1
Barkley ENP-C Diagnostic Readiness Test (DRT) #2 | 100
Predictor Questions and Answers
Section 1: Cardiovascular Emergencies (Questions 1–12)
1. A 72-year-old woman with hypertension and diabetes presents with a 2-hour
history of substernal chest pressure radiating to the left jaw, diaphoresis, and
nausea. An ECG reveals ST-segment elevation in leads II, III, and aVF. The patient
is in the emergency department with an interventional cardiology team
available in 90 minutes. What is the most appropriate immediate management?
A. Administer tenecteplase (TNK) immediately
B. Start a heparin infusion and transfer to the catheterization lab for primary PCI
C. Administer clopidogrel 600 mg and aspirin 324 mg, then transfer for primary
PCI
D. Give IV nitroglycerin and observe for 2 hours
: Correct Answer : C
Rationale: For an inferior STEMI with expected PCI within 90 minutes, primary PCI
is the preferred reperfusion strategy over fibrinolysis (A). Dual antiplatelet
therapy with aspirin and a P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel)
should be initiated prior to or upon arrival in the catheterization lab. Heparin
alone (B) is insufficient. Nitroglycerin (D) may provide symptom relief but does
not address reperfusion. The correct answer is to load antiplatelets and proceed
to PCI.
2. A 64-year-old man with a history of heart failure with reduced ejection
fraction (HFrEF) presents with worsening dyspnea, orthopnea, and 3-plus pitting
edema. His blood pressure is 100/62 mmHg, heart rate 70 bpm. He is currently
on lisinopril 10 mg BID, carvedilol 25 mg BID, spironolactone 25 mg daily, and
furosemide 40 mg daily. Which of the following medication adjustments is most
appropriate during this acute decompensated heart failure admission?
A. Increase carvedilol to 50 mg BID
B. Hold carvedilol, increase furosemide, and add a thiazide diuretic for sequential
nephron blockade
pg. 1
,2
C. Start sacubitril/valsartan immediately
D. Administer a 500 mL normal saline bolus
: Correct Answer : B
Rationale: In acute decompensated heart failure with low blood pressure,
beta-blockers should be held or reduced to allow the heart to compensate with
appropriate sympathetic drive, and aggressive diuresis is the priority. Adding a
thiazide (metolazone) to a loop diuretic overcomes diuretic resistance.
Sacubitril/valsartan (C) is initiated in stable, euvolemic patients. A saline bolus (D)
would worsen volume overload.
3. A 25-year-old man presents after a motor vehicle collision with tachycardia,
hypotension, muffled heart tones, and distended neck veins. Breath sounds are
equal bilaterally. FAST exam reveals a pericardial effusion. What is the
immediate intervention?
A. Needle decompression of the left chest
B. Pericardiocentesis
C. Large-volume IV crystalloid resuscitation
D. Immediate thoracotomy
: Correct Answer : B
Rationale: Beck’s triad (hypotension, muffled heart sounds, JVD) with a
pericardial effusion on FAST is cardiac tamponade. Pericardiocentesis is the
emergent, life-saving procedure to remove fluid from the pericardial sac. Needle
decompression (A) is for tension pneumothorax, which would present with absent
breath sounds and tracheal deviation. Fluids (C) are a temporizing measure.
Thoracotomy (D) is a last resort in the operating room.
4. A 55-year-old man presents with “tearing” chest pain radiating to the back, a
blood pressure of 180/110 mmHg, and a widened mediastinum on chest X-ray.
CT angiogram confirms a Stanford type B aortic dissection. What is the definitive
initial management?
A. Emergency open surgical repair
B. Aggressive blood pressure control with beta-blockers and vasodilators, and
close monitoring
C. Endovascular stent grafting within 2 hours
D. Intra-aortic balloon pump
pg. 2
,3
: Correct Answer : B
Rationale: Stanford type B dissections (distal to the left subclavian artery) are
typically managed medically with strict blood pressure control (target SBP 100–
120 mmHg) using a beta-blocker first (e.g., esmolol) followed by a vasodilator
(e.g., nitroprusside), unless complicated by malperfusion, rupture, or refractory
hypertension. Surgery or endovascular repair (A, C) is reserved for complications.
An intra-aortic balloon pump (D) is contraindicated.
5. A 70-year-old woman with atrial fibrillation not on anticoagulation presents
with acute onset of right upper quadrant pain, nausea, and a history of
congestive heart failure. Her abdomen is soft with mild tenderness. An ECG
shows atrial fibrillation. She is mildly hypotensive. Laboratory studies are
pending. Which diagnosis is most concerning?
A. Acute cholecystitis
B. Mesenteric ischemia
C. Renal infarction
D. Splenic abscess
: Correct Answer : B
Rationale: Atrial fibrillation predisposes to embolic events. Acute mesenteric
ischemia from a superior mesenteric artery embolism presents with severe pain
out of proportion to exam, often with nausea and vomiting, and can rapidly lead
to bowel necrosis and shock. Early CT angiography is critical. The other options
are less likely given the acute nature and AF.
