NSG 6001 COMPREHENSIVE FINAL EXAM :
Advanced Nursing Practice I – LATEST
2026-2027 UPDATE (SOUTH UNIVERSITY)
Question 1
A 68-year-old male with HFrEF (EF 32%) is on lisinopril, metoprolol succinate, and
spironolactone. He remains dyspneic with NYHA class III symptoms. His potassium is
4.2 mEq/L and creatinine is 1.3 mg/dL. What is the next evidence-based addition to his
regimen?
A. Add digoxin 0.125 mg daily
B. Switch lisinopril to sacubitril/valsartan (Entresto)
C. Add hydralazine/isosorbide dinitrate
D. Increase spironolactone to 50 mg daily
Correct Answer: B
Rationale: The PARADIGM-HF trial demonstrated that sacubitril/valsartan (ARNI)
reduced cardiovascular death and HF hospitalization compared to enalapril in
patients with HFrEF (EF ≤40%) who remained symptomatic on ACEi, beta-blocker,
and MRA. It is now guideline-recommended to replace ACEi/ARB in eligible patients.
Digoxin is adjunctive for symptoms/hospitalizations but does not reduce mortality.
Hydralazine/isosorbide is for African Americans or ACEi-intolerant patients.
Increasing spironolactone risks hyperkalemia.
Question 2
A 42-year-old female with type 2 diabetes, BMI 38, and HbA1c 9.1% on metformin
2000 mg daily. She has no CVD or CKD. Which add-on agent is MOST appropriate to
achieve glycemic control and promote weight loss?
A. Glipizide 10 mg daily
B. Pioglitazone 30 mg daily
, C. Semaglutide 1.0 mg SC weekly
D. Insulin glargine 20 units at bedtime
Correct Answer: C
Rationale: Semaglutide (GLP-1 RA) is the most appropriate choice: it lowers HbA1c
by ~1.5-1.8%, promotes significant weight loss (~10-15% body weight), has low
hypoglycemia risk, and is preferred in patients with obesity. Glipizide causes weight
gain and hypoglycemia. Pioglitazone causes weight gain and fluid retention. Basal
insulin is effective but causes weight gain and hypoglycemia; it is not first-line add-
on when obesity is a concern.
Question 3
A 71-year-old with atrial fibrillation (CHA₂DS₂-VASc 4) is started on apixaban. He
develops acute appendicitis and requires emergency laparoscopic appendectomy.
When should apixaban be held pre-operatively?
A. Hold 12 hours before surgery
B. Hold 24-48 hours before surgery (last dose 2 days prior)
C. Hold 5 days before surgery
D. Continue apixaban through surgery
Correct Answer: B
Rationale: For DOACs with low bleeding risk surgery, apixaban should be held for 24-
48 hours (last dose 1-2 days before) depending on renal function and bleeding risk.
For high bleeding risk surgery (intra-abdominal), hold 48 hours (CrCl ≥30) or 72 hours
(CrCl 15-29). Resuming 24-72 hours post-op when hemostasis is secure. 12 hours is
too short. 5 days is excessive (warfarin requires 5 days). Continuing through surgery
risks bleeding.
Question 4
,A patient with COPD has an FEV₁ of 48% predicted, FEV₁/FVC 0.58, and 2 exacerbations
in the past year requiring oral steroids. He is on tiotropium and salmeterol. What is
the next step per GOLD 2024?
A. Add low-dose inhaled corticosteroid (ICS)
B. Switch to SABA-only as needed
C. Add roflumilast
D. Discontinue LABA and increase LAMA dose
Correct Answer: A
Rationale: This patient has GOLD group D (FEV₁ <50% + ≥2 exacerbations). Per GOLD
2024, initial therapy for Group D is LABA + LAMA. If exacerbations persist on dual
bronchodilation, add ICS (triple therapy: ICS + LABA + LAMA). Roflumilast is for
severe COPD (FEV₁ <50%) with chronic bronchitis and frequent exacerbations on
triple therapy. SABA-only is inappropriate. Discontinuing LABA worsens control.
Question 5
A 35-year-old with type 1 diabetes presents with polyuria, polydipsia, weight loss,
glucose 540 mg/dL, pH 7.12, HCO₃ 8 mEq/L, and positive serum ketones. After initial
fluid resuscitation with NS, what is the next critical step?
