1
Barkley ENP-C Diagnostic Readiness Test (DRT) | 100
Emergency NP Practice Questions and Answers
Barkley ENP-C Diagnostic Readiness Test – 100 Questions
Section 1: Cardiovascular Emergencies (Questions 1–12)
1. A 60-year-old man presents with acute, severe, “tearing” chest pain radiating
to the back. He has a history of hypertension. Blood pressure is 168/92 mmHg in
the right arm and 106/70 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
: Answer : B
Rationale: The classic presentation of aortic dissection is sudden, tearing chest
pain radiating to the back. A difference in systolic BP >20 mmHg between arms
suggests involvement of the aortic arch branches. Widened mediastinum on CXR is
a classic but not definitive sign. Immediate CT angiography or transesophageal
echocardiography is required.
2. A 68-year-old woman with atrial fibrillation (not on anticoagulation) presents
with sudden onset of right-sided weakness and aphasia 90 minutes ago. CT head
without contrast is negative for hemorrhage. What is the most appropriate next
step?
A. Administer aspirin 325 mg and admit
B. Administer IV tissue plasminogen activator (tPA) if no contraindications
C. Start a heparin infusion immediately
D. Order MRI and await results
: Answer : B
Rationale: This is an acute ischemic stroke within the 3–4.5-hour thrombolytic
pg. 1
,2
window. A negative non-contrast CT rules out hemorrhage, making her a
candidate for IV tPA. Aspirin is given later (24 hours post-tPA); immediate heparin
is not standard for acute stroke unless for specific indications; MRI should not
delay tPA.
3. A 45-year-old man with chest pressure, diaphoresis, and nausea. ECG shows
ST-segment elevation in leads V1–V4. What is the most likely infarct location?
A. Inferior wall
B. Anterior wall
C. Lateral wall
D. Posterior wall
: Answer : B
Rationale: ST elevation in V1–V4 indicates anterior wall MI, usually due to left
anterior descending (LAD) artery occlusion. Inferior wall MI shows ST elevation in
II, III, aVF. Lateral wall involves I, aVL, V5–V6.
4. A 55-year-old man with chest pain and a history of GERD has a normal ECG
and normal troponin. Pain is reproducible with palpation of the left chest wall.
What is the most likely diagnosis?
A. Unstable angina
B. Costochondritis
C. Pulmonary embolism
D. Acute pericarditis
: Answer : B
Rationale: Reproducible chest wall tenderness suggests a musculoskeletal cause
like costochondritis. Unstable angina would have a concerning history and possibly
ECG changes. Pericarditis often has diffuse ST elevation and a friction rub.
5. A patient with heart failure with reduced ejection fraction (HFrEF) presents
with worsening dyspnea, orthopnea, and bilateral crackles. BNP is 1,200 pg/mL.
Which medication combination is proven to reduce mortality in HFrEF?
A. ACE inhibitor, beta blocker, mineralocorticoid receptor antagonist, SGLT2
inhibitor
B. Digoxin, furosemide, amlodipine
C. Hydralazine, isosorbide dinitrate, digoxin
D. Metoprolol, verapamil, furosemide
pg. 2
,3
: Answer : A
*Rationale: Guideline-directed medical therapy for HFrEF includes an ACE
inhibitor (or ARB/ARNI), a beta blocker, a mineralocorticoid receptor antagonist,
and an SGLT2 inhibitor. This “quadruple therapy” reduces mortality. Verapamil is
contraindicated in HFrEF; digoxin reduces hospitalizations but not mortality.*
6. A 30-year-old woman with palpitations and lightheadedness has a heart rate
of 180 bpm. ECG shows a narrow-complex tachycardia, no visible P waves, and
blood pressure 90/60 mmHg. What is the immediate treatment?
A. Adenosine 6 mg IV push
B. Synchronized cardioversion
C. Amiodarone 150 mg IV
D. Diltiazem 0.25 mg/kg IV
: Answer : B
Rationale: This is an unstable supraventricular tachycardia (SVT) with
hypotension. Unstable tachycardia requires immediate synchronized
cardioversion. Adenosine and diltiazem are for stable SVT. Amiodarone is
second-line.
7. An elderly patient with known coronary artery disease presents with
syncope. ECG shows Mobitz type II second-degree AV block. What is the most
appropriate management?
