ANCC FNP Exam Prep 2026 | Bank with Rationales |
Pass Guarantee
1. In a patient with suspected acute coronary syndrome, the initial high-sensitivity cardiac
troponin I level is below the 99th percentile upper reference limit. The patient has had chest
discomfort for 4 hours, is hemodynamically stable, and has a normal ECG. Which of the following
management strategies is most appropriate according to current guidelines?
A. Admit for observation and repeat troponin at 3 hours; if negative, perform exercise stress test.
B. Discharge home with outpatient follow-up and a prescription for aspirin 81 mg daily.
C. Administer thrombolytic therapy empirically given high clinical suspicion.
D. Proceed directly to coronary angiography for definitive diagnosis.
Answer: A
Rationale: The 2020 ESC guidelines recommend serial troponin measurements (0 and 3 hours) in
patients with suspected NSTEMI and low-risk features. Option A aligns with this strategy. Discharge
without repeat testing (B) risks missing evolving MI. Thrombolysis (C) is not indicated without
ST-elevation or new LBBB. Angiography (D) is reserved for high-risk patients (e.g., refractory ischemia,
hemodynamic instability).
2. A 30-year-old patient with a history of well-controlled type 1 diabetes mellitus and no other
comorbidities presents with acute onset of severe right lower quadrant abdominal pain, nausea,
and low-grade fever. Laboratory studies show leukocytosis with left shift, normal lipase, and
urinalysis negative for infection. CT scan reveals a non-enlarged appendix with wall thickening
and periappendiceal fat stranding. Which of the following is the most appropriate next step?
A. Initiate intravenous antibiotics and schedule for urgent appendectomy.
B. Administer a single dose of broad-spectrum antibiotics and observe for 24 hours.
C. Recommend non-steroidal anti-inflammatory drugs and outpatient follow-up.
D. Perform colonoscopy to rule out inflammatory bowel disease before intervention.
Answer: A
Rationale: CT findings confirm acute appendicitis. Current surgical guidelines (e.g., EAST, WSES)
recommend urgent appendectomy with preoperative antibiotics. Observation (B) is not standard for
confirmed appendicitis; it is reserved for equivocal cases. NSAIDs alone (C) delay definitive care.
Colonoscopy (D) is contraindicated in acute inflammation due to perforation risk.
3. Which of the following mechanisms best explains the increased risk of venous thromboembolism
in patients with antiphospholipid syndrome (APS) compared to those with factor V Leiden
mutation?
A. APS causes direct activation of protein C, leading to uncontrolled coagulation.
B. APS antibodies inhibit annexin A5 anticoagulant shield on endothelial cells.
Page 1
,C. Factor V Leiden mutation results in resistance to activated protein C, but APS causes deficiency of
antithrombin III.
D. Both conditions increase tissue factor expression, but APS additionally impairs fibrinolysis.
Answer: B
Rationale: APS antibodies disrupt the annexin A5 anticoagulant shield, exposing procoagulant
phospholipids. Factor V Leiden causes activated protein C resistance, but not via annexin A5. Option A
is incorrect because APS does not activate protein C. Option C is false: APS does not cause
antithrombin III deficiency. Option D: while both may involve tissue factor, impaired fibrinolysis is not a
primary mechanism in APS.
4. A patient with chronic kidney disease stage G3b (eGFR 38 mL/min/1.73m²) and hypertension is
currently on lisinopril 20 mg daily and amlodipine 5 mg daily. Blood pressure is 148/92 mmHg.
Urine albumin-to-creatinine ratio is 300 mg/g. Which of the following medication adjustments is
most appropriate to achieve target blood pressure and reduce proteinuria?
A. Increase lisinopril to 40 mg daily and add chlorthalidone 12.5 mg daily.
B. Discontinue amlodipine and start hydralazine 25 mg three times daily.
C. Add spironolactone 25 mg daily to the current regimen.
D. Switch lisinopril to losartan 50 mg daily and add metoprolol 25 mg daily.
Answer: A
Rationale: KDIGO guidelines recommend maximizing ACEi/ARB dose for proteinuria >300 mg/g, then
adding a thiazide diuretic (chlorthalidone preferred in CKD). Option A achieves both goals.
