1
BARKLEY ENP-C DIAGNOSTIC READINESS TEST (DRT) #3 \
100 Practice Questions with Detailed Rationales
SECTION 1: CARDIOVASCULAR EMERGENCIES (1–12)
1. A 68-year-old man presents with acute-onset tearing chest pain radiating to
the back. Blood pressure is 170/95 mmHg in the right arm and 135/80 mmHg in
the left arm. Chest X-ray shows a widened mediastinum. What is the most likely
diagnosis?
A. Acute myocardial infarction
B. Aortic dissection
C. Pulmonary embolism
D. Tension pneumothorax
: Correct Answer : B
Rationale: The classic presentation of aortic dissection is sudden, severe “tearing”
or “ripping” chest pain, often radiating to the back. A difference in systolic blood
pressure >15–20 mmHg between arms is a key physical finding. Widened
mediastinum on chest X-ray supports the diagnosis. This is a surgical emergency
requiring immediate blood pressure control and vascular surgery consultation.
Acute MI typically has crushing chest pain with ST-segment changes; pulmonary
embolism causes dyspnea and tachycardia; tension pneumothorax causes
tracheal deviation and absent breath sounds.
2. A 55-year-old male with a history of hypertension and dyslipidemia presents
with substernal chest pressure, diaphoresis, and nausea. ECG shows ST-segment
elevation of 3 mm in leads II, III, and aVF. Which coronary artery is most likely
occluded?
A. Left anterior descending (LAD)
B. Left circumflex (LCx)
pg. 1
,2
C. Right coronary artery (RCA)
D. Left main coronary artery
: Correct Answer : C
Rationale: ST-segment elevation in leads II, III, and aVF indicates an inferior wall
myocardial infarction. The inferior wall is typically supplied by the right coronary
artery (RCA) in the majority of patients (right-dominant circulation). The LAD
supplies the anterior wall and septum (V1–V4). The LCx supplies the lateral wall (I,
aVL, V5–V6). Left main occlusion would cause widespread ischemia and often
fatal arrhythmias.
3. A patient with an acute STEMI is being prepared for percutaneous coronary
intervention (PCI). The nurse practitioner is reviewing the medications. Which
antiplatelet agent is most critical to administer as a loading dose prior to PCI?
A. Aspirin 81 mg
B. Clopidogrel 600 mg or ticagrelor 180 mg (P2Y12 inhibitor)
C. Warfarin
D. Heparin only
: Correct Answer : B
Rationale: Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor
(clopidogrel, ticagrelor, or prasugrel) is essential before and after PCI to prevent
stent thrombosis. A loading dose of a P2Y12 inhibitor is given as soon as possible.
Aspirin 324 mg (chewed) is also given, but the P2Y12 inhibitor is the specific
loading dose question. Unfractionated heparin or bivalirudin is used for
anticoagulation during the procedure.
4. A 70-year-old female with atrial fibrillation on warfarin presents with
acute-onset left-sided weakness, facial droop, and aphasia. Onset was 2 hours
ago. CT head is negative for hemorrhage. INR is 2.8. Can she receive IV
alteplase?
A. Yes, because CT is negative
B. No, because INR >1.7 is a contraindication to thrombolysis
pg. 2
,3
C. Yes, after reversing warfarin with vitamin K and PCC
D. Only if she has a large vessel occlusion
: Correct Answer : B
Rationale: Current guidelines list INR >1.7 as a contraindication to IV alteplase for
acute ischemic stroke. Even though the CT is negative for hemorrhage, the
elevated INR increases the risk of hemorrhagic transformation. Reversal could be
considered, but would delay treatment beyond the window. Mechanical
thrombectomy may be an option if a large vessel occlusion is present.
5. A 62-year-old male with heart failure with reduced ejection fraction (HFrEF)
presents with worsening dyspnea, orthopnea, and bilateral lower extremity
edema. He is on lisinopril, carvedilol, and furosemide. Vital signs: BP 100/60, HR
90, SpO2 92%. On exam, JVD is present and crackles are heard in the bases.
Which of the following additional therapies has a mortality benefit?
A. Digoxin
B. Spironolactone
C. Amlodipine
D. Isosorbide dinitrate/hydralazine
: Correct Answer : B
Rationale: Mineralocorticoid receptor antagonists (spironolactone, eplerenone)
have been shown to reduce mortality and heart failure hospitalizations in patients
with HFrEF (LVEF ≤35%) who are already on standard therapy. The RALES trial
demonstrated a 30% reduction in mortality with spironolactone. Digoxin reduces
hospitalizations but not mortality. Amlodipine is safe but does not improve
mortality. Isosorbide dinitrate/hydralazine is an alternative for patients who
cannot tolerate ACEi/ARBs, but spironolactone is the best answer here.
