1
NBME 10 EXAM ACTUAL 2026/2027 | 200 Questions and
Correct Verified Answers | A Grade | USMLE Step 2 & Step 3
Prep | Pass Guaranteed - A+ Graded
Section 1: Internal Medicine - Cardiology & Pulmonology (Questions 1-25)
Q1. A 58-year-old man presents with crushing substernal chest pain radiating to his
left arm for 45 minutes. He is diaphoretic and hypotensive (BP 88/54 mmHg). ECG
shows ST elevations in leads V1-V4. Which is the most appropriate next step in
management?
A. Sublingual nitroglycerin
B. Aspirin and immediate primary PCI
C. Thrombolytics alone
D. β-blocker therapy and observation
B. Aspirin and immediate primary PCI [CORRECT]
Rationale: STEMI with cardiogenic shock requires emergent reperfusion; primary PCI
is preferred over thrombolytics when available within 90 minutes. Nitroglycerin is
contraindicated in hypotension.
Correct Answer: B
Q2. A 72-year-old woman with a history of atrial fibrillation on warfarin presents with
acute onset right-sided weakness and aphasia. CT head shows no hemorrhage. INR is
2.8. Which is the most appropriate management?
A. Immediate IV tissue plasminogen activator (tPA)
B. Await INR normalization before thrombolysis
C. Mechanical thrombectomy if within 6 hours and large vessel occlusion
D. Aspirin 325 mg immediately
C. Mechanical thrombectomy if within 6 hours and large vessel occlusion
[CORRECT]
Rationale: tPA is contraindicated with INR >1.7; mechanical thrombectomy is
indicated for large vessel occlusion within 6-24 hours in selected patients. Aspirin is
given after hemorrhage is excluded but does not address large vessel occlusion.
Correct Answer: C
,2
Q3. A 45-year-old man with hypertension presents with exertional dyspnea and
orthopnea. On exam, an S4 gallop and displaced PMI are noted. ECG shows left
ventricular hypertrophy. Echocardiogram reveals an ejection fraction of 30% with
dilated left ventricle. Which medication has been shown to reduce mortality in this
patient?
A. Digoxin
B. Hydralazine
C. Sacubitril/valsartan
D. Diltiazem
C. Sacubitril/valsartan [CORRECT]
Rationale: In HFrEF (EF ≤40%), ACE inhibitors/ARBs/ARNI reduce mortality;
sacubitril/valsartan (ARNI) is superior to enalapril in reducing cardiovascular death
and hospitalization. Digoxin improves symptoms but not mortality. Diltiazem is
contraindicated in HFrEF.
Correct Answer: C
Q4. A 62-year-old man with a mechanical mitral valve replacement presents for a
dental cleaning. He has no drug allergies. Which prophylactic regimen is most
appropriate?
A. Amoxicillin 2 g PO single dose
B. Clindamycin 600 mg PO single dose
C. Ampicillin/sulbactam 3 g IV single dose
D. No antibiotic prophylaxis needed
A. Amoxicillin 2 g PO single dose [CORRECT]
Rationale: AHA guidelines recommend prophylaxis against viridans streptococci for
high-risk cardiac conditions (prosthetic valves, prior IE, unrepaired cyanotic CHD)
before dental procedures involving gingival manipulation. Amoxicillin is first-line.
Correct Answer: A
Q5. A 35-year-old woman presents with palpitations and lightheadedness. ECG
shows irregularly irregular rhythm, no P waves, and narrow QRS complexes. HR is 150
bpm. She is hemodynamically stable. What is the next best step?
A. Immediate synchronized cardioversion
B. IV adenosine
,3
C. IV metoprolol or diltiazem for rate control
D. IV heparin and transesophageal echocardiogram-guided cardioversion
C. IV metoprolol or diltiazem for rate control [CORRECT]
Rationale: Hemodynamically stable AF with rapid ventricular response requires rate
control first; beta-blockers or non-DHP CCBs are preferred. Adenosine is used for
SVT/AVNRT, not AF. Cardioversion is for unstable patients or after anticoagulation if
>48 hours.
Correct Answer: C
Q6. A 68-year-old man with COPD presents with worsening dyspnea, increased
sputum production, and fever. He is alert with RR 28, O2 sat 88% on room air. ABG:
pH 7.32, PaCO2 58, PaO2 52. Which is the most appropriate initial oxygen delivery
strategy?
A. 100% non-rebreather mask
B. Nasal cannula at 2 L/min, titrated to SpO2 88-92%
C. High-flow nasal cannula at 60 L/min
D. BiPAP with FiO2 1.0
B. Nasal cannula at 2 L/min, titrated to SpO2 88-92% [CORRECT]
Rationale: In COPD with chronic hypercapnia, high-concentration oxygen suppresses
hypoxic drive causing CO2 retention; target SpO2 88-92%. NRB or high FiO2 risks
respiratory acidosis worsening. BiPAP is indicated if acidosis persists despite
controlled O2.