Hydralazine (B) is third-line and not first add-on. Spironolactone (C) increases hyperkalemia risk with
ACEi in CKD. Switching to ARB (D) is not superior; adding beta-blocker is not first-line for
hypertension without compelling indication.
5. A 45-year-old patient with a body mass index of 34 kg/m², impaired fasting glucose (110 mg/dL),
and triglycerides 280 mg/dL is found to have a fasting plasma glucose of 126 mg/dL on two
separate occasions. HbA1c is 6.8%. According to the American Diabetes Association Standards of
Medical Care in Diabetes-2024, which of the following is the most appropriate pharmacologic
agent to initiate as first-line therapy?
A. Metformin titrated to 2000 mg daily, with lifestyle modification.
B. Liraglutide 1.2 mg daily, given the need for weight loss.
C. Empagliflozin 10 mg daily, due to cardiovascular risk reduction.
D. Insulin glargine 10 units at bedtime, given the elevated fasting glucose.
Answer: A
Rationale: Metformin remains first-line for type 2 diabetes (ADA 2024). The patient has no ASCVD, HF,
or CKD to mandate SGLT2i/GLP-1 RA as first-line. Liraglutide (B) is second-line or if ASCVD/high
risk. Empagliflozin (C) is indicated if ASCVD, HF, or CKD. Insulin (D) is not first-line unless
symptomatic hyperglycemia (HbA1c >9-10% or glucose >300 mg/dL).
Page 2
,6. A patient with a history of opioid use disorder on buprenorphine/naloxone maintenance presents
with acute onset of severe, colicky right upper quadrant pain radiating to the back, nausea, and
emesis. Vital signs: temperature 38.5°C, heart rate 110 bpm, blood pressure 100/70 mmHg.
Laboratory studies show WBC 14,000/µL, total bilirubin 3.2 mg/dL, direct bilirubin 2.1 mg/dL,
AST 85 U/L, ALT 90 U/L, alkaline phosphatase 350 U/L, lipase 45 U/L. Right upper quadrant
ultrasound shows a distended gallbladder with a thickened wall and a 1.2 cm stone at the neck, but
no common bile duct dilation. Which of the following is the most appropriate next step?
A. Administer intravenous fluids, antibiotics, and schedule for laparoscopic cholecystectomy within 24 hours.
B. Start intravenous antibiotics and perform endoscopic retrograde cholangiopancreatography (ERCP) urgently.
C. Place a nasogastric tube, administer intravenous fluids, and schedule cholecystectomy in 6 weeks.
D. Obtain a magnetic resonance cholangiopancreatography (MRCP) to evaluate for choledocholithiasis before
intervention.
Answer: A
Rationale: The patient has acute cholecystitis (Murphy's sign implied, ultrasound findings). Tokyo
Guidelines recommend early cholecystectomy (within 24-72 hours) for mild to moderate cholecystitis.
ERCP (B) is indicated if cholangitis or CBD stone suspected; here, no CBD dilation and elevated
bilirubin may be due to Mirizzi syndrome or inflammation. Delayed surgery (C) increases recurrence
risk. MRCP (D) would delay care and is not necessary if no CBD dilation.
7. A patient with a history of recurrent major depressive disorder (MDD) currently on sertraline
200 mg daily for 8 weeks reports persistent depressive symptoms with a PHQ-9 score of 18. The
patient denies suicidal ideation. Which of the following is the most appropriate next step according
to the STAR*D trial evidence?
A. Switch to venlafaxine 75 mg daily and titrate upward.
B. Augment with aripiprazole 2 mg daily.
C. Increase sertraline to 250 mg daily.
D. Add bupropion sustained-release 150 mg daily.
Answer: D
Rationale: The STAR*D trial showed that after non-response to an SSRI, augmentation with bupropion
was effective and well-tolerated. Switching to another class (A) is an option but augmentation is
preferred given partial response? Actually, the patient has been on maximum SSRI dose for 8 weeks with
no response; STAR*D supports augmentation or switch. Among options, bupropion augmentation (D) is
a first-line augmentation strategy. Aripiprazole (B) is FDA-approved but typically after 2 failed trials.