6. A 30-year-old woman with palpitations and a heart rate of 190 bpm has a
narrow-complex, regular tachycardia on ECG. Blood pressure is 100/70 mmHg.
She is alert but anxious. Vagal maneuvers are unsuccessful. What is the first-line
pharmacologic agent?
A. Adenosine 6 mg rapid IV push
B. Diltiazem 0.25 mg/kg IV
C. Metoprolol 5 mg IV
D. Synchronized cardioversion
: Correct Answer : A
Rationale: This is stable supraventricular tachycardia (SVT). After failed vagal
maneuvers, adenosine is the first-line drug due to its rapid onset and short
pg. 3
, 4
half-life, blocking the AV node and terminating most reentrant SVTs. Diltiazem (B)
and metoprolol (C) are second-line options for rate control. Synchronized
cardioversion (D) is for unstable patients (hypotension, altered mental status).
Her BP is adequate, making her stable.
7. A 58-year-old man presents with syncope while shoveling snow. He now has
chest pain. ECG shows ST-segment elevation in leads V1–V4. He becomes
unresponsive, and the monitor shows ventricular fibrillation. What is the first
action?
A. Administer amiodarone 300 mg IV
B. Immediate defibrillation
C. Start cardiopulmonary resuscitation (CPR) for 2 minutes before defibrillation
D. Give epinephrine 1 mg IV
: Correct Answer : B
Rationale: For witnessed ventricular fibrillation in a monitored setting, immediate
defibrillation is the priority, not CPR first. CPR is initiated if defibrillation is delayed
or after the first shock. Amiodarone and epinephrine are given after initial
defibrillation attempts if the rhythm persists.
8. A 62-year-old woman with a history of diabetes and hypertension develops
acute onset of severe, diffuse abdominal pain and is in atrial fibrillation on ECG.
Her lactate is 6 mmol/L. CT angiography reveals superior mesenteric artery
occlusion. What is the most appropriate next step?
A. Start therapeutic heparin and observe
B. Emergent surgical embolectomy or endovascular thrombectomy
C. Broad-spectrum antibiotics and bowel rest
D. Vasodilator therapy with papaverine
: Correct Answer : B
Rationale: Acute mesenteric ischemia with an embolic occlusion and elevated
lactate indicates bowel infarction is imminent. The definitive treatment is urgent
revascularization via embolectomy (surgical or endovascular) and assessment of
bowel viability. Heparin alone (A) will not restore flow. Antibiotics and bowel rest
(C) are supportive, not definitive. Papaverine (D) is sometimes used for
non-occlusive mesenteric ischemia.
pg. 4
Barkley ENP-C Diagnostic Readiness Test (DRT) #2 | 100
Predictor Questions and Answers
Section 1: Cardiovascular Emergencies (Questions 1–12)
1. A 72-year-old woman with hypertension and diabetes presents with a 2-hour
history of substernal chest pressure radiating to the left jaw, diaphoresis, and
nausea. An ECG reveals ST-segment elevation in leads II, III, and aVF. The patient
is in the emergency department with an interventional cardiology team
available in 90 minutes. What is the most appropriate immediate management?
A. Administer tenecteplase (TNK) immediately
B. Start a heparin infusion and transfer to the catheterization lab for primary PCI
C. Administer clopidogrel 600 mg and aspirin 324 mg, then transfer for primary
PCI
D. Give IV nitroglycerin and observe for 2 hours
: Correct Answer : C
Rationale: For an inferior STEMI with expected PCI within 90 minutes, primary PCI
is the preferred reperfusion strategy over fibrinolysis (A). Dual antiplatelet
therapy with aspirin and a P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel)
should be initiated prior to or upon arrival in the catheterization lab. Heparin
alone (B) is insufficient. Nitroglycerin (D) may provide symptom relief but does
not address reperfusion. The correct answer is to load antiplatelets and proceed
to PCI.
2. A 64-year-old man with a history of heart failure with reduced ejection
fraction (HFrEF) presents with worsening dyspnea, orthopnea, and 3-plus pitting
edema. His blood pressure is 100/62 mmHg, heart rate 70 bpm. He is currently
on lisinopril 10 mg BID, carvedilol 25 mg BID, spironolactone 25 mg daily, and
furosemide 40 mg daily. Which of the following medication adjustments is most
appropriate during this acute decompensated heart failure admission?
A. Increase carvedilol to 50 mg BID
B. Hold carvedilol, increase furosemide, and add a thiazide diuretic for sequential
nephron blockade
pg. 1
,2
C. Start sacubitril/valsartan immediately
D. Administer a 500 mL normal saline bolus
: Correct Answer : B
Rationale: In acute decompensated heart failure with low blood pressure,
beta-blockers should be held or reduced to allow the heart to compensate with
appropriate sympathetic drive, and aggressive diuresis is the priority. Adding a
thiazide (metolazone) to a loop diuretic overcomes diuretic resistance.
Sacubitril/valsartan (C) is initiated in stable, euvolemic patients. A saline bolus (D)
would worsen volume overload.
