NSG 554 Exam 3 Nurse Practitioners in
Primary Care I 2026/2027 | Questions,
Answers & Expert Rationales
NSG 554: NURSE PRACTITIONERS IN PRIMARY CARE I | 2026/2027
Comprehensive Exam Study Guide: 200 Questions, Answers & Expert
Rationales
DOCUMENT OVERVIEW:
• This comprehensive study guide contains 200 rigorously crafted multiple-choice
questions designed to prepare you for NSG 554 Exam 3, covering all essential
primary care nurse practitioner competencies with expert-level rationales for each
answer
• Study strategically by reviewing questions thematically, focusing on areas of
weakness, and using detailed rationales to build clinical reasoning skills—work
through sections daily and complete full-length practice sets to simulate actual
exam conditions
SECTION 1: HYPERTENSION MANAGEMENT IN PRIMARY CARE
QUESTION 1
A 54-year-old male presents to your clinic with a blood pressure reading of
158/98 mmHg on two separate occasions. He has no evidence of end-organ
damage and his laboratory work is normal. Which of the following is the most
appropriate initial management approach?
A) Immediately start combination antihypertensive therapy with ACE inhibitor and
calcium channel blocker
B) Initiate lifestyle modifications and recheck blood pressure in 3-4 weeks
C) Refer to cardiology for specialist evaluation before starting any medications
D) Start a diuretic monotherapy and titrate aggressively over 2 weeks
E) Begin ACE inhibitor monotherapy and add second agent if BP not controlled in 4-
6 weeks
CORRECT ANSWER: B) Initiate lifestyle modifications and recheck blood
pressure in 3-4 weeks
RATIONALE: According to current ACC/AHA guidelines, for Stage 1 hypertension
without evidence of cardiovascular disease or end-organ damage, lifestyle
modifications (DASH diet, weight loss, sodium restriction, exercise, stress reduction,
alcohol moderation) should be initiated first with reassessment in 3-4 weeks.
Pharmacotherapy should be considered if BP remains elevated after lifestyle
intervention or if the patient has additional cardiovascular risk factors. This
,approach aligns with guideline-recommended risk stratification before initiating
medication. Starting monotherapy would be premature at this point, and
aggressive combination therapy is not indicated for initial management without
established cardiovascular disease.
QUESTION 2
Which of the following blood pressure readings most accurately defines Stage
2 hypertension according to 2017 ACC/AHA guidelines?
A) Systolic 130-139 mmHg and/or diastolic 80-89 mmHg
B) Systolic 140 mmHg or higher and/or diastolic 90 mmHg or higher
C) Systolic 160 mmHg or higher and/or diastolic 100 mmHg or higher
D) Systolic 150 mmHg or higher and/or diastolic 95 mmHg or higher
E) Any reading above 140/90 mmHg regardless of organ damage
CORRECT ANSWER: B) Systolic 140 mmHg or higher and/or diastolic 90 mmHg
or higher
RATIONALE: The 2017 ACC/AHA guidelines redefined hypertension categories.
Stage 2 hypertension is defined as SBP ≥140 mmHg or DBP ≥90 mmHg. This
represents a significant change from prior JNC 7 guidelines which used 160/100 as
the Stage 2 cutoff. The new lower threshold reflects evidence supporting more
aggressive BP control to reduce cardiovascular events. Stage 1 hypertension is 130-
139/<80-89 mmHg. Option C represents higher pressures that would indicate more
severe disease. Understanding these updated definitions is essential for
appropriate risk stratification and treatment decisions in primary care.
QUESTION 3
A 62-year-old woman with hypertension, diabetes, and chronic kidney disease
(stage 3b) is starting antihypertensive therapy. Which medication class would
be most beneficial given her comorbidities?
A) Calcium channel blocker monotherapy
B) ACE inhibitor or ARB as initial therapy
C) Beta-blocker as first-line agent
D) Diuretic monotherapy
E) Direct vasodilator combined with hydralazine
CORRECT ANSWER: B) ACE inhibitor or ARB as initial therapy
RATIONALE: In patients with diabetes and chronic kidney disease, ACE inhibitors or
ARBs are strongly recommended as first-line agents because they provide renal
protection through reduction of intraglomerular pressure and proteinuria. These
agents have been shown to slow progression of diabetic nephropathy and reduce
albuminuria independent of blood pressure lowering effects. They also reduce
,cardiovascular mortality in diabetic patients. The combination of diabetes and CKD
makes renal protective therapy essential. Calcium channel blockers lack renal
protective effects in diabetes. Beta-blockers are not ideal first-line in diabetes due
to metabolic effects. Diuretics alone don't address the specific needs of this patient
population.
