NR511 Week 4 Midterm Exam Due 29th March 2026
Complete Actual Exam Questions 1.pdf
1. A 45-year-old patient with type 2 diabetes and chronic kidney disease (eGFR 35
mL/min/1.73m²) presents with hypertension. Which antihypertensive agent requires dose
adjustment or avoidance due to its renal elimination and risk of hyperkalemia?
A. Lisinopril
B. Amlodipine
C. Metoprolol tartrate
D. Hydrochlorothiazide
Answer: A
Rationale: Lisinopril is an ACE inhibitor primarily excreted by the kidneys; in CKD, accumulation can
cause hyperkalemia and acute kidney injury. Amlodipine and metoprolol are hepatically metabolized;
hydrochlorothiazide is less effective at low GFR and not first-line.
2. Which of the following best explains the mechanism by which metformin reduces hepatic glucose
production?
A. Inhibition of mitochondrial complex I leading to decreased gluconeogenesis
B. Activation of PPAR- receptors in adipose tissue
C. Increased pancreatic insulin secretion via sulfonylurea receptor binding
D. Blockade of SGLT2 in the proximal renal tubule
Answer: A
Rationale: Metformin inhibits mitochondrial complex I, reducing ATP and increasing AMP, which
suppresses gluconeogenesis and glycogenolysis. Option B describes thiazolidinediones; C describes
sulfonylureas; D describes SGLT2 inhibitors.
3. A patient presents with acute-onset confusion, ataxia, and diplopia. MRI shows a hyperintense
lesion in the cerebellar peduncle. Which of the following is the most likely diagnosis?
A. Wernicke encephalopathy
B. Multiple sclerosis
C. Acute cerebellar stroke
D. Glioblastoma multiforme
Answer: A
Rationale: Wernicke encephalopathy presents with confusion, ataxia, and oculomotor abnormalities, and
MRI often shows T2 hyperintensities in the periaqueductal gray, thalamus, and cerebellar peduncles.
Multiple sclerosis typically has periventricular plaques; stroke follows vascular territory; glioblastoma
has mass effect.
Page 1
,4. A patient with a history of hypertension and asthma develops acute sinusitis. Which of the
following antibiotics should be avoided due to the risk of drug interaction with their
antihypertensive?
A. Amoxicillin-clavulanate
B. Doxycycline
C. Trimethoprim-sulfamethoxazole
D. Azithromycin
Answer: C
Rationale: Trimethoprim-sulfamethoxazole can increase serum potassium and potentiate ACE
inhibitor/ARB-induced hyperkalemia. It also may cause sulfonamide cross-reactivity in asthma.
Amoxicillin-clavulanate, doxycycline, and azithromycin have no significant interaction with
antihypertensives.
5. Which of the following findings on a peripheral blood smear is most consistent with a diagnosis
of hemolytic uremic syndrome (HUS) in a child?
A. Schistocytes and thrombocytopenia
B. Spherocytes and elevated bilirubin
C. Basophilic stippling and lead poisoning
D. Target cells and hemoglobin C crystals
Answer: A
Rationale: HUS is characterized by microangiopathic hemolytic anemia with schistocytes (fragmented
RBCs) and thrombocytopenia. Spherocytes suggest autoimmune hemolytic anemia; basophilic stippling
is seen in lead poisoning; target cells and hemoglobin C crystals are seen in hemoglobinopathies.
6. A 30-year-old female with no known medical history presents with acute onset of severe right
lower quadrant pain and nausea. Urinalysis shows microscopic hematuria. Which of the following
is the most likely diagnosis?
A. Acute appendicitis
B. Ureteral calculus
C. Ovarian torsion
D. Ectopic pregnancy
Answer: B
Rationale: Microscopic hematuria strongly suggests a ureteral stone, which often presents with colicky
pain radiating to the groin. Appendicitis typically has fever and leukocytosis without hematuria; ovarian
torsion presents with adnexal mass; ectopic pregnancy requires positive hCG.
7. Which of the following lipid-lowering medications is most likely to increase the risk of new-onset
diabetes mellitus?
A. Atorvastatin
B. Fenofibrate
C. Ezetimibe
D. Niacin
Page 2
,Answer: A
Rationale: Statins, particularly high-potency ones like atorvastatin, have been associated with a modest
increase in new-onset diabetes, likely due to effects on insulin sensitivity. Fenofibrate and ezetimibe have
neutral effects; niacin can worsen glycemic control but is less common.