3. A 25-year-old man presents after a motor vehicle collision with tachycardia,
hypotension, muffled heart tones, and distended neck veins. Breath sounds are
equal bilaterally. FAST exam reveals a pericardial effusion. What is the
immediate intervention?
A. Needle decompression of the left chest
B. Pericardiocentesis
C. Large-volume IV crystalloid resuscitation
D. Immediate thoracotomy
: Correct Answer : B
Rationale: Beck’s triad (hypotension, muffled heart sounds, JVD) with a
pericardial effusion on FAST is cardiac tamponade. Pericardiocentesis is the
emergent, life-saving procedure to remove fluid from the pericardial sac. Needle
decompression (A) is for tension pneumothorax, which would present with absent
breath sounds and tracheal deviation. Fluids (C) are a temporizing measure.
Thoracotomy (D) is a last resort in the operating room.
4. A 55-year-old man presents with “tearing” chest pain radiating to the back, a
blood pressure of 180/110 mmHg, and a widened mediastinum on chest X-ray.
CT angiogram confirms a Stanford type B aortic dissection. What is the definitive
initial management?
A. Emergency open surgical repair
B. Aggressive blood pressure control with beta-blockers and vasodilators, and
close monitoring
C. Endovascular stent grafting within 2 hours
D. Intra-aortic balloon pump
pg. 2
,3
: Correct Answer : B
Rationale: Stanford type B dissections (distal to the left subclavian artery) are
typically managed medically with strict blood pressure control (target SBP 100–
120 mmHg) using a beta-blocker first (e.g., esmolol) followed by a vasodilator
(e.g., nitroprusside), unless complicated by malperfusion, rupture, or refractory
hypertension. Surgery or endovascular repair (A, C) is reserved for complications.
An intra-aortic balloon pump (D) is contraindicated.
5. A 70-year-old woman with atrial fibrillation not on anticoagulation presents
with acute onset of right upper quadrant pain, nausea, and a history of
congestive heart failure. Her abdomen is soft with mild tenderness. An ECG
shows atrial fibrillation. She is mildly hypotensive. Laboratory studies are
pending. Which diagnosis is most concerning?
A. Acute cholecystitis
B. Mesenteric ischemia
C. Renal infarction
D. Splenic abscess
: Correct Answer : B
Rationale: Atrial fibrillation predisposes to embolic events. Acute mesenteric
ischemia from a superior mesenteric artery embolism presents with severe pain
out of proportion to exam, often with nausea and vomiting, and can rapidly lead
to bowel necrosis and shock. Early CT angiography is critical. The other options
are less likely given the acute nature and AF.
6. A 30-year-old woman with palpitations and a heart rate of 190 bpm has a
narrow-complex, regular tachycardia on ECG. Blood pressure is 100/70 mmHg.
She is alert but anxious. Vagal maneuvers are unsuccessful. What is the first-line
pharmacologic agent?
A. Adenosine 6 mg rapid IV push
B. Diltiazem 0.25 mg/kg IV
C. Metoprolol 5 mg IV
D. Synchronized cardioversion
: Correct Answer : A
Rationale: This is stable supraventricular tachycardia (SVT). After failed vagal
maneuvers, adenosine is the first-line drug due to its rapid onset and short
pg. 3
, 4
half-life, blocking the AV node and terminating most reentrant SVTs. Diltiazem (B)
and metoprolol (C) are second-line options for rate control. Synchronized
cardioversion (D) is for unstable patients (hypotension, altered mental status).
Her BP is adequate, making her stable.
7. A 58-year-old man presents with syncope while shoveling snow. He now has
chest pain. ECG shows ST-segment elevation in leads V1–V4. He becomes
unresponsive, and the monitor shows ventricular fibrillation. What is the first
action?
A. Administer amiodarone 300 mg IV
B. Immediate defibrillation
C. Start cardiopulmonary resuscitation (CPR) for 2 minutes before defibrillation
D. Give epinephrine 1 mg IV
: Correct Answer : B
Rationale: For witnessed ventricular fibrillation in a monitored setting, immediate
defibrillation is the priority, not CPR first. CPR is initiated if defibrillation is delayed
or after the first shock. Amiodarone and epinephrine are given after initial
defibrillation attempts if the rhythm persists.
8. A 62-year-old woman with a history of diabetes and hypertension develops
acute onset of severe, diffuse abdominal pain and is in atrial fibrillation on ECG.
Her lactate is 6 mmol/L. CT angiography reveals superior mesenteric artery
occlusion. What is the most appropriate next step?
A. Start therapeutic heparin and observe
B. Emergent surgical embolectomy or endovascular thrombectomy
C. Broad-spectrum antibiotics and bowel rest
D. Vasodilator therapy with papaverine
: Correct Answer : B
Rationale: Acute mesenteric ischemia with an embolic occlusion and elevated
lactate indicates bowel infarction is imminent. The definitive treatment is urgent
revascularization via embolectomy (surgical or endovascular) and assessment of
bowel viability. Heparin alone (A) will not restore flow. Antibiotics and bowel rest
(C) are supportive, not definitive. Papaverine (D) is sometimes used for
non-occlusive mesenteric ischemia.
pg. 4