QUESTION 4
Which of the following patient scenarios would necessitate urgent or
emergent intervention for hypertension?
A) Asymptomatic BP 160/100 mmHg during routine office visit
B) BP 180/120 mmHg with acute chest pain and troponin elevation
C) BP 170/105 mmHg in a patient with complaint of mild headache
D) Stable BP readings of 145/92 mmHg on current medication
E) BP 155/98 mmHg with no systemic symptoms
CORRECT ANSWER: B) BP 180/120 mmHg with acute chest pain and troponin
elevation
RATIONALE: This clinical presentation is consistent with hypertensive urgency with
evidence of acute myocardial infarction (elevated troponin with chest pain). This
requires emergent intervention with hospital admission, ICU monitoring, and
immediate cardiology consultation. Hypertensive emergencies are defined by the
presence of target organ damage (MI, stroke, acute kidney injury, hypertensive
encephalopathy, pulmonary edema) and require immediate BP reduction, typically
with IV agents. Asymptomatic hypertension, even at very high readings, does not
require emergent intervention. Mild symptoms like headache without end-organ
damage indicators represent hypertensive urgency at most, managed with oral
medications over hours to days, not emergently.
QUESTION 5
A 48-year-old male with controlled hypertension on lisinopril 10mg daily
presents for routine follow-up. His creatinine has increased from 0.9 to 1.3
mg/dL over 6 months. What is the most appropriate next step?
A) Discontinue lisinopril immediately and switch to calcium channel blocker
B) Check serum potassium and renal ultrasound; adjust dose based on results
C) Increase lisinopril dose to improve renal perfusion
D) Add a second antihypertensive without further evaluation
E) Order a renal biopsy to rule out glomerulonephritis
CORRECT ANSWER: B) Check serum potassium and renal ultrasound; adjust
dose based on results
, RATIONALE: An ACE inhibitor can cause an expected mild, transient increase in
creatinine (up to 30%) due to hemodynamic changes and should not be
automatically discontinued. However, this significant rise warrants investigation to
rule out other causes such as dehydration, renal artery stenosis, or progressive
kidney disease. Essential workup includes serum potassium (to assess for
hyperkalemia), renal ultrasound (to evaluate for structural abnormalities,
asymmetric kidney size suggesting renal artery stenosis), and assessment of
medication adherence and fluid status. If the creatinine increase exceeds 30% or
potassium becomes elevated, ACE inhibitor dose reduction or discontinuation may
be necessary. Immediately discontinuing the medication is premature without
investigation. A renal biopsy is not indicated at this point without evidence of
glomerulonephritis.
QUESTION 6
Which of the following represents the most common side effect of ACE
inhibitors that leads to medication discontinuation?
A) Persistent dry cough occurring in 5-10% of patients
B) Hyperkalemia requiring immediate intervention
C) Acute kidney injury in all elderly patients
D) Angioedema within the first week of therapy
E) Hypotension immediately after first dose
CORRECT ANSWER: A) Persistent dry cough occurring in 5-10% of patients
RATIONALE: The dry, persistent cough is the most common side effect of ACE
inhibitors, occurring in approximately 5-10% of patients, and it is the primary
reason for drug discontinuation in primary care. The cough is caused by
accumulation of bradykinin in the lungs and typically occurs within the first few
weeks of therapy. It is benign and resolves within days to weeks after discontinuing
the medication. Hyperkalemia can occur but is less common when baseline kidney
function is normal. Angioedema is a serious but rare adverse effect (0.1-0.2%
incidence). Acute kidney injury is not universal in elderly patients and usually
represents hypersenitivity rather than routine effect. Hypotension immediately
after first dose is uncommon with appropriate dosing.
QUESTION 7
A 67-year-old woman with Stage 2 hypertension, hyperlipidemia, and no prior
cardiovascular disease starts combination therapy with lisinopril and
hydrochlorothiazide. At her one-week follow-up, she reports fatigue, polyuria,
and weight loss. Laboratory values show fasting glucose 280 mg/dL. What is
the most likely medication-related cause?