A. Start regular insulin IV at 0.1 units/kg/hr immediately
B. Start regular insulin IV bolus 0.1 units/kg, then 0.1 units/kg/hr infusion
C. Start subcutaneous insulin glargine 20 units
D. Start oral metformin 1000 mg BID
Correct Answer: B
Rationale: DKA management: After initial fluid resuscitation (NS 15-20 mL/kg in first
hour), start regular insulin IV bolus 0.1 units/kg followed by continuous infusion 0.1
units/kg/hr. Some protocols omit the bolus if the infusion is started promptly. The
key is IV regular insulin, NOT subcutaneous basal insulin (poor absorption in
dehydration) and NOT metformin (contraindicated in DKA and T1DM).
, Question 6
A patient with hypertension and CKD stage 3b (eGFR 38, UACR 220 mg/g) has BP
148/92 on amlodipine 10 mg daily. What is the most appropriate next step?
A. Add hydrochlorothiazide 25 mg daily
B. Add lisinopril 10 mg daily
C. Increase amlodipine to 20 mg daily
D. Add clonidine 0.1 mg BID
Correct Answer: B
Rationale: This patient has CKD with albuminuria (UACR 220 = macroalbuminuria
range). ADA/KDIGO recommend ACE inhibitor or ARB as first-line antihypertensives
in diabetes with albuminuria for renoprotection. Adding lisinopril (ACEi) will lower
BP AND slow progression of nephropathy. HCTZ is less effective at eGFR <30 and
does not provide renoprotection. Amlodipine max is 10 mg. Clonidine is not first-line.
Question 7
A 52-year-old with Graves' disease is started on methimazole 30 mg daily. After 4
weeks, he develops fever, sore throat, and severe malaise. CBC shows WBC 2.1 x10⁹/L
with absolute neutrophil count 800. What is the most appropriate action?
A. Continue methimazole and start G-CSF
B. Stop methimazole immediately and obtain serial CBCs
C. Switch to propylthiouracil (PTU)
D. Continue methimazole and add prednisone
Correct Answer: B
Rationale: Agranulocytosis (ANC <500) is a rare but life-threatening side effect of
thionamides (methimazole > PTU). The drug must be STOPPED immediately and
NEVER rechallenge. The patient needs serial CBCs, broad-spectrum antibiotics if
febrile, and G-CSF if severe. Switching to PTU is contraindicated due to cross-
reactivity (~50%). Definitive treatment (radioactive iodine or surgery) should be
pursued once recovered.
Advanced Nursing Practice I – LATEST
2026-2027 UPDATE (SOUTH UNIVERSITY)
Question 1
A 68-year-old male with HFrEF (EF 32%) is on lisinopril, metoprolol succinate, and
spironolactone. He remains dyspneic with NYHA class III symptoms. His potassium is
4.2 mEq/L and creatinine is 1.3 mg/dL. What is the next evidence-based addition to his
regimen?
A. Add digoxin 0.125 mg daily
B. Switch lisinopril to sacubitril/valsartan (Entresto)
C. Add hydralazine/isosorbide dinitrate
D. Increase spironolactone to 50 mg daily
Correct Answer: B
Rationale: The PARADIGM-HF trial demonstrated that sacubitril/valsartan (ARNI)
reduced cardiovascular death and HF hospitalization compared to enalapril in
patients with HFrEF (EF ≤40%) who remained symptomatic on ACEi, beta-blocker,
and MRA. It is now guideline-recommended to replace ACEi/ARB in eligible patients.
Digoxin is adjunctive for symptoms/hospitalizations but does not reduce mortality.
Hydralazine/isosorbide is for African Americans or ACEi-intolerant patients.
Increasing spironolactone risks hyperkalemia.
Question 2
A 42-year-old female with type 2 diabetes, BMI 38, and HbA1c 9.1% on metformin
2000 mg daily. She has no CVD or CKD. Which add-on agent is MOST appropriate to
achieve glycemic control and promote weight loss?
A. Glipizide 10 mg daily
B. Pioglitazone 30 mg daily
, C. Semaglutide 1.0 mg SC weekly
D. Insulin glargine 20 units at bedtime
Correct Answer: C
Rationale: Semaglutide (GLP-1 RA) is the most appropriate choice: it lowers HbA1c
by ~1.5-1.8%, promotes significant weight loss (~10-15% body weight), has low
hypoglycemia risk, and is preferred in patients with obesity. Glipizide causes weight
gain and hypoglycemia. Pioglitazone causes weight gain and fluid retention. Basal
insulin is effective but causes weight gain and hypoglycemia; it is not first-line add-
on when obesity is a concern.