A. Observe on telemetry
B. Administer atropine 0.5 mg IV
C. Prepare for transcutaneous pacing and urgent cardiology consultation for
pacemaker
D. Discharge with a Holter monitor
: Answer : C
Rationale: Mobitz II block is often infranodal and can progress unpredictably to
complete heart block. It requires immediate pacing (transcutaneous or
transvenous) and permanent pacemaker. Atropine may be ineffective for
infranodal block.
8. A 72-year-old woman with hypertension and diabetes presents with an acute,
severe headache, altered mental status, and a blood pressure of 220/130
mmHg. Fundoscopy reveals papilledema. What is the diagnosis?
pg. 3
, 4
A. Hypertensive urgency
B. Hypertensive emergency (malignant hypertension)
C. Migraine headache
D. Subarachnoid hemorrhage
: Answer : B
*Rationale: Hypertensive emergency is defined as severely elevated BP (>180/120
mmHg) with evidence of acute end-organ damage (encephalopathy, papilledema,
acute kidney injury, pulmonary edema). This requires immediate, controlled BP
reduction with IV agents. Hypertensive urgency lacks end-organ damage. SAH
typically presents with “thunderclap” headache.*
9. A patient with a prosthetic mitral valve and fever has a new regurgitant
murmur, splinter hemorrhages, and positive blood cultures for Staphylococcus
epidermidis. What is the most likely diagnosis?
A. Rheumatic fever
B. Infective endocarditis
C. Systemic lupus erythematosus
D. Disseminated intravascular coagulation
: Answer : B
Rationale: The triad of fever, new or changing murmur, and positive blood cultures
in a patient with a prosthetic valve strongly suggests infective endocarditis. S.
epidermidis is a common cause of prosthetic valve endocarditis. Embolic
phenomena (splinter hemorrhages) support the diagnosis.
10. A 25-year-old tall, thin male presents with sudden onset of right-sided chest
pain and dyspnea. Breath sounds are absent on the right, percussion is
hyperresonant, and the trachea is deviated to the left. What is the immediate
intervention?
A. Obtain a stat CT pulmonary angiogram
B. Perform needle decompression at the right 2nd intercostal space, midclavicular
line
C. Administer albuterol nebulizer
D. Insert a chest tube
: Answer : B
Rationale: This is a tension pneumothorax with mediastinal shift and
pg. 4
Barkley ENP-C Diagnostic Readiness Test (DRT) | 100
Emergency NP Practice Questions and Answers
Barkley ENP-C Diagnostic Readiness Test – 100 Questions
Section 1: Cardiovascular Emergencies (Questions 1–12)
1. A 60-year-old man presents with acute, severe, “tearing” chest pain radiating
to the back. He has a history of hypertension. Blood pressure is 168/92 mmHg in
the right arm and 106/70 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
: Answer : B
Rationale: The classic presentation of aortic dissection is sudden, tearing chest
pain radiating to the back. A difference in systolic BP >20 mmHg between arms
suggests involvement of the aortic arch branches. Widened mediastinum on CXR is
a classic but not definitive sign. Immediate CT angiography or transesophageal
echocardiography is required.
2. A 68-year-old woman with atrial fibrillation (not on anticoagulation) presents
with sudden onset of right-sided weakness and aphasia 90 minutes ago. CT head
without contrast is negative for hemorrhage. What is the most appropriate next
step?
A. Administer aspirin 325 mg and admit
B. Administer IV tissue plasminogen activator (tPA) if no contraindications
C. Start a heparin infusion immediately
D. Order MRI and await results
: Answer : B
Rationale: This is an acute ischemic stroke within the 3–4.5-hour thrombolytic
pg. 1
,2
window. A negative non-contrast CT rules out hemorrhage, making her a
candidate for IV tPA. Aspirin is given later (24 hours post-tPA); immediate heparin
is not standard for acute stroke unless for specific indications; MRI should not
delay tPA.
3. A 45-year-old man with chest pressure, diaphoresis, and nausea. ECG shows
ST-segment elevation in leads V1–V4. What is the most likely infarct location?
A. Inferior wall
B. Anterior wall
C. Lateral wall
D. Posterior wall
: Answer : B
Rationale: ST elevation in V1–V4 indicates anterior wall MI, usually due to left
anterior descending (LAD) artery occlusion. Inferior wall MI shows ST elevation in
II, III, aVF. Lateral wall involves I, aVL, V5–V6.
4. A 55-year-old man with chest pain and a history of GERD has a normal ECG
and normal troponin. Pain is reproducible with palpation of the left chest wall.