Dose >200 mg (C) is off-label and not recommended. Venlafaxine switch (A) is reasonable but not as
strongly supported as augmentation in the context of this question.
8. A patient with a history of hypertension and type 2 diabetes presents with a blood pressure of
168/104 mmHg, serum creatinine 1.5 mg/dL (eGFR 48 mL/min/1.73m²), and potassium 5.1
mEq/L. Current medications: lisinopril 40 mg daily, amlodipine 10 mg daily, and
hydrochlorothiazide 25 mg daily. Which of the following antihypertensive agents is safest to add to
achieve blood pressure control?
A. Spironolactone 25 mg daily.
B. Metoprolol tartrate 50 mg twice daily.
Page 3
, C. Clonidine 0.1 mg twice daily.
D. Hydralazine 25 mg three times daily.
Answer: B
Rationale: The patient has resistant hypertension with CKD and hyperkalemia. Beta-blockers
(metoprolol) are safe and effective add-on therapy. Spironolactone (A) increases hyperkalemia risk with
ACEi and CKD. Clonidine (C) can cause rebound hypertension and is not preferred. Hydralazine (D) is
third-line and requires co-administration with a beta-blocker to prevent reflex tachycardia, making it
less ideal than adding a beta-blocker directly.
9. A patient with a history of asthma presents with acute dyspnea, wheezing, and a peak expiratory
flow (PEF) of 50% of personal best. After three doses of albuterol via nebulizer, PEF improves to
60%. Vital signs: respiratory rate 26, heart rate 110, SpO2 94% on room air. Which of the
following is the most appropriate next step in management?
A. Discharge home with a course of oral prednisone and a written asthma action plan.
B. Admit to the hospital for continuous nebulized albuterol and intravenous magnesium sulfate.
C. Start intravenous methylprednisolone and repeat PEF in 1 hour; if still <70%, consider admission.
D. Administer a single dose of intramuscular epinephrine and observe for 4 hours.
Answer: C
Rationale: According to NAEPP EPR-3 guidelines, patients with moderate exacerbation (PEF 40-69%)
who do not achieve PEF >70% after initial beta-agonist therapy should receive systemic corticosteroids
and be monitored for response before discharge decision. Option C aligns with this. Discharge (A) is
premature. Admission (B) is for severe exacerbations or poor response. Epinephrine (D) is reserved for
anaphylaxis or life-threatening asthma.
10. A patient with a history of recurrent urinary tract infections (UTIs) presents with dysuria,
frequency, and urgency. Urinalysis shows positive nitrites and leukocyte esterase, with 50
WBC/hpf and many bacteria. Urine culture grows Escherichia coli >100,000 CFU/mL. The patient
has a documented allergy to sulfonamides (hives). Which of the following antibiotics is most
appropriate for a 3-day course?
A. Trimethoprim-sulfamethoxazole double strength twice daily.
B. Nitrofurantoin monohydrate/macrocrystals 100 mg twice daily.
C. Ciprofloxacin 250 mg twice daily.
D. Cephalexin 500 mg four times daily.
Answer: B
Rationale: Nitrofurantoin is a first-line agent for uncomplicated UTI and is safe in sulfa allergy.
TMP-SMX (A) is contraindicated. Fluoroquinolones (C) are reserved for complicated UTI due to
resistance and adverse effects. Cephalexin (D) has a 10% cross-reactivity risk with penicillins but not
sulfa; however, it is less preferred as first-line due to lower efficacy and higher resistance rates.
11. A patient with a history of recurrent Clostridioides difficile infection (rCDI) is being considered
for fecal microbiota transplantation (FMT). Which of the following best describes the current
evidence-based indication for FMT in this setting?