Primary Care I 2026/2027 | Questions,
Answers & Expert Rationales
NSG 554: NURSE PRACTITIONERS IN PRIMARY CARE I | 2026/2027
Comprehensive Exam Study Guide: 200 Questions, Answers & Expert
Rationales
DOCUMENT OVERVIEW:
• This comprehensive study guide contains 200 rigorously crafted multiple-choice
questions designed to prepare you for NSG 554 Exam 3, covering all essential
primary care nurse practitioner competencies with expert-level rationales for each
answer
• Study strategically by reviewing questions thematically, focusing on areas of
weakness, and using detailed rationales to build clinical reasoning skills—work
through sections daily and complete full-length practice sets to simulate actual
exam conditions
SECTION 1: HYPERTENSION MANAGEMENT IN PRIMARY CARE
QUESTION 1
A 54-year-old male presents to your clinic with a blood pressure reading of
158/98 mmHg on two separate occasions. He has no evidence of end-organ
damage and his laboratory work is normal. Which of the following is the most
appropriate initial management approach?
A) Immediately start combination antihypertensive therapy with ACE inhibitor and
calcium channel blocker
B) Initiate lifestyle modifications and recheck blood pressure in 3-4 weeks
C) Refer to cardiology for specialist evaluation before starting any medications
D) Start a diuretic monotherapy and titrate aggressively over 2 weeks
E) Begin ACE inhibitor monotherapy and add second agent if BP not controlled in 4-
6 weeks
CORRECT ANSWER: B) Initiate lifestyle modifications and recheck blood
pressure in 3-4 weeks
RATIONALE: According to current ACC/AHA guidelines, for Stage 1 hypertension
without evidence of cardiovascular disease or end-organ damage, lifestyle
modifications (DASH diet, weight loss, sodium restriction, exercise, stress reduction,
alcohol moderation) should be initiated first with reassessment in 3-4 weeks.
Pharmacotherapy should be considered if BP remains elevated after lifestyle
intervention or if the patient has additional cardiovascular risk factors. This
,approach aligns with guideline-recommended risk stratification before initiating
medication. Starting monotherapy would be premature at this point, and
aggressive combination therapy is not indicated for initial management without
established cardiovascular disease.
QUESTION 2
Which of the following blood pressure readings most accurately defines Stage
2 hypertension according to 2017 ACC/AHA guidelines?
A) Systolic 130-139 mmHg and/or diastolic 80-89 mmHg
B) Systolic 140 mmHg or higher and/or diastolic 90 mmHg or higher
C) Systolic 160 mmHg or higher and/or diastolic 100 mmHg or higher
D) Systolic 150 mmHg or higher and/or diastolic 95 mmHg or higher
E) Any reading above 140/90 mmHg regardless of organ damage
CORRECT ANSWER: B) Systolic 140 mmHg or higher and/or diastolic 90 mmHg
or higher
RATIONALE: The 2017 ACC/AHA guidelines redefined hypertension categories.
Stage 2 hypertension is defined as SBP ≥140 mmHg or DBP ≥90 mmHg. This
represents a significant change from prior JNC 7 guidelines which used 160/100 as
the Stage 2 cutoff. The new lower threshold reflects evidence supporting more
aggressive BP control to reduce cardiovascular events. Stage 1 hypertension is 130-
139/<80-89 mmHg. Option C represents higher pressures that would indicate more
severe disease. Understanding these updated definitions is essential for
appropriate risk stratification and treatment decisions in primary care.
QUESTION 3
A 62-year-old woman with hypertension, diabetes, and chronic kidney disease
(stage 3b) is starting antihypertensive therapy. Which medication class would
be most beneficial given her comorbidities?
A) Calcium channel blocker monotherapy
B) ACE inhibitor or ARB as initial therapy
C) Beta-blocker as first-line agent
D) Diuretic monotherapy
E) Direct vasodilator combined with hydralazine
CORRECT ANSWER: B) ACE inhibitor or ARB as initial therapy
RATIONALE: In patients with diabetes and chronic kidney disease, ACE inhibitors or
ARBs are strongly recommended as first-line agents because they provide renal
protection through reduction of intraglomerular pressure and proteinuria. These
agents have been shown to slow progression of diabetic nephropathy and reduce
albuminuria independent of blood pressure lowering effects. They also reduce
,cardiovascular mortality in diabetic patients. The combination of diabetes and CKD
makes renal protective therapy essential. Calcium channel blockers lack renal
protective effects in diabetes. Beta-blockers are not ideal first-line in diabetes due
to metabolic effects. Diuretics alone don't address the specific needs of this patient
population.