What is the most likely diagnosis?
A. Unstable angina
B. Costochondritis
C. Pulmonary embolism
D. Acute pericarditis
: Answer : B
Rationale: Reproducible chest wall tenderness suggests a musculoskeletal cause
like costochondritis. Unstable angina would have a concerning history and possibly
ECG changes. Pericarditis often has diffuse ST elevation and a friction rub.
5. A patient with heart failure with reduced ejection fraction (HFrEF) presents
with worsening dyspnea, orthopnea, and bilateral crackles. BNP is 1,200 pg/mL.
Which medication combination is proven to reduce mortality in HFrEF?
A. ACE inhibitor, beta blocker, mineralocorticoid receptor antagonist, SGLT2
inhibitor
B. Digoxin, furosemide, amlodipine
C. Hydralazine, isosorbide dinitrate, digoxin
D. Metoprolol, verapamil, furosemide
pg. 2
,3
: Answer : A
*Rationale: Guideline-directed medical therapy for HFrEF includes an ACE
inhibitor (or ARB/ARNI), a beta blocker, a mineralocorticoid receptor antagonist,
and an SGLT2 inhibitor. This “quadruple therapy” reduces mortality. Verapamil is
contraindicated in HFrEF; digoxin reduces hospitalizations but not mortality.*
6. A 30-year-old woman with palpitations and lightheadedness has a heart rate
of 180 bpm. ECG shows a narrow-complex tachycardia, no visible P waves, and
blood pressure 90/60 mmHg. What is the immediate treatment?
A. Adenosine 6 mg IV push
B. Synchronized cardioversion
C. Amiodarone 150 mg IV
D. Diltiazem 0.25 mg/kg IV
: Answer : B
Rationale: This is an unstable supraventricular tachycardia (SVT) with
hypotension. Unstable tachycardia requires immediate synchronized
cardioversion. Adenosine and diltiazem are for stable SVT. Amiodarone is
second-line.
7. An elderly patient with known coronary artery disease presents with
syncope. ECG shows Mobitz type II second-degree AV block. What is the most
appropriate management?
A. Observe on telemetry
B. Administer atropine 0.5 mg IV
C. Prepare for transcutaneous pacing and urgent cardiology consultation for
pacemaker
D. Discharge with a Holter monitor
: Answer : C
Rationale: Mobitz II block is often infranodal and can progress unpredictably to
complete heart block. It requires immediate pacing (transcutaneous or
transvenous) and permanent pacemaker. Atropine may be ineffective for
infranodal block.
8. A 72-year-old woman with hypertension and diabetes presents with an acute,
severe headache, altered mental status, and a blood pressure of 220/130
mmHg. Fundoscopy reveals papilledema. What is the diagnosis?
pg. 3
, 4
A. Hypertensive urgency
B. Hypertensive emergency (malignant hypertension)
C. Migraine headache
D. Subarachnoid hemorrhage
: Answer : B
*Rationale: Hypertensive emergency is defined as severely elevated BP (>180/120
mmHg) with evidence of acute end-organ damage (encephalopathy, papilledema,
acute kidney injury, pulmonary edema). This requires immediate, controlled BP
reduction with IV agents. Hypertensive urgency lacks end-organ damage. SAH
typically presents with “thunderclap” headache.*
9. A patient with a prosthetic mitral valve and fever has a new regurgitant
murmur, splinter hemorrhages, and positive blood cultures for Staphylococcus
epidermidis. What is the most likely diagnosis?
A. Rheumatic fever
B. Infective endocarditis
C. Systemic lupus erythematosus
D. Disseminated intravascular coagulation
: Answer : B
Rationale: The triad of fever, new or changing murmur, and positive blood cultures
in a patient with a prosthetic valve strongly suggests infective endocarditis. S.
epidermidis is a common cause of prosthetic valve endocarditis. Embolic
phenomena (splinter hemorrhages) support the diagnosis.
10. A 25-year-old tall, thin male presents with sudden onset of right-sided chest
pain and dyspnea. Breath sounds are absent on the right, percussion is
hyperresonant, and the trachea is deviated to the left. What is the immediate
intervention?
A. Obtain a stat CT pulmonary angiogram
B. Perform needle decompression at the right 2nd intercostal space, midclavicular
line
C. Administer albuterol nebulizer
D. Insert a chest tube
: Answer : B
Rationale: This is a tension pneumothorax with mediastinal shift and
pg. 4
