USMLE STEP 2 CK PRACTICE
EXAMINATION QUESTIONS WITH
CORRECT ANSWERS PLUS
RATIONALES 2026/2027 EDITION
WITH INSTANT PDF DOWNLOAD
1. A 67-year-old man with a history of hypertension,
hyperlipidemia, and a 40-pack-year smoking history presents with
45 minutes of crushing substernal chest pain radiating to his left
arm. ECG shows ST-segment elevations in leads II, III, and aVF.
Blood pressure is 88/54 mm Hg, and jugular venous pressure is
elevated. Lungs are clear to auscultation. Which of the following
is the most likely diagnosis?
A. Left ventricular free-wall rupture
B. Right ventricular infarction
C. Acute mitral regurgitation
D. Ventricular septal rupture
Correct answer: B. Right ventricular infarction
Rationale: Inferior myocardial infarction with hypotension,
elevated jugular venous pressure, and clear lungs strongly
suggests right ventricular infarction, usually caused by proximal
right coronary artery occlusion. These patients are preload
dependent, so cautious intravenous fluid administration is
generally preferred. Nitrates and aggressive diuresis can worsen
hypotension by reducing preload.
,2. A 24-year-old woman presents with dysuria, urinary frequency,
and suprapubic discomfort for 2 days. She has no fever, flank
pain, vaginal discharge, or pregnancy. Urinalysis shows positive
leukocyte esterase and nitrites. Which of the following is the most
appropriate initial treatment?
A. Oral ciprofloxacin for 14 days
B. Intravenous ceftriaxone
C. Nitrofurantoin for 5 days
D. Metronidazole for 7 days
Correct answer: C. Nitrofurantoin for 5 days
Rationale: This patient has uncomplicated acute cystitis.
Nitrofurantoin is an appropriate first-line treatment when there are
no signs of pyelonephritis. Fluoroquinolones are generally
reserved when appropriate alternatives are unavailable because
of their adverse-effect profile and antimicrobial stewardship
considerations. Fever, flank pain, or systemic illness would
suggest pyelonephritis and require a different approach.
3. A 72-year-old woman develops sudden right-sided weakness
and expressive aphasia 90 minutes ago. CT of the head shows no
hemorrhage. Blood glucose is normal, and there are no
contraindications to thrombolysis. Which of the following is the
most appropriate next step?
A. Aspirin only
B. Intravenous alteplase
C. Immediate carotid endarterectomy
D. Intravenous heparin
Correct answer: B. Intravenous alteplase
,Rationale: This patient has an acute ischemic stroke with a clearly
established time of onset and is within the standard window for
intravenous thrombolytic therapy. A noncontrast head CT is
performed primarily to exclude intracranial hemorrhage.
Anticoagulation with heparin is not routinely used for acute
ischemic stroke because it does not provide the same acute
benefit and increases bleeding risk.
4. A 35-year-old woman presents with fatigue, weight gain,
constipation, and cold intolerance. Examination reveals dry skin
and delayed relaxation of deep tendon reflexes. Laboratory
studies show an elevated TSH and low free T4. Which of the
following is the most appropriate treatment?
A. Methimazole
B. Levothyroxine
C. Propranolol
D. Radioactive iodine
Correct answer: B. Levothyroxine
Rationale: Elevated TSH with low free T4 indicates primary
hypothyroidism. Levothyroxine, synthetic T4, is the standard
treatment. Methimazole and radioactive iodine are used for
hyperthyroidism, while propranolol can temporarily control
adrenergic symptoms of hyperthyroidism.
5. A 58-year-old man with cirrhosis presents with hematemesis
and hypotension. After airway stabilization and intravenous
access are established, which of the following medications
, should be administered immediately while preparing for
endoscopy?
A. Omeprazole only
B. Octreotide
C. Warfarin
D. Sucralfate
Correct answer: B. Octreotide
Rationale: In a patient with cirrhosis and suspected acute variceal
hemorrhage, vasoactive therapy with octreotide should be started
promptly to reduce portal venous pressure and bleeding.
Prophylactic antibiotics are also indicated, and urgent
endoscopic therapy is required. Proton pump inhibitors alone are
insufficient when variceal bleeding is suspected.
6. A 29-year-old woman presents with episodic headaches,
palpitations, diaphoresis, and severe hypertension. Plasma
metanephrines are markedly elevated. Which of the following
should be initiated before beta-blockade if surgery is planned?
A. Phenoxybenzamine
B. Propranolol
C. Hydrochlorothiazide
D. Digoxin
Correct answer: A. Phenoxybenzamine
Rationale: Pheochromocytoma causes episodic catecholamine
release. Alpha-adrenergic blockade must be established before
beta-blockade to prevent unopposed alpha-mediated
vasoconstriction, which can precipitate severe hypertension.