Page 4
Pass Guarantee
1. In a patient with suspected acute coronary syndrome, the initial high-sensitivity cardiac
troponin I level is below the 99th percentile upper reference limit. The patient has had chest
discomfort for 4 hours, is hemodynamically stable, and has a normal ECG. Which of the following
management strategies is most appropriate according to current guidelines?
A. Admit for observation and repeat troponin at 3 hours; if negative, perform exercise stress test.
B. Discharge home with outpatient follow-up and a prescription for aspirin 81 mg daily.
C. Administer thrombolytic therapy empirically given high clinical suspicion.
D. Proceed directly to coronary angiography for definitive diagnosis.
Answer: A
Rationale: The 2020 ESC guidelines recommend serial troponin measurements (0 and 3 hours) in
patients with suspected NSTEMI and low-risk features. Option A aligns with this strategy. Discharge
without repeat testing (B) risks missing evolving MI. Thrombolysis (C) is not indicated without
ST-elevation or new LBBB. Angiography (D) is reserved for high-risk patients (e.g., refractory ischemia,
hemodynamic instability).
2. A 30-year-old patient with a history of well-controlled type 1 diabetes mellitus and no other
comorbidities presents with acute onset of severe right lower quadrant abdominal pain, nausea,
and low-grade fever. Laboratory studies show leukocytosis with left shift, normal lipase, and
urinalysis negative for infection. CT scan reveals a non-enlarged appendix with wall thickening
and periappendiceal fat stranding. Which of the following is the most appropriate next step?
A. Initiate intravenous antibiotics and schedule for urgent appendectomy.
B. Administer a single dose of broad-spectrum antibiotics and observe for 24 hours.
C. Recommend non-steroidal anti-inflammatory drugs and outpatient follow-up.
D. Perform colonoscopy to rule out inflammatory bowel disease before intervention.
Answer: A
Rationale: CT findings confirm acute appendicitis. Current surgical guidelines (e.g., EAST, WSES)
recommend urgent appendectomy with preoperative antibiotics. Observation (B) is not standard for
confirmed appendicitis; it is reserved for equivocal cases. NSAIDs alone (C) delay definitive care.
Colonoscopy (D) is contraindicated in acute inflammation due to perforation risk.
3. Which of the following mechanisms best explains the increased risk of venous thromboembolism
in patients with antiphospholipid syndrome (APS) compared to those with factor V Leiden
mutation?
A. APS causes direct activation of protein C, leading to uncontrolled coagulation.
B. APS antibodies inhibit annexin A5 anticoagulant shield on endothelial cells.
Page 1
,C. Factor V Leiden mutation results in resistance to activated protein C, but APS causes deficiency of
antithrombin III.
D. Both conditions increase tissue factor expression, but APS additionally impairs fibrinolysis.
Answer: B
Rationale: APS antibodies disrupt the annexin A5 anticoagulant shield, exposing procoagulant
phospholipids. Factor V Leiden causes activated protein C resistance, but not via annexin A5. Option A
is incorrect because APS does not activate protein C. Option C is false: APS does not cause
antithrombin III deficiency. Option D: while both may involve tissue factor, impaired fibrinolysis is not a
primary mechanism in APS.
4. A patient with chronic kidney disease stage G3b (eGFR 38 mL/min/1.73m²) and hypertension is
currently on lisinopril 20 mg daily and amlodipine 5 mg daily. Blood pressure is 148/92 mmHg.
Urine albumin-to-creatinine ratio is 300 mg/g. Which of the following medication adjustments is
most appropriate to achieve target blood pressure and reduce proteinuria?
A. Increase lisinopril to 40 mg daily and add chlorthalidone 12.5 mg daily.
B. Discontinue amlodipine and start hydralazine 25 mg three times daily.
C. Add spironolactone 25 mg daily to the current regimen.
D. Switch lisinopril to losartan 50 mg daily and add metoprolol 25 mg daily.
Answer: A
Rationale: KDIGO guidelines recommend maximizing ACEi/ARB dose for proteinuria >300 mg/g, then
adding a thiazide diuretic (chlorthalidone preferred in CKD). Option A achieves both goals.
