatory monitoring is for
diagnostic clarification in stable patients, not an unstable emergency. Aspirin does not correct the unstable rhythm and is not an adequate
substitute for indicated anticoagulation.
Question 7. A hemodynamically stable patient with atrial fibrillation and rapid ventricular response has preserved
left ventricular systolic function. Which medication class is a reasonable initial option for ventricular rate control?
A. A fibrinolytic agent
B. A beta blocker or nondihydropyridine calcium channel blocker
C. A loop diuretic as the only rate-control therapy
D. A nitrate as the primary rhythm-control drug
Correct Answer: B. A beta blocker or nondihydropyridine calcium channel blocker
Explanation: Beta blockers and nondihydropyridine calcium channel blockers are commonly used for acute or chronic ventricular rate
control when clinically appropriate. The choice depends on blood pressure, ventricular function, comorbidities, and concurrent
medications. Fibrinolytics do not provide routine rate control for atrial fibrillation. Diuretics and nitrates may treat other cardiovascular
problems but do not serve as primary rate-control drugs.
Question 8. Which rate-control medication should generally be avoided in atrial fibrillation when the patient has
decompensated heart failure with markedly reduced ejection fraction?
A. A carefully selected beta blocker after stabilization
B. Digoxin in selected patients
C. An anticoagulant when stroke prevention is indicated
D. Diltiazem
Correct Answer: D. Diltiazem
Explanation: Diltiazem has negative inotropic effects and is generally avoided in decompensated heart failure with reduced ejection
fraction. Digoxin can be useful for rate control in selected patients with reduced systolic function, although it requires individualized
monitoring. Beta blockers may be used when the patient is clinically stable and appropriately selected. Anticoagulation addresses
thromboembolic risk rather than ventricular rate and may still be indicated.
Page 2
,NR601 Week 3 - Questions With Answers and Explanations
Question 9. For most patients with nonvalvular atrial fibrillation who need oral anticoagulation, which strategy is
generally preferred?
A. A direct oral anticoagulant when no contraindication is present
B. Aspirin alone regardless of stroke risk
C. Dual antiplatelet therapy in place of anticoagulation
D. No therapy because paroxysmal AF carries no stroke risk
Correct Answer: A. A direct oral anticoagulant when no contraindication is present
Explanation: Current AF guidance generally prefers a direct oral anticoagulant over warfarin when anticoagulation is indicated and no
specific exception applies. Aspirin is not an equivalent substitute for stroke prevention in eligible patients with atrial fibrillation. Paroxysmal
AF still carries thromboembolic risk, so stroke prevention is based on risk rather than the rhythm pattern alone. Antiplatelet combinations
also do not replace indicated anticoagulation in routine AF care.
Question 10. A patient with atrial fibrillation also has a mechanical prosthetic heart valve. Which anticoagulation
approach is appropriate?
A. Aspirin alone
B. No antithrombotic therapy
C. A direct oral anticoagulant as the preferred replacement for warfarin
D. Warfarin-based anticoagulation
Correct Answer: D. Warfarin-based anticoagulation
Explanation: Mechanical prosthetic valves remain an important setting in which warfarin is used rather than a direct oral anticoagulant.
Anticoagulation intensity depends on the valve type and other risk factors. Aspirin alone does not provide adequate protection against
valve-related thrombosis and embolism. The presence of atrial fibrillation further reinforces the need for appropriate anticoagulant
management.
Question 11. A patient with atrial fibrillation has moderate-to-severe rheumatic mitral stenosis. Which anticoagulant
is generally preferred for stroke prevention?
A. Warfarin
B. Apixaban as the routine first choice
C. Clopidogrel alone
D. Aspirin alone
Correct Answer: A. Warfarin
Explanation: Rheumatic mitral stenosis with atrial fibrillation is a key exception to the general preference for direct oral anticoagulants.
Warfarin remains the standard oral anticoagulant in this setting. Antiplatelet drugs do not provide equivalent prevention of cardioembolic
stroke. The valvular diagnosis therefore materially changes the anticoagulation choice.