Correct Answer: B
Q7. A 55-year-old man presents with sudden onset pleuritic chest pain and dyspnea.
He recently had a long-haul flight. D-dimer is 1200 ng/mL. CT pulmonary
angiography shows a filling defect in the right pulmonary artery. BP is 110/70. Which
is the preferred initial treatment?
A. Unfractionated heparin IV
B. Subcutaneous enoxaparin
C. Thrombolytics
D. Inferior vena cava filter
B. Subcutaneous enoxaparin [CORRECT]
Rationale: Hemodynamically stable PE is treated with anticoagulation; LMWH
, 4
(enoxaparin) is preferred over unfractionated heparin for stable patients due to ease
of administration and no need for monitoring. Thrombolytics are for massive PE with
hemodynamic compromise.
Correct Answer: B
Q8. A 40-year-old woman presents with progressive dyspnea and dry cough. She has
no smoking history. CT chest shows bilateral reticular opacities with traction
bronchiectasis predominantly in lower lobes. HRCT shows honeycombing. Pulmonary
function tests show restrictive pattern with decreased DLCO. Which diagnosis is most
likely?
A. Sarcoidosis
B. Idiopathic pulmonary fibrosis
C. Nonspecific interstitial pneumonia
D. Hypersensitivity pneumonitis
B. Idiopathic pulmonary fibrosis [CORRECT]
Rationale: UIP pattern on HRCT (subpleural, basal predominant reticulation,
honeycombing, traction bronchiectasis) with restrictive physiology and reduced
DLCO is diagnostic of IPF without biopsy if classic. Sarcoidosis shows upper lobe/hilar
predominance. NSIP has ground glass without honeycombing.
Correct Answer: B
Q9. A 28-year-old man is brought to the ED after a syncopal episode during
basketball. Family history reveals a brother who died suddenly at age 24. ECG shows
left ventricular hypertrophy with deep S waves in V1 and tall R waves in V5-V6, and
diffuse ST-segment depression with T-wave inversions. Which is the most likely
diagnosis?
A. Arrhythmogenic right ventricular cardiomyopathy
B. Hypertrophic cardiomyopathy
C. Dilated cardiomyopathy
D. Long QT syndrome
B. Hypertrophic cardiomyopathy [CORRECT]
Rationale: HCM presents with exertional syncope, family history of sudden death, and
ECG showing LVH with strain pattern; it is the most common cause of sudden cardiac
death in young athletes. ARVC shows epsilon waves and T-wave inversions in V1-V3.
Correct Answer: B
NBME 10 EXAM ACTUAL 2026/2027 | 200 Questions and
Correct Verified Answers | A Grade | USMLE Step 2 & Step 3
Prep | Pass Guaranteed - A+ Graded
Section 1: Internal Medicine - Cardiology & Pulmonology (Questions 1-25)
Q1. A 58-year-old man presents with crushing substernal chest pain radiating to his
left arm for 45 minutes. He is diaphoretic and hypotensive (BP 88/54 mmHg). ECG
shows ST elevations in leads V1-V4. Which is the most appropriate next step in
management?
A. Sublingual nitroglycerin
B. Aspirin and immediate primary PCI
C. Thrombolytics alone
D. β-blocker therapy and observation
B. Aspirin and immediate primary PCI [CORRECT]
Rationale: STEMI with cardiogenic shock requires emergent reperfusion; primary PCI
is preferred over thrombolytics when available within 90 minutes. Nitroglycerin is
contraindicated in hypotension.
Correct Answer: B
Q2. A 72-year-old woman with a history of atrial fibrillation on warfarin presents with
acute onset right-sided weakness and aphasia. CT head shows no hemorrhage. INR is
2.8. Which is the most appropriate management?
A. Immediate IV tissue plasminogen activator (tPA)
B. Await INR normalization before thrombolysis
C. Mechanical thrombectomy if within 6 hours and large vessel occlusion
D. Aspirin 325 mg immediately
C. Mechanical thrombectomy if within 6 hours and large vessel occlusion
[CORRECT]
Rationale: tPA is contraindicated with INR >1.7; mechanical thrombectomy is
indicated for large vessel occlusion within 6-24 hours in selected patients. Aspirin is
given after hemorrhage is excluded but does not address large vessel occlusion.
Correct Answer: C
,2
Q3. A 45-year-old man with hypertension presents with exertional dyspnea and
orthopnea. On exam, an S4 gallop and displaced PMI are noted. ECG shows left
ventricular hypertrophy. Echocardiogram reveals an ejection fraction of 30% with
dilated left ventricle. Which medication has been shown to reduce mortality in this
patient?
A. Digoxin
B. Hydralazine
C. Sacubitril/valsartan
D. Diltiazem
C. Sacubitril/valsartan [CORRECT]
Rationale: In HFrEF (EF ≤40%), ACE inhibitors/ARBs/ARNI reduce mortality;
sacubitril/valsartan (ARNI) is superior to enalapril in reducing cardiovascular death
and hospitalization. Digoxin improves symptoms but not mortality. Diltiazem is
contraindicated in HFrEF.