8. A patient with chronic obstructive pulmonary disease (COPD) is started on a long-acting
muscarinic antagonist (LAMA). Which of the following is a potential adverse effect specific to this
drug class?
A. Tachycardia and palpitations
B. Urinary retention and glaucoma
C. Hypokalemia and QT prolongation
D. Osteoporosis and weight gain
Answer: B
Rationale: LAMAs (e.g., tiotropium) block muscarinic receptors, leading to anticholinergic effects such
as dry mouth, urinary retention, and exacerbation of angle-closure glaucoma. Beta-agonists cause
tachycardia; methylxanthines cause hypokalemia; corticosteroids cause osteoporosis.
9. Which of the following is the most appropriate next step in managing a patient with suspected
acute coronary syndrome (ACS) who has a non-diagnostic ECG and negative initial troponin?
A. Discharge home with aspirin and follow-up
B. Repeat troponin in 3-6 hours and observe
C. Immediate coronary angiography
D. Stress echocardiography within 24 hours
Answer: B
Rationale: In ACS, initial troponin may be negative if drawn too early; serial troponin measurement (3-6
hours apart) is recommended to detect rising levels. Discharge is unsafe; immediate angiography is for
STEMI; stress testing is done after ruling out MI.
10. A patient with rheumatoid arthritis on methotrexate develops a new pulmonary infiltrate and
hypoxemia. Which of the following is the most likely cause?
A. Methotrexate-induced pneumonitis
B. Community-acquired pneumonia
C. Pulmonary embolism
D. Pulmonary edema
Answer: A
Rationale: Methotrexate is known to cause hypersensitivity pneumonitis, presenting with cough, fever,
dyspnea, and bilateral infiltrates, often within weeks to months of therapy. Infection is possible but less
specific; PE typically has pleuritic pain and hemoptysis; pulmonary edema is cardiac in origin.
Page 3
, 11. A patient presents with acute onset of severe, colicky flank pain radiating to the groin,
associated with nausea and hematuria. Noncontrast CT reveals a 7 mm calculus in the proximal
ureter with mild hydronephrosis. Urinalysis shows pH 6.5, no crystals. The patient has no fever,
and renal function is normal. Which management strategy is most appropriate at this time?
A. Immediate ureteroscopic lithotripsy
B. Tamsulosin 0.4 mg daily and observation for 4-6 weeks
C. Extracorporeal shock wave lithotripsy (ESWL)
D. Percutaneous nephrostomy tube placement
Answer: B
Rationale: Stones "d10 mm in the proximal ureter with mild hydronephrosis and no infection have a high
likelihood of spontaneous passage. Medical expulsive therapy with tamsulosin and observation is
first-line. ESWL is effective but not first-line for proximal ureteral stones; ureteroscopy is reserved for
failed passage or larger stones; nephrostomy is for infected obstruction.
12. A patient with a history of recurrent calcium oxalate nephrolithiasis is found to have
hypercalciuria on 24-hour urine collection. Serum calcium is normal, and PTH is within normal
limits. Which of the following is the most appropriate initial pharmacotherapy to reduce stone
recurrence?
A. Hydrochlorothiazide 25 mg daily
B. Allopurinol 300 mg daily
C. Potassium citrate 20 mEq twice daily
D. Sodium bicarbonate 650 mg three times daily
Answer: A
Rationale: Idiopathic hypercalciuria with normal serum calcium and PTH is best managed with thiazide
diuretics, which reduce urinary calcium excretion. Allopurinol is for hyperuricosuria; potassium citrate
is for hypocitraturia or uric acid stones; sodium bicarbonate is for renal tubular acidosis or cystinuria.
13. A patient with a history of recurrent calcium phosphate stones has a 24-hour urine showing low
volume, high pH (7.2), and low citrate. Which of the following is the most likely underlying
disorder?
A. Primary hyperparathyroidism
B. Distal renal tubular acidosis (type 1 RTA)
C. Medullary sponge kidney
D. Cystinuria
Answer: B
Rationale: Distal RTA (type 1) leads to alkaline urine, hypocitraturia, and calcium phosphate stones.
Primary hyperparathyroidism causes hypercalcemia and hypercalciuria but not necessarily alkaline
urine or hypocitraturia. Medullary sponge kidney is associated with calcium oxalate stones; cystinuria
causes cystine stones with acidic urine.