Hydralazine (B) is third-line and not first add-on. Spironolactone (C) increases hyperkalemia risk with
ACEi in CKD. Switching to ARB (D) is not superior; adding beta-blocker is not first-line for
hypertension without compelling indication.
5. A 45-year-old patient with a body mass index of 34 kg/m², impaired fasting glucose (110 mg/dL),
and triglycerides 280 mg/dL is found to have a fasting plasma glucose of 126 mg/dL on two
separate occasions. HbA1c is 6.8%. According to the American Diabetes Association Standards of
Medical Care in Diabetes-2024, which of the following is the most appropriate pharmacologic
agent to initiate as first-line therapy?
A. Metformin titrated to 2000 mg daily, with lifestyle modification.
B. Liraglutide 1.2 mg daily, given the need for weight loss.
C. Empagliflozin 10 mg daily, due to cardiovascular risk reduction.
D. Insulin glargine 10 units at bedtime, given the elevated fasting glucose.
Answer: A
Rationale: Metformin remains first-line for type 2 diabetes (ADA 2024). The patient has no ASCVD, HF,
or CKD to mandate SGLT2i/GLP-1 RA as first-line. Liraglutide (B) is second-line or if ASCVD/high
risk. Empagliflozin (C) is indicated if ASCVD, HF, or CKD. Insulin (D) is not first-line unless
symptomatic hyperglycemia (HbA1c >9-10% or glucose >300 mg/dL).
Page 2
,6. A patient with a history of opioid use disorder on buprenorphine/naloxone maintenance presents
with acute onset of severe, colicky right upper quadrant pain radiating to the back, nausea, and
emesis. Vital signs: temperature 38.5°C, heart rate 110 bpm, blood pressure 100/70 mmHg.
Laboratory studies show WBC 14,000/µL, total bilirubin 3.2 mg/dL, direct bilirubin 2.1 mg/dL,
AST 85 U/L, ALT 90 U/L, alkaline phosphatase 350 U/L, lipase 45 U/L. Right upper quadrant
ultrasound shows a distended gallbladder with a thickened wall and a 1.2 cm stone at the neck, but
no common bile duct dilation. Which of the following is the most appropriate next step?
A. Administer intravenous fluids, antibiotics, and schedule for laparoscopic cholecystectomy within 24 hours.
B. Start intravenous antibiotics and perform endoscopic retrograde cholangiopancreatography (ERCP) urgently.
C. Place a nasogastric tube, administer intravenous fluids, and schedule cholecystectomy in 6 weeks.
D. Obtain a magnetic resonance cholangiopancreatography (MRCP) to evaluate for choledocholithiasis before
intervention.
Answer: A
Rationale: The patient has acute cholecystitis (Murphy's sign implied, ultrasound findings). Tokyo
Guidelines recommend early cholecystectomy (within 24-72 hours) for mild to moderate cholecystitis.
ERCP (B) is indicated if cholangitis or CBD stone suspected; here, no CBD dilation and elevated
bilirubin may be due to Mirizzi syndrome or inflammation. Delayed surgery (C) increases recurrence
risk. MRCP (D) would delay care and is not necessary if no CBD dilation.
7. A patient with a history of recurrent major depressive disorder (MDD) currently on sertraline
200 mg daily for 8 weeks reports persistent depressive symptoms with a PHQ-9 score of 18. The
patient denies suicidal ideation. Which of the following is the most appropriate next step according
to the STAR*D trial evidence?
A. Switch to venlafaxine 75 mg daily and titrate upward.
B. Augment with aripiprazole 2 mg daily.
C. Increase sertraline to 250 mg daily.
D. Add bupropion sustained-release 150 mg daily.
Answer: D
Rationale: The STAR*D trial showed that after non-response to an SSRI, augmentation with bupropion
was effective and well-tolerated. Switching to another class (A) is an option but augmentation is
preferred given partial response? Actually, the patient has been on maximum SSRI dose for 8 weeks with
no response; STAR*D supports augmentation or switch. Among options, bupropion augmentation (D) is
a first-line augmentation strategy. Aripiprazole (B) is FDA-approved but typically after 2 failed trials.