Question 12. Which statement about aspirin for stroke prevention in atrial fibrillation is most accurate?
A. Aspirin is preferred to anticoagulation whenever the patient is older than 75
B. Aspirin is not an adequate alternative to indicated oral anticoagulation
C. Aspirin eliminates the need to assess thromboembolic risk
D. Aspirin and anticoagulants have equivalent stroke-prevention efficacy in AF
Correct Answer: B. Aspirin is not an adequate alternative to indicated oral anticoagulation
Explanation: Aspirin is not considered an adequate substitute when oral anticoagulation is indicated for atrial fibrillation. Stroke risk
should be estimated using a validated approach and balanced with bleeding risk and patient factors. Older age generally increases
thromboembolic risk rather than automatically favoring aspirin. Anticoagulants reduce cardioembolic stroke more effectively than
antiplatelet therapy in appropriate patients.
Page 3
, NR601 Week 3 - Questions With Answers and Explanations
Question 13. A stable patient has atrial fibrillation of more than 48 hours' duration and elective cardioversion is
planned. Which approach best reduces pericardioversion thromboembolic risk?
A. Immediate elective cardioversion without anticoagulation assessment
B. Aspirin for one dose immediately before cardioversion only
C. Delay all treatment for six months regardless of symptoms
D. Therapeutic anticoagulation before cardioversion or imaging to exclude atrial thrombus, followed by appropriate
post-cardioversion anticoagulation
Correct Answer: D. Therapeutic anticoagulation before cardioversion or imaging to exclude atrial thrombus, followed by
appropriate post-cardioversion anticoagulation
Explanation: Atrial fibrillation lasting at least 48 hours or of uncertain duration can permit atrial thrombus formation. Elective cardioversion
therefore requires an anticoagulation strategy or imaging-based exclusion of thrombus according to current guidance. Anticoagulation is
generally continued for at least four weeks after cardioversion because atrial mechanical recovery may lag behind electrical recovery. A
single aspirin dose does not provide adequate protection in this setting.
Question 14. After cardioversion of atrial fibrillation lasting at least 48 hours, how long is anticoagulation generally
continued at minimum unless a specific circumstance changes the plan?
A. 24 hours only
B. 3 days only
C. At least 4 weeks
D. Anticoagulation is always stopped immediately after sinus rhythm returns
Correct Answer: C. At least 4 weeks
Explanation: Anticoagulation is generally continued for at least four weeks after cardioversion when AF has lasted at least 48 hours or its
duration is uncertain. Restoration of sinus rhythm does not immediately normalize atrial mechanical function. Longer-term anticoagulation
is then based on the patient's ongoing thromboembolic risk rather than cardioversion success alone. Stopping anticoagulation
immediately can leave a vulnerable period for embolic events.
Question 15. Transesophageal echocardiography before planned cardioversion reveals a left atrial appendage
thrombus. What is the best next step?
A. Defer cardioversion and provide therapeutic anticoagulation
B. Proceed immediately because the thrombus is already identified
C. Switch to aspirin only
D. Perform an exercise stress test instead of treating the thrombus
Correct Answer: A. Defer cardioversion and provide therapeutic anticoagulation
Explanation: An identified left atrial or appendage thrombus increases the risk of embolization with cardioversion. Cardioversion is
therefore deferred while therapeutic anticoagulation is established and follow-up management is arranged. Aspirin alone is insufficient
treatment for this cardioembolic risk. Exercise testing does not resolve the thrombus or make immediate cardioversion safe.
Question 16. In the CHA2DS2-VASc score, which condition contributes one point under the letter C?
A. Chronic cough
B. Cataract
C. Clinical heart failure or left ventricular dysfunction
D. Celiac disease
Correct Answer: C. Clinical heart failure or left ventricular dysfunction
Explanation: The C in CHA2DS2-VASc refers to clinical heart failure or left ventricular dysfunction. This factor contributes to estimated
thromboembolic risk in atrial fibrillation. Chronic cough, cataract, and celiac disease are not components of this score. Risk scoring should
still be integrated with clinical judgment and current guideline thresholds.
Page 4