6. A patient with acute decompensated heart failure is placed on nitroglycerin
infusion. The nurse practitioner understands that the primary mechanism of
benefit in this setting is:
A. Afterload reduction and coronary vasodilation
B. Positive inotropy
pg. 3
, 4
C. Heart rate reduction
D. Diuresis
: Correct Answer : A
Rationale: Nitroglycerin at high intravenous doses acts primarily as a venodilator
(reducing preload) and also as an arteriolar dilator (reducing afterload), which
decreases myocardial oxygen demand. It also dilates coronary arteries, improving
myocardial perfusion. It does not have positive inotropic effects (that’s
dobutamine/milrinone), does not primarily reduce heart rate, and is not a
diuretic.
7. A 75-year-old man with a history of coronary artery disease and a
biventricular ICD presents with palpitations and an ICD shock. Device
interrogation reveals a single appropriate shock for ventricular fibrillation. He is
hemodynamically stable. What is the most appropriate next step?
A. Discharge home with no further intervention
B. Admit for observation, electrolyte repletion, and possible antiarrhythmic
therapy
C. Immediate electrophysiology study and ablation
D. Replace the ICD generator
: Correct Answer : B
Rationale: An appropriate ICD shock indicates a life-threatening ventricular
arrhythmia. Even if the patient is stable post-shock, admission for telemetry
monitoring, evaluation of electrolytes (hypokalemia, hypomagnesemia),
assessment for ischemia, and optimization of antiarrhythmic medications (e.g.,
amiodarone, beta-blocker) is standard. Immediate ablation is not required unless
there is recurrent VT/VF storm. ICD generator replacement is indicated for battery
depletion, not for a single shock.
8. A 55-year-old woman presents with sudden onset of palpitations,
lightheadedness, and dyspnea. ECG shows a regular narrow-complex
tachycardia at 180 bpm. P waves are not visible. What is the most likely
diagnosis?
pg. 4
BARKLEY ENP-C DIAGNOSTIC READINESS TEST (DRT) #3 \
100 Practice Questions with Detailed Rationales
SECTION 1: CARDIOVASCULAR EMERGENCIES (1–12)
1. A 68-year-old man presents with acute-onset tearing chest pain radiating to
the back. Blood pressure is 170/95 mmHg in the right arm and 135/80 mmHg in
the left arm. Chest X-ray shows a widened mediastinum. What is the most likely
diagnosis?
A. Acute myocardial infarction
B. Aortic dissection
C. Pulmonary embolism
D. Tension pneumothorax
: Correct Answer : B
Rationale: The classic presentation of aortic dissection is sudden, severe “tearing”
or “ripping” chest pain, often radiating to the back. A difference in systolic blood
pressure >15–20 mmHg between arms is a key physical finding. Widened
mediastinum on chest X-ray supports the diagnosis. This is a surgical emergency
requiring immediate blood pressure control and vascular surgery consultation.
Acute MI typically has crushing chest pain with ST-segment changes; pulmonary
embolism causes dyspnea and tachycardia; tension pneumothorax causes
tracheal deviation and absent breath sounds.
2. A 55-year-old male with a history of hypertension and dyslipidemia presents
with substernal chest pressure, diaphoresis, and nausea. ECG shows ST-segment
elevation of 3 mm in leads II, III, and aVF. Which coronary artery is most likely
occluded?
A. Left anterior descending (LAD)
B. Left circumflex (LCx)
pg. 1
,2
C. Right coronary artery (RCA)
D. Left main coronary artery
: Correct Answer : C
Rationale: ST-segment elevation in leads II, III, and aVF indicates an inferior wall
myocardial infarction. The inferior wall is typically supplied by the right coronary
artery (RCA) in the majority of patients (right-dominant circulation). The LAD
supplies the anterior wall and septum (V1–V4). The LCx supplies the lateral wall (I,
aVL, V5–V6). Left main occlusion would cause widespread ischemia and often
fatal arrhythmias.
3. A patient with an acute STEMI is being prepared for percutaneous coronary
intervention (PCI). The nurse practitioner is reviewing the medications. Which
antiplatelet agent is most critical to administer as a loading dose prior to PCI?