Dose >200 mg (C) is off-label and not recommended. Venlafaxine switch (A) is reasonable but not as
strongly supported as augmentation in the context of this question.
8. A patient with a history of hypertension and type 2 diabetes presents with a blood pressure of
168/104 mmHg, serum creatinine 1.5 mg/dL (eGFR 48 mL/min/1.73m²), and potassium 5.1
mEq/L. Current medications: lisinopril 40 mg daily, amlodipine 10 mg daily, and
hydrochlorothiazide 25 mg daily. Which of the following antihypertensive agents is safest to add to
achieve blood pressure control?
A. Spironolactone 25 mg daily.
B. Metoprolol tartrate 50 mg twice daily.
Page 3
, C. Clonidine 0.1 mg twice daily.
D. Hydralazine 25 mg three times daily.
Answer: B
Rationale: The patient has resistant hypertension with CKD and hyperkalemia. Beta-blockers
(metoprolol) are safe and effective add-on therapy. Spironolactone (A) increases hyperkalemia risk with
ACEi and CKD. Clonidine (C) can cause rebound hypertension and is not preferred. Hydralazine (D) is
third-line and requires co-administration with a beta-blocker to prevent reflex tachycardia, making it
less ideal than adding a beta-blocker directly.
9. A patient with a history of asthma presents with acute dyspnea, wheezing, and a peak expiratory
flow (PEF) of 50% of personal best. After three doses of albuterol via nebulizer, PEF improves to
60%. Vital signs: respiratory rate 26, heart rate 110, SpO2 94% on room air. Which of the
following is the most appropriate next step in management?
A. Discharge home with a course of oral prednisone and a written asthma action plan.
B. Admit to the hospital for continuous nebulized albuterol and intravenous magnesium sulfate.
C. Start intravenous methylprednisolone and repeat PEF in 1 hour; if still <70%, consider admission.
D. Administer a single dose of intramuscular epinephrine and observe for 4 hours.
Answer: C
Rationale: According to NAEPP EPR-3 guidelines, patients with moderate exacerbation (PEF 40-69%)
who do not achieve PEF >70% after initial beta-agonist therapy should receive systemic corticosteroids
and be monitored for response before discharge decision. Option C aligns with this. Discharge (A) is
premature. Admission (B) is for severe exacerbations or poor response. Epinephrine (D) is reserved for
anaphylaxis or life-threatening asthma.
10. A patient with a history of recurrent urinary tract infections (UTIs) presents with dysuria,
frequency, and urgency. Urinalysis shows positive nitrites and leukocyte esterase, with 50
WBC/hpf and many bacteria. Urine culture grows Escherichia coli >100,000 CFU/mL. The patient
has a documented allergy to sulfonamides (hives). Which of the following antibiotics is most
appropriate for a 3-day course?
A. Trimethoprim-sulfamethoxazole double strength twice daily.
B. Nitrofurantoin monohydrate/macrocrystals 100 mg twice daily.
C. Ciprofloxacin 250 mg twice daily.
D. Cephalexin 500 mg four times daily.
Answer: B
Rationale: Nitrofurantoin is a first-line agent for uncomplicated UTI and is safe in sulfa allergy.
TMP-SMX (A) is contraindicated. Fluoroquinolones (C) are reserved for complicated UTI due to
resistance and adverse effects. Cephalexin (D) has a 10% cross-reactivity risk with penicillins but not
sulfa; however, it is less preferred as first-line due to lower efficacy and higher resistance rates.
11. A patient with a history of recurrent Clostridioides difficile infection (rCDI) is being considered
for fecal microbiota transplantation (FMT). Which of the following best describes the current
evidence-based indication for FMT in this setting?
Page 4
