A 65-year-old male with no prior medical history presents to the ED with a complaint of c.) Rectal Exam
low back pain and fatigue x1 month. The pain is constant, a dull ache, does not radiate
and has progressively gotten worse. Lab results: WBC 5,000, Hgb 7.0 g/dL, HCT 30%, MCV Rationale:
80%, platelets 500,000, creatinine 1.0 mg/dL, BUN 15 mg/dL, Na 135 mEq/L, potassium 3.5 The patient has many manifestations which are concerning for a malignant process. A nor-
mEq/L, calcium is 10.5 mg/dL, Alkaline Phosphatase is 300 units/L. A lumbar x-ray shows lytic mocytic anemia in a male is never normal and should concern the AGACNP for a possible
lesions. It is most important for the AGACNP to perform an exam on which body part/system? malignancy. Hypercalcemia with an elevated alkaline phosphatase is concerning for bone
a.) Pulmonary Exam issues and coupled with lytic lesions on the lumbar vertebrae is very concerning for a
b.) Cardiovascular exam malignancy. The most likely malignancy in this patient is prostate cancer, therefore the AGACNP
c.) Rectal Exam should perform a rectal examination to assess the prostate. Prostate cancer most commonly
d.) Abdominal Exam metastasizes to the vertebrae.
A female patient presents to your oflce for follow up after having a CT of the abdomen and
pelvis completed to evaluate a complaint of abdominal pain. The CT scan showed liver lesions d.) Refer to GI for a colonoscopy
consistent with metastatic cancer with an unknown primary site. Her mother died from colon
Rationale:
cancer. Which intervention should the AGACNP complete next?
The next stage in this patient's evaluation is to search for the primary cancer site, obtain
a.) Order an echocardiogram
a tissue biopsy and assess for any other sites of metastasis. The most likely location of the
b.) Complete a referral to hospice
primary cancer is the colon. Colon cancer commonly metastasizes to the liver and she needs
c.) Refer for a preoperative cardiac evaluation
a colonoscopy.
d.) Refer to GI for a colonoscopy
A 20-year-old male expresses concern about testicular cancer and wants to know if he should
perform testicular self-examinations. Which response from the AGACNP best demonstrates a.) Testicular self-examinations are no longer recommended.
their knowledge of current recommendations?
Rationale:
a.) Testicular self-examinations are no longer recommended.
Currently the USPSTF, the American Academy of Physicians and the American Academy of
b.) Testicular self-examinations should be done monthly, after a hot shower.
Pediatrics do not recommend testicular self-examinations because there is no data to support
c.) Testicular self-examinations are inettective, and your PCP should draw an AFP level.
their ettectiveness.
d.) Testicular examinations should only be done by your primary care provider.
A 68-year-old female presents to the ED for a complaint of intermittent vaginal bleeding for
the last two months. She is post-menopausal and has no other complaints. Vitals and exam c.) Transvaginal Ultrasound
are normal. Which diagnostic test should the AGACNP order next?
a.) CT of the abdomen and Pelvis Rationale:
b.) Gonorrhea and chlamydia screening This patient's symptoms are concerning for endometrial cancer. She requires a transvaginal
c.) Transvaginal Ultrasound US to assess the uterine endometrium.
d.) Chest X-ray
A patient with colon cancer is 5 days status post her cycle of chemotherapy. She presents to b.) Medical Floor
the ED with a fever of 101. Her ANC is 400. Which level of care does this patient require?
a.) Intensive care Rationale:
b.) Medical Floor Any patient with a fever and neutropenia should be admitted. There are no clinical indicators
c.) Step down unit in the question to suggest she needs a step-down unit or ICU, therefore admission to the
d.) Discharge home medical floor is most appropriate.
You are asked to admit a 45-year-old female with a brain tumor to your service for an altered
mental status. The spouse reports that the patient has been increasingly restless for the
last 3 days and experiencing worsening confusion. An MRI of the brain completed 1 month
b.) Dexamethasone
ago showed some cerebral edema secondary to the brain tumor. The ED has only given her
ondansetron (Zofran) for nausea. She is thrashing around in bed and uncooperative with your
Rationale:
examination and nursing care. What additional medication is most important for the AGACNP
This patient is demonstrating signs of increased intracranial pressure secondary to the cere-
to order immediately?
bral swelling from her tumor. The standard treatment for this is dexamethasone. There is no
a.) Furosemide (Lasix)
indication to give her lorazepam, morphine or furosemide.
b.) Dexamethasone
c.) Morphine
d.) Lorazepam (Ativan)
1/7
, c.) A 50-year-old male with a VTE which was diagnosed 15 days ago taking warfarin.