A. Aspirin 81 mg
B. Clopidogrel 600 mg or ticagrelor 180 mg (P2Y12 inhibitor)
C. Warfarin
D. Heparin only
: Correct Answer : B
Rationale: Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor
(clopidogrel, ticagrelor, or prasugrel) is essential before and after PCI to prevent
stent thrombosis. A loading dose of a P2Y12 inhibitor is given as soon as possible.
Aspirin 324 mg (chewed) is also given, but the P2Y12 inhibitor is the specific
loading dose question. Unfractionated heparin or bivalirudin is used for
anticoagulation during the procedure.
4. A 70-year-old female with atrial fibrillation on warfarin presents with
acute-onset left-sided weakness, facial droop, and aphasia. Onset was 2 hours
ago. CT head is negative for hemorrhage. INR is 2.8. Can she receive IV
alteplase?
A. Yes, because CT is negative
B. No, because INR >1.7 is a contraindication to thrombolysis
pg. 2
,3
C. Yes, after reversing warfarin with vitamin K and PCC
D. Only if she has a large vessel occlusion
: Correct Answer : B
Rationale: Current guidelines list INR >1.7 as a contraindication to IV alteplase for
acute ischemic stroke. Even though the CT is negative for hemorrhage, the
elevated INR increases the risk of hemorrhagic transformation. Reversal could be
considered, but would delay treatment beyond the window. Mechanical
thrombectomy may be an option if a large vessel occlusion is present.
5. A 62-year-old male with heart failure with reduced ejection fraction (HFrEF)
presents with worsening dyspnea, orthopnea, and bilateral lower extremity
edema. He is on lisinopril, carvedilol, and furosemide. Vital signs: BP 100/60, HR
90, SpO2 92%. On exam, JVD is present and crackles are heard in the bases.
Which of the following additional therapies has a mortality benefit?
A. Digoxin
B. Spironolactone
C. Amlodipine
D. Isosorbide dinitrate/hydralazine
: Correct Answer : B
Rationale: Mineralocorticoid receptor antagonists (spironolactone, eplerenone)
have been shown to reduce mortality and heart failure hospitalizations in patients
with HFrEF (LVEF ≤35%) who are already on standard therapy. The RALES trial
demonstrated a 30% reduction in mortality with spironolactone. Digoxin reduces
hospitalizations but not mortality. Amlodipine is safe but does not improve
mortality. Isosorbide dinitrate/hydralazine is an alternative for patients who
cannot tolerate ACEi/ARBs, but spironolactone is the best answer here.
6. A patient with acute decompensated heart failure is placed on nitroglycerin
infusion. The nurse practitioner understands that the primary mechanism of
benefit in this setting is:
A. Afterload reduction and coronary vasodilation
B. Positive inotropy
pg. 3
, 4
C. Heart rate reduction
D. Diuresis
: Correct Answer : A
Rationale: Nitroglycerin at high intravenous doses acts primarily as a venodilator
(reducing preload) and also as an arteriolar dilator (reducing afterload), which
decreases myocardial oxygen demand. It also dilates coronary arteries, improving
myocardial perfusion. It does not have positive inotropic effects (that’s
dobutamine/milrinone), does not primarily reduce heart rate, and is not a
diuretic.
7. A 75-year-old man with a history of coronary artery disease and a
biventricular ICD presents with palpitations and an ICD shock. Device
interrogation reveals a single appropriate shock for ventricular fibrillation. He is
hemodynamically stable. What is the most appropriate next step?
A. Discharge home with no further intervention
B. Admit for observation, electrolyte repletion, and possible antiarrhythmic
therapy
C. Immediate electrophysiology study and ablation
D. Replace the ICD generator
: Correct Answer : B
Rationale: An appropriate ICD shock indicates a life-threatening ventricular
arrhythmia. Even if the patient is stable post-shock, admission for telemetry
monitoring, evaluation of electrolytes (hypokalemia, hypomagnesemia),
assessment for ischemia, and optimization of antiarrhythmic medications (e.g.,
amiodarone, beta-blocker) is standard. Immediate ablation is not required unless
there is recurrent VT/VF storm. ICD generator replacement is indicated for battery
depletion, not for a single shock.
8. A 55-year-old woman presents with sudden onset of palpitations,
lightheadedness, and dyspnea. ECG shows a regular narrow-complex
tachycardia at 180 bpm. P waves are not visible. What is the most likely
diagnosis?
pg. 4