EXAMINATION QUESTIONS WITH
CORRECT ANSWERS PLUS
RATIONALES 2026/2027 EDITION
WITH INSTANT PDF DOWNLOAD
1. A 67-year-old man with a history of hypertension,
hyperlipidemia, and a 40-pack-year smoking history presents with
45 minutes of crushing substernal chest pain radiating to his left
arm. ECG shows ST-segment elevations in leads II, III, and aVF.
Blood pressure is 88/54 mm Hg, and jugular venous pressure is
elevated. Lungs are clear to auscultation. Which of the following
is the most likely diagnosis?
A. Left ventricular free-wall rupture
B. Right ventricular infarction
C. Acute mitral regurgitation
D. Ventricular septal rupture
Correct answer: B. Right ventricular infarction
Rationale: Inferior myocardial infarction with hypotension,
elevated jugular venous pressure, and clear lungs strongly
suggests right ventricular infarction, usually caused by proximal
right coronary artery occlusion. These patients are preload
dependent, so cautious intravenous fluid administration is
generally preferred. Nitrates and aggressive diuresis can worsen
hypotension by reducing preload.
,2. A 24-year-old woman presents with dysuria, urinary frequency,
and suprapubic discomfort for 2 days. She has no fever, flank
pain, vaginal discharge, or pregnancy. Urinalysis shows positive
leukocyte esterase and nitrites. Which of the following is the most
appropriate initial treatment?
A. Oral ciprofloxacin for 14 days
B. Intravenous ceftriaxone
C. Nitrofurantoin for 5 days
D. Metronidazole for 7 days
Correct answer: C. Nitrofurantoin for 5 days
Rationale: This patient has uncomplicated acute cystitis.
Nitrofurantoin is an appropriate first-line treatment when there are
no signs of pyelonephritis. Fluoroquinolones are generally
reserved when appropriate alternatives are unavailable because
of their adverse-effect profile and antimicrobial stewardship
considerations. Fever, flank pain, or systemic illness would
suggest pyelonephritis and require a different approach.
3. A 72-year-old woman develops sudden right-sided weakness
and expressive aphasia 90 minutes ago. CT of the head shows no
hemorrhage. Blood glucose is normal, and there are no
contraindications to thrombolysis. Which of the following is the
most appropriate next step?
A. Aspirin only
B. Intravenous alteplase
C. Immediate carotid endarterectomy
D. Intravenous heparin
Correct answer: B. Intravenous alteplase
,Rationale: This patient has an acute ischemic stroke with a clearly
established time of onset and is within the standard window for
intravenous thrombolytic therapy. A noncontrast head CT is
performed primarily to exclude intracranial hemorrhage.
Anticoagulation with heparin is not routinely used for acute
ischemic stroke because it does not provide the same acute
benefit and increases bleeding risk.
4. A 35-year-old woman presents with fatigue, weight gain,
constipation, and cold intolerance. Examination reveals dry skin
and delayed relaxation of deep tendon reflexes. Laboratory
studies show an elevated TSH and low free T4. Which of the
following is the most appropriate treatment?
A. Methimazole
B. Levothyroxine
C. Propranolol
D. Radioactive iodine
Correct answer: B. Levothyroxine
Rationale: Elevated TSH with low free T4 indicates primary
hypothyroidism. Levothyroxine, synthetic T4, is the standard
treatment. Methimazole and radioactive iodine are used for
hyperthyroidism, while propranolol can temporarily control
adrenergic symptoms of hyperthyroidism.
5. A 58-year-old man with cirrhosis presents with hematemesis
and hypotension. After airway stabilization and intravenous
access are established, which of the following medications
, should be administered immediately while preparing for
endoscopy?
A. Omeprazole only
B. Octreotide
C. Warfarin
D. Sucralfate
Correct answer: B. Octreotide
Rationale: In a patient with cirrhosis and suspected acute variceal
hemorrhage, vasoactive therapy with octreotide should be started
promptly to reduce portal venous pressure and bleeding.
Prophylactic antibiotics are also indicated, and urgent
endoscopic therapy is required. Proton pump inhibitors alone are
insufficient when variceal bleeding is suspected.
6. A 29-year-old woman presents with episodic headaches,
palpitations, diaphoresis, and severe hypertension. Plasma
metanephrines are markedly elevated. Which of the following
should be initiated before beta-blockade if surgery is planned?
A. Phenoxybenzamine
B. Propranolol
C. Hydrochlorothiazide
D. Digoxin
Correct answer: A. Phenoxybenzamine
Rationale: Pheochromocytoma causes episodic catecholamine
release. Alpha-adrenergic blockade must be established before
beta-blockade to prevent unopposed alpha-mediated
vasoconstriction, which can precipitate severe hypertension.