Which patient going for a total hip replacement requires the use of bridge therapy with
heparin?
Rationale:
a.) A 70-year-old female who had an ischemic stroke 4 months ago.
Bridge therapy is only done for persons who are considered high risk for thrombosis and are
b.) A 65-year-old male with atrial fibrillation, a CHADSvasc2 score of 3, taking rivaroxaban
on warfarin therapy. A CHADSvasc2 score of 1 is not considered high risk and does not require
(Xarelto).
bridge therapy. A person who has an ischemic stroke requires bridge therapy if the event
c.) A 50-year-old male with a VTE which was diagnosed 15 days ago taking warfarin.
happens within the last 3 months. A CHADSvasc2 score of 3 is considered high risk, however
d.) A 60-year-old female with atrial fibrillation and a CHADSvasc2 score of 1.
bridge therapy is only done for warfarin.
A patient with a mechanical mitral valve is currently receiving bridge therapy with a continuous
heparin gtt and is 2 days post ORIF of a left hip fracture. When should the AGACNP discontinue
d.) When the INR is 2.5 or greater
the heparin infusion?
a.) With the first dose of coumadin
A therapeutic INR for a mechanical valve is 2.5-3.5. The heparin infusion should not be stopped
b.) When the INR is at 2.0
until the INR is therapeutic.
c.) When there is a 5,000-point drop in platelets
d.) When the INR is 2.5 or greater
a.) Warfarin
A patient with a mechanical heart valve requires anticoagulation to prevent an embolic stroke.
Which medication is most appropriate for the AGACNP to order? Heparin SC TID dosing is only ettective for DVT prevention in the medical patient. Warfarin
a.) Warfarin is the only medication which has an FDA indication for the prevention of embolic events
b.) Heparin SC TID secondary to a mechanical heart valve. Dabigatran has a US Box Warning from the FDA which
c.) Rivaroxaban (Xarelto) states that it can not be used for this indication because it is not ettective at preventing embolic
d.) Dabigatran (Pradaxa) events in this setting. Rivaroxaban does not have an FDA indication for this purpose and should
not be used in this manner.
b.) A 30-year-old female patient who developed an unprovoked DVT.
Which patient warrants an evaluation for a hereditary hypercoagulable condition?
a.) A 25-year-old male patient with testicular cancer and a new diagnosis of DVT.
b.) A 30-year-old female patient who developed an unprovoked DVT. The indications which necessitate a work up for a hereditary hypercoagulable condition
c.) A 65-year-old male patient status post total right knee replacement with an acute DVT. include: a recurrent thromboembolism, VTE in a person younger than 50, a family history of
d.) A 70-year-old female nursing home bed bound patient with an acute DVT. VTE, and thrombosis in unusual sites. The 30-year-old female is the only one which requires
a workup. The other patients have significant risk factors which explain the VTE.
The AGACNP is treating a patient with ITP for an acute upper GI bleed. His platelet count is d.) Consult hematology
currently 10,000 and hgb is 7.0 g/dL. Vitals are stable. Which action should the AGACNP take
first? A person with ITP who is actively bleeding requires specialty consultation. While a platelet
a.) Order one unit of platelets transfusion may be required, hematology should make that decision because the platelet
b.) Order DDAVP count is likely to get worse from any platelet transfusion. Platelet transfusions are generally
c.) Order Fresh Frozen plasma contraindicated in an ITP, unless ordered by hematology. This patient is bleeding secondary
d.) Consult hematology to a severe thrombocytopenia and FFP or DDAVP will not help in this instance.
Why should caution be exercised when using enoxaparin (Lovenox) in a patient with acute
kidney injury (AKI)?
a.) Enoxaparin can cause hyperkalemia by impairing potassium excretion in patients with
AKI. d.) Enoxaparin is renally cleared, and its accumulation can occur in patients with impaired
b.) Enoxaparin can accelerate the progression of AKI by promoting vasoconstriction in the kidney function, leading to an increased risk of bleeding.
kidneys.
c.) Enoxaparin can exacerbate fluid overload and worsen kidney function by increasing renal Enoxaparin, a low molecular weight heparin, is predominantly cleared by the kidneys. In
blood flow. patients with acute kidney injury (AKI), impaired renal function can lead to the accumulation
d.) Enoxaparin is renally cleared, and its accumulation can occur in patients with impaired of enoxaparin, increasing the risk of bleeding due to reduced clearance of the medication.
kidney function, leading to an increased risk of bleeding.