Page 4
Complete Actual Exam Questions 1.pdf
1. A 45-year-old patient with type 2 diabetes and chronic kidney disease (eGFR 35
mL/min/1.73m²) presents with hypertension. Which antihypertensive agent requires dose
adjustment or avoidance due to its renal elimination and risk of hyperkalemia?
A. Lisinopril
B. Amlodipine
C. Metoprolol tartrate
D. Hydrochlorothiazide
Answer: A
Rationale: Lisinopril is an ACE inhibitor primarily excreted by the kidneys; in CKD, accumulation can
cause hyperkalemia and acute kidney injury. Amlodipine and metoprolol are hepatically metabolized;
hydrochlorothiazide is less effective at low GFR and not first-line.
2. Which of the following best explains the mechanism by which metformin reduces hepatic glucose
production?
A. Inhibition of mitochondrial complex I leading to decreased gluconeogenesis
B. Activation of PPAR- receptors in adipose tissue
C. Increased pancreatic insulin secretion via sulfonylurea receptor binding
D. Blockade of SGLT2 in the proximal renal tubule
Answer: A
Rationale: Metformin inhibits mitochondrial complex I, reducing ATP and increasing AMP, which
suppresses gluconeogenesis and glycogenolysis. Option B describes thiazolidinediones; C describes
sulfonylureas; D describes SGLT2 inhibitors.
3. A patient presents with acute-onset confusion, ataxia, and diplopia. MRI shows a hyperintense
lesion in the cerebellar peduncle. Which of the following is the most likely diagnosis?
A. Wernicke encephalopathy
B. Multiple sclerosis
C. Acute cerebellar stroke
D. Glioblastoma multiforme
Answer: A
Rationale: Wernicke encephalopathy presents with confusion, ataxia, and oculomotor abnormalities, and
MRI often shows T2 hyperintensities in the periaqueductal gray, thalamus, and cerebellar peduncles.
Multiple sclerosis typically has periventricular plaques; stroke follows vascular territory; glioblastoma
has mass effect.
Page 1
,4. A patient with a history of hypertension and asthma develops acute sinusitis. Which of the
following antibiotics should be avoided due to the risk of drug interaction with their
antihypertensive?
A. Amoxicillin-clavulanate
B. Doxycycline
C. Trimethoprim-sulfamethoxazole
D. Azithromycin
Answer: C
Rationale: Trimethoprim-sulfamethoxazole can increase serum potassium and potentiate ACE
inhibitor/ARB-induced hyperkalemia. It also may cause sulfonamide cross-reactivity in asthma.
Amoxicillin-clavulanate, doxycycline, and azithromycin have no significant interaction with
antihypertensives.
5. Which of the following findings on a peripheral blood smear is most consistent with a diagnosis
of hemolytic uremic syndrome (HUS) in a child?
A. Schistocytes and thrombocytopenia
B. Spherocytes and elevated bilirubin
C. Basophilic stippling and lead poisoning
D. Target cells and hemoglobin C crystals
Answer: A
Rationale: HUS is characterized by microangiopathic hemolytic anemia with schistocytes (fragmented
RBCs) and thrombocytopenia. Spherocytes suggest autoimmune hemolytic anemia; basophilic stippling
is seen in lead poisoning; target cells and hemoglobin C crystals are seen in hemoglobinopathies.
6. A 30-year-old female with no known medical history presents with acute onset of severe right
lower quadrant pain and nausea. Urinalysis shows microscopic hematuria. Which of the following
is the most likely diagnosis?
A. Acute appendicitis
B. Ureteral calculus
C. Ovarian torsion
D. Ectopic pregnancy
Answer: B
Rationale: Microscopic hematuria strongly suggests a ureteral stone, which often presents with colicky
pain radiating to the groin. Appendicitis typically has fever and leukocytosis without hematuria; ovarian
torsion presents with adnexal mass; ectopic pregnancy requires positive hCG.
7. Which of the following lipid-lowering medications is most likely to increase the risk of new-onset
diabetes mellitus?
A. Atorvastatin
B. Fenofibrate
C. Ezetimibe
D. Niacin
Page 2
,Answer: A
Rationale: Statins, particularly high-potency ones like atorvastatin, have been associated with a modest
increase in new-onset diabetes, likely due to effects on insulin sensitivity. Fenofibrate and ezetimibe have
neutral effects; niacin can worsen glycemic control but is less common.