QUESTION 4
Which of the following patient scenarios would necessitate urgent or
emergent intervention for hypertension?
A) Asymptomatic BP 160/100 mmHg during routine office visit
B) BP 180/120 mmHg with acute chest pain and troponin elevation
C) BP 170/105 mmHg in a patient with complaint of mild headache
D) Stable BP readings of 145/92 mmHg on current medication
E) BP 155/98 mmHg with no systemic symptoms
CORRECT ANSWER: B) BP 180/120 mmHg with acute chest pain and troponin
elevation
RATIONALE: This clinical presentation is consistent with hypertensive urgency with
evidence of acute myocardial infarction (elevated troponin with chest pain). This
requires emergent intervention with hospital admission, ICU monitoring, and
immediate cardiology consultation. Hypertensive emergencies are defined by the
presence of target organ damage (MI, stroke, acute kidney injury, hypertensive
encephalopathy, pulmonary edema) and require immediate BP reduction, typically
with IV agents. Asymptomatic hypertension, even at very high readings, does not
require emergent intervention. Mild symptoms like headache without end-organ
damage indicators represent hypertensive urgency at most, managed with oral
medications over hours to days, not emergently.
QUESTION 5
A 48-year-old male with controlled hypertension on lisinopril 10mg daily
presents for routine follow-up. His creatinine has increased from 0.9 to 1.3
mg/dL over 6 months. What is the most appropriate next step?
A) Discontinue lisinopril immediately and switch to calcium channel blocker
B) Check serum potassium and renal ultrasound; adjust dose based on results
C) Increase lisinopril dose to improve renal perfusion
D) Add a second antihypertensive without further evaluation
E) Order a renal biopsy to rule out glomerulonephritis
CORRECT ANSWER: B) Check serum potassium and renal ultrasound; adjust
dose based on results
, RATIONALE: An ACE inhibitor can cause an expected mild, transient increase in
creatinine (up to 30%) due to hemodynamic changes and should not be
automatically discontinued. However, this significant rise warrants investigation to
rule out other causes such as dehydration, renal artery stenosis, or progressive
kidney disease. Essential workup includes serum potassium (to assess for
hyperkalemia), renal ultrasound (to evaluate for structural abnormalities,
asymmetric kidney size suggesting renal artery stenosis), and assessment of
medication adherence and fluid status. If the creatinine increase exceeds 30% or
potassium becomes elevated, ACE inhibitor dose reduction or discontinuation may
be necessary. Immediately discontinuing the medication is premature without
investigation. A renal biopsy is not indicated at this point without evidence of
glomerulonephritis.
QUESTION 6
Which of the following represents the most common side effect of ACE
inhibitors that leads to medication discontinuation?
A) Persistent dry cough occurring in 5-10% of patients
B) Hyperkalemia requiring immediate intervention
C) Acute kidney injury in all elderly patients
D) Angioedema within the first week of therapy
E) Hypotension immediately after first dose
CORRECT ANSWER: A) Persistent dry cough occurring in 5-10% of patients
RATIONALE: The dry, persistent cough is the most common side effect of ACE
inhibitors, occurring in approximately 5-10% of patients, and it is the primary
reason for drug discontinuation in primary care. The cough is caused by
accumulation of bradykinin in the lungs and typically occurs within the first few
weeks of therapy. It is benign and resolves within days to weeks after discontinuing
the medication. Hyperkalemia can occur but is less common when baseline kidney
function is normal. Angioedema is a serious but rare adverse effect (0.1-0.2%
incidence). Acute kidney injury is not universal in elderly patients and usually
represents hypersenitivity rather than routine effect. Hypotension immediately
after first dose is uncommon with appropriate dosing.
QUESTION 7
A 67-year-old woman with Stage 2 hypertension, hyperlipidemia, and no prior
cardiovascular disease starts combination therapy with lisinopril and
hydrochlorothiazide. At her one-week follow-up, she reports fatigue, polyuria,
and weight loss. Laboratory values show fasting glucose 280 mg/dL. What is
the most likely medication-related cause?