Enoxaparin, a low molecular weight heparin, is predominantly cleared by the kidneys. In
2/7
low back pain and fatigue x1 month. The pain is constant, a dull ache, does not radiate
and has progressively gotten worse. Lab results: WBC 5,000, Hgb 7.0 g/dL, HCT 30%, MCV Rationale:
80%, platelets 500,000, creatinine 1.0 mg/dL, BUN 15 mg/dL, Na 135 mEq/L, potassium 3.5 The patient has many manifestations which are concerning for a malignant process. A nor-
mEq/L, calcium is 10.5 mg/dL, Alkaline Phosphatase is 300 units/L. A lumbar x-ray shows lytic mocytic anemia in a male is never normal and should concern the AGACNP for a possible
lesions. It is most important for the AGACNP to perform an exam on which body part/system? malignancy. Hypercalcemia with an elevated alkaline phosphatase is concerning for bone
a.) Pulmonary Exam issues and coupled with lytic lesions on the lumbar vertebrae is very concerning for a
b.) Cardiovascular exam malignancy. The most likely malignancy in this patient is prostate cancer, therefore the AGACNP
c.) Rectal Exam should perform a rectal examination to assess the prostate. Prostate cancer most commonly
d.) Abdominal Exam metastasizes to the vertebrae.
A female patient presents to your oflce for follow up after having a CT of the abdomen and
pelvis completed to evaluate a complaint of abdominal pain. The CT scan showed liver lesions d.) Refer to GI for a colonoscopy
consistent with metastatic cancer with an unknown primary site. Her mother died from colon
Rationale:
cancer. Which intervention should the AGACNP complete next?
The next stage in this patient's evaluation is to search for the primary cancer site, obtain
a.) Order an echocardiogram
a tissue biopsy and assess for any other sites of metastasis. The most likely location of the
b.) Complete a referral to hospice
primary cancer is the colon. Colon cancer commonly metastasizes to the liver and she needs
c.) Refer for a preoperative cardiac evaluation
a colonoscopy.
d.) Refer to GI for a colonoscopy
A 20-year-old male expresses concern about testicular cancer and wants to know if he should
perform testicular self-examinations. Which response from the AGACNP best demonstrates a.) Testicular self-examinations are no longer recommended.
their knowledge of current recommendations?
Rationale:
a.) Testicular self-examinations are no longer recommended.
Currently the USPSTF, the American Academy of Physicians and the American Academy of
b.) Testicular self-examinations should be done monthly, after a hot shower.
Pediatrics do not recommend testicular self-examinations because there is no data to support
c.) Testicular self-examinations are inettective, and your PCP should draw an AFP level.
their ettectiveness.
d.) Testicular examinations should only be done by your primary care provider.
A 68-year-old female presents to the ED for a complaint of intermittent vaginal bleeding for
the last two months. She is post-menopausal and has no other complaints. Vitals and exam c.) Transvaginal Ultrasound
are normal. Which diagnostic test should the AGACNP order next?
a.) CT of the abdomen and Pelvis Rationale:
b.) Gonorrhea and chlamydia screening This patient's symptoms are concerning for endometrial cancer. She requires a transvaginal
c.) Transvaginal Ultrasound US to assess the uterine endometrium.
d.) Chest X-ray
A patient with colon cancer is 5 days status post her cycle of chemotherapy. She presents to b.) Medical Floor
the ED with a fever of 101. Her ANC is 400. Which level of care does this patient require?
a.) Intensive care Rationale:
b.) Medical Floor Any patient with a fever and neutropenia should be admitted. There are no clinical indicators
c.) Step down unit in the question to suggest she needs a step-down unit or ICU, therefore admission to the
d.) Discharge home medical floor is most appropriate.
You are asked to admit a 45-year-old female with a brain tumor to your service for an altered
mental status. The spouse reports that the patient has been increasingly restless for the
last 3 days and experiencing worsening confusion. An MRI of the brain completed 1 month
b.) Dexamethasone
ago showed some cerebral edema secondary to the brain tumor. The ED has only given her
ondansetron (Zofran) for nausea. She is thrashing around in bed and uncooperative with your
Rationale:
examination and nursing care. What additional medication is most important for the AGACNP
This patient is demonstrating signs of increased intracranial pressure secondary to the cere-
to order immediately?
bral swelling from her tumor. The standard treatment for this is dexamethasone. There is no
a.) Furosemide (Lasix)
indication to give her lorazepam, morphine or furosemide.
b.) Dexamethasone
c.) Morphine
d.) Lorazepam (Ativan)
1/7
, c.) A 50-year-old male with a VTE which was diagnosed 15 days ago taking warfarin.