Correct Answer: C
Q4. A 62-year-old man with a mechanical mitral valve replacement presents for a
dental cleaning. He has no drug allergies. Which prophylactic regimen is most
appropriate?
A. Amoxicillin 2 g PO single dose
B. Clindamycin 600 mg PO single dose
C. Ampicillin/sulbactam 3 g IV single dose
D. No antibiotic prophylaxis needed
A. Amoxicillin 2 g PO single dose [CORRECT]
Rationale: AHA guidelines recommend prophylaxis against viridans streptococci for
high-risk cardiac conditions (prosthetic valves, prior IE, unrepaired cyanotic CHD)
before dental procedures involving gingival manipulation. Amoxicillin is first-line.
Correct Answer: A
Q5. A 35-year-old woman presents with palpitations and lightheadedness. ECG
shows irregularly irregular rhythm, no P waves, and narrow QRS complexes. HR is 150
bpm. She is hemodynamically stable. What is the next best step?
A. Immediate synchronized cardioversion
B. IV adenosine
,3
C. IV metoprolol or diltiazem for rate control
D. IV heparin and transesophageal echocardiogram-guided cardioversion
C. IV metoprolol or diltiazem for rate control [CORRECT]
Rationale: Hemodynamically stable AF with rapid ventricular response requires rate
control first; beta-blockers or non-DHP CCBs are preferred. Adenosine is used for
SVT/AVNRT, not AF. Cardioversion is for unstable patients or after anticoagulation if
>48 hours.
Correct Answer: C
Q6. A 68-year-old man with COPD presents with worsening dyspnea, increased
sputum production, and fever. He is alert with RR 28, O2 sat 88% on room air. ABG:
pH 7.32, PaCO2 58, PaO2 52. Which is the most appropriate initial oxygen delivery
strategy?
A. 100% non-rebreather mask
B. Nasal cannula at 2 L/min, titrated to SpO2 88-92%
C. High-flow nasal cannula at 60 L/min
D. BiPAP with FiO2 1.0
B. Nasal cannula at 2 L/min, titrated to SpO2 88-92% [CORRECT]
Rationale: In COPD with chronic hypercapnia, high-concentration oxygen suppresses
hypoxic drive causing CO2 retention; target SpO2 88-92%. NRB or high FiO2 risks
respiratory acidosis worsening. BiPAP is indicated if acidosis persists despite
controlled O2.
Correct Answer: B
Q7. A 55-year-old man presents with sudden onset pleuritic chest pain and dyspnea.
He recently had a long-haul flight. D-dimer is 1200 ng/mL. CT pulmonary
angiography shows a filling defect in the right pulmonary artery. BP is 110/70. Which
is the preferred initial treatment?
A. Unfractionated heparin IV
B. Subcutaneous enoxaparin
C. Thrombolytics
D. Inferior vena cava filter
B. Subcutaneous enoxaparin [CORRECT]
Rationale: Hemodynamically stable PE is treated with anticoagulation; LMWH
, 4
(enoxaparin) is preferred over unfractionated heparin for stable patients due to ease
of administration and no need for monitoring. Thrombolytics are for massive PE with
hemodynamic compromise.
Correct Answer: B
Q8. A 40-year-old woman presents with progressive dyspnea and dry cough. She has
no smoking history. CT chest shows bilateral reticular opacities with traction
bronchiectasis predominantly in lower lobes. HRCT shows honeycombing. Pulmonary
function tests show restrictive pattern with decreased DLCO. Which diagnosis is most
likely?
A. Sarcoidosis
B. Idiopathic pulmonary fibrosis
C. Nonspecific interstitial pneumonia
D. Hypersensitivity pneumonitis
B. Idiopathic pulmonary fibrosis [CORRECT]
Rationale: UIP pattern on HRCT (subpleural, basal predominant reticulation,
honeycombing, traction bronchiectasis) with restrictive physiology and reduced
DLCO is diagnostic of IPF without biopsy if classic. Sarcoidosis shows upper lobe/hilar
predominance. NSIP has ground glass without honeycombing.
Correct Answer: B
Q9. A 28-year-old man is brought to the ED after a syncopal episode during
basketball. Family history reveals a brother who died suddenly at age 24. ECG shows
left ventricular hypertrophy with deep S waves in V1 and tall R waves in V5-V6, and
diffuse ST-segment depression with T-wave inversions. Which is the most likely
diagnosis?
A. Arrhythmogenic right ventricular cardiomyopathy
B. Hypertrophic cardiomyopathy
C. Dilated cardiomyopathy
D. Long QT syndrome
B. Hypertrophic cardiomyopathy [CORRECT]
Rationale: HCM presents with exertional syncope, family history of sudden death, and
ECG showing LVH with strain pattern; it is the most common cause of sudden cardiac
death in young athletes. ARVC shows epsilon waves and T-wave inversions in V1-V3.
Correct Answer: B