8. A patient with chronic obstructive pulmonary disease (COPD) is started on a long-acting
muscarinic antagonist (LAMA). Which of the following is a potential adverse effect specific to this
drug class?
A. Tachycardia and palpitations
B. Urinary retention and glaucoma
C. Hypokalemia and QT prolongation
D. Osteoporosis and weight gain
Answer: B
Rationale: LAMAs (e.g., tiotropium) block muscarinic receptors, leading to anticholinergic effects such
as dry mouth, urinary retention, and exacerbation of angle-closure glaucoma. Beta-agonists cause
tachycardia; methylxanthines cause hypokalemia; corticosteroids cause osteoporosis.
9. Which of the following is the most appropriate next step in managing a patient with suspected
acute coronary syndrome (ACS) who has a non-diagnostic ECG and negative initial troponin?
A. Discharge home with aspirin and follow-up
B. Repeat troponin in 3-6 hours and observe
C. Immediate coronary angiography
D. Stress echocardiography within 24 hours
Answer: B
Rationale: In ACS, initial troponin may be negative if drawn too early; serial troponin measurement (3-6
hours apart) is recommended to detect rising levels. Discharge is unsafe; immediate angiography is for
STEMI; stress testing is done after ruling out MI.
10. A patient with rheumatoid arthritis on methotrexate develops a new pulmonary infiltrate and
hypoxemia. Which of the following is the most likely cause?
A. Methotrexate-induced pneumonitis
B. Community-acquired pneumonia
C. Pulmonary embolism
D. Pulmonary edema
Answer: A
Rationale: Methotrexate is known to cause hypersensitivity pneumonitis, presenting with cough, fever,
dyspnea, and bilateral infiltrates, often within weeks to months of therapy. Infection is possible but less
specific; PE typically has pleuritic pain and hemoptysis; pulmonary edema is cardiac in origin.
Page 3
, 11. A patient presents with acute onset of severe, colicky flank pain radiating to the groin,
associated with nausea and hematuria. Noncontrast CT reveals a 7 mm calculus in the proximal
ureter with mild hydronephrosis. Urinalysis shows pH 6.5, no crystals. The patient has no fever,
and renal function is normal. Which management strategy is most appropriate at this time?
A. Immediate ureteroscopic lithotripsy
B. Tamsulosin 0.4 mg daily and observation for 4-6 weeks
C. Extracorporeal shock wave lithotripsy (ESWL)
D. Percutaneous nephrostomy tube placement
Answer: B
Rationale: Stones "d10 mm in the proximal ureter with mild hydronephrosis and no infection have a high
likelihood of spontaneous passage. Medical expulsive therapy with tamsulosin and observation is
first-line. ESWL is effective but not first-line for proximal ureteral stones; ureteroscopy is reserved for
failed passage or larger stones; nephrostomy is for infected obstruction.
12. A patient with a history of recurrent calcium oxalate nephrolithiasis is found to have
hypercalciuria on 24-hour urine collection. Serum calcium is normal, and PTH is within normal
limits. Which of the following is the most appropriate initial pharmacotherapy to reduce stone
recurrence?
A. Hydrochlorothiazide 25 mg daily
B. Allopurinol 300 mg daily
C. Potassium citrate 20 mEq twice daily
D. Sodium bicarbonate 650 mg three times daily
Answer: A
Rationale: Idiopathic hypercalciuria with normal serum calcium and PTH is best managed with thiazide
diuretics, which reduce urinary calcium excretion. Allopurinol is for hyperuricosuria; potassium citrate
is for hypocitraturia or uric acid stones; sodium bicarbonate is for renal tubular acidosis or cystinuria.
13. A patient with a history of recurrent calcium phosphate stones has a 24-hour urine showing low
volume, high pH (7.2), and low citrate. Which of the following is the most likely underlying
disorder?
A. Primary hyperparathyroidism
B. Distal renal tubular acidosis (type 1 RTA)
C. Medullary sponge kidney
D. Cystinuria
Answer: B
Rationale: Distal RTA (type 1) leads to alkaline urine, hypocitraturia, and calcium phosphate stones.
Primary hyperparathyroidism causes hypercalcemia and hypercalciuria but not necessarily alkaline
urine or hypocitraturia. Medullary sponge kidney is associated with calcium oxalate stones; cystinuria
causes cystine stones with acidic urine.
Page 4