Which patient going for a total hip replacement requires the use of bridge therapy with
heparin?
Rationale:
a.) A 70-year-old female who had an ischemic stroke 4 months ago.
Bridge therapy is only done for persons who are considered high risk for thrombosis and are
b.) A 65-year-old male with atrial fibrillation, a CHADSvasc2 score of 3, taking rivaroxaban
on warfarin therapy. A CHADSvasc2 score of 1 is not considered high risk and does not require
(Xarelto).
bridge therapy. A person who has an ischemic stroke requires bridge therapy if the event
c.) A 50-year-old male with a VTE which was diagnosed 15 days ago taking warfarin.
happens within the last 3 months. A CHADSvasc2 score of 3 is considered high risk, however
d.) A 60-year-old female with atrial fibrillation and a CHADSvasc2 score of 1.
bridge therapy is only done for warfarin.
A patient with a mechanical mitral valve is currently receiving bridge therapy with a continuous
heparin gtt and is 2 days post ORIF of a left hip fracture. When should the AGACNP discontinue
d.) When the INR is 2.5 or greater
the heparin infusion?
a.) With the first dose of coumadin
A therapeutic INR for a mechanical valve is 2.5-3.5. The heparin infusion should not be stopped
b.) When the INR is at 2.0
until the INR is therapeutic.
c.) When there is a 5,000-point drop in platelets
d.) When the INR is 2.5 or greater
a.) Warfarin
A patient with a mechanical heart valve requires anticoagulation to prevent an embolic stroke.
Which medication is most appropriate for the AGACNP to order? Heparin SC TID dosing is only ettective for DVT prevention in the medical patient. Warfarin
a.) Warfarin is the only medication which has an FDA indication for the prevention of embolic events
b.) Heparin SC TID secondary to a mechanical heart valve. Dabigatran has a US Box Warning from the FDA which
c.) Rivaroxaban (Xarelto) states that it can not be used for this indication because it is not ettective at preventing embolic
d.) Dabigatran (Pradaxa) events in this setting. Rivaroxaban does not have an FDA indication for this purpose and should
not be used in this manner.
b.) A 30-year-old female patient who developed an unprovoked DVT.
Which patient warrants an evaluation for a hereditary hypercoagulable condition?
a.) A 25-year-old male patient with testicular cancer and a new diagnosis of DVT.
b.) A 30-year-old female patient who developed an unprovoked DVT. The indications which necessitate a work up for a hereditary hypercoagulable condition
c.) A 65-year-old male patient status post total right knee replacement with an acute DVT. include: a recurrent thromboembolism, VTE in a person younger than 50, a family history of
d.) A 70-year-old female nursing home bed bound patient with an acute DVT. VTE, and thrombosis in unusual sites. The 30-year-old female is the only one which requires
a workup. The other patients have significant risk factors which explain the VTE.
The AGACNP is treating a patient with ITP for an acute upper GI bleed. His platelet count is d.) Consult hematology
currently 10,000 and hgb is 7.0 g/dL. Vitals are stable. Which action should the AGACNP take
first? A person with ITP who is actively bleeding requires specialty consultation. While a platelet
a.) Order one unit of platelets transfusion may be required, hematology should make that decision because the platelet
b.) Order DDAVP count is likely to get worse from any platelet transfusion. Platelet transfusions are generally
c.) Order Fresh Frozen plasma contraindicated in an ITP, unless ordered by hematology. This patient is bleeding secondary
d.) Consult hematology to a severe thrombocytopenia and FFP or DDAVP will not help in this instance.
Why should caution be exercised when using enoxaparin (Lovenox) in a patient with acute
kidney injury (AKI)?
a.) Enoxaparin can cause hyperkalemia by impairing potassium excretion in patients with
AKI. d.) Enoxaparin is renally cleared, and its accumulation can occur in patients with impaired
b.) Enoxaparin can accelerate the progression of AKI by promoting vasoconstriction in the kidney function, leading to an increased risk of bleeding.
kidneys.
c.) Enoxaparin can exacerbate fluid overload and worsen kidney function by increasing renal Enoxaparin, a low molecular weight heparin, is predominantly cleared by the kidneys. In
blood flow. patients with acute kidney injury (AKI), impaired renal function can lead to the accumulation
d.) Enoxaparin is renally cleared, and its accumulation can occur in patients with impaired of enoxaparin, increasing the risk of bleeding due to reduced clearance of the medication.
kidney function, leading to an increased risk of bleeding.
Enoxaparin, a low molecular weight heparin, is predominantly cleared by the kidneys. In
2/7