Question 3
A 71-year-old with atrial fibrillation (CHA₂DS₂-VASc 4) is started on apixaban. He
develops acute appendicitis and requires emergency laparoscopic appendectomy.
When should apixaban be held pre-operatively?
A. Hold 12 hours before surgery
B. Hold 24-48 hours before surgery (last dose 2 days prior)
C. Hold 5 days before surgery
D. Continue apixaban through surgery
Correct Answer: B
Rationale: For DOACs with low bleeding risk surgery, apixaban should be held for 24-
48 hours (last dose 1-2 days before) depending on renal function and bleeding risk.
For high bleeding risk surgery (intra-abdominal), hold 48 hours (CrCl ≥30) or 72 hours
(CrCl 15-29). Resuming 24-72 hours post-op when hemostasis is secure. 12 hours is
too short. 5 days is excessive (warfarin requires 5 days). Continuing through surgery
risks bleeding.
Question 4
,A patient with COPD has an FEV₁ of 48% predicted, FEV₁/FVC 0.58, and 2 exacerbations
in the past year requiring oral steroids. He is on tiotropium and salmeterol. What is
the next step per GOLD 2024?
A. Add low-dose inhaled corticosteroid (ICS)
B. Switch to SABA-only as needed
C. Add roflumilast
D. Discontinue LABA and increase LAMA dose
Correct Answer: A
Rationale: This patient has GOLD group D (FEV₁ <50% + ≥2 exacerbations). Per GOLD
2024, initial therapy for Group D is LABA + LAMA. If exacerbations persist on dual
bronchodilation, add ICS (triple therapy: ICS + LABA + LAMA). Roflumilast is for
severe COPD (FEV₁ <50%) with chronic bronchitis and frequent exacerbations on
triple therapy. SABA-only is inappropriate. Discontinuing LABA worsens control.
Question 5
A 35-year-old with type 1 diabetes presents with polyuria, polydipsia, weight loss,
glucose 540 mg/dL, pH 7.12, HCO₃ 8 mEq/L, and positive serum ketones. After initial
fluid resuscitation with NS, what is the next critical step?
A. Start regular insulin IV at 0.1 units/kg/hr immediately
B. Start regular insulin IV bolus 0.1 units/kg, then 0.1 units/kg/hr infusion
C. Start subcutaneous insulin glargine 20 units
D. Start oral metformin 1000 mg BID
Correct Answer: B
Rationale: DKA management: After initial fluid resuscitation (NS 15-20 mL/kg in first
hour), start regular insulin IV bolus 0.1 units/kg followed by continuous infusion 0.1
units/kg/hr. Some protocols omit the bolus if the infusion is started promptly. The
key is IV regular insulin, NOT subcutaneous basal insulin (poor absorption in
dehydration) and NOT metformin (contraindicated in DKA and T1DM).
, Question 6
A patient with hypertension and CKD stage 3b (eGFR 38, UACR 220 mg/g) has BP
148/92 on amlodipine 10 mg daily. What is the most appropriate next step?
A. Add hydrochlorothiazide 25 mg daily
B. Add lisinopril 10 mg daily
C. Increase amlodipine to 20 mg daily
D. Add clonidine 0.1 mg BID
Correct Answer: B
Rationale: This patient has CKD with albuminuria (UACR 220 = macroalbuminuria
range). ADA/KDIGO recommend ACE inhibitor or ARB as first-line antihypertensives
in diabetes with albuminuria for renoprotection. Adding lisinopril (ACEi) will lower
BP AND slow progression of nephropathy. HCTZ is less effective at eGFR <30 and
does not provide renoprotection. Amlodipine max is 10 mg. Clonidine is not first-line.
Question 7
A 52-year-old with Graves' disease is started on methimazole 30 mg daily. After 4
weeks, he develops fever, sore throat, and severe malaise. CBC shows WBC 2.1 x10⁹/L
with absolute neutrophil count 800. What is the most appropriate action?
A. Continue methimazole and start G-CSF
B. Stop methimazole immediately and obtain serial CBCs
C. Switch to propylthiouracil (PTU)
D. Continue methimazole and add prednisone
Correct Answer: B
Rationale: Agranulocytosis (ANC <500) is a rare but life-threatening side effect of
thionamides (methimazole > PTU). The drug must be STOPPED immediately and
NEVER rechallenge. The patient needs serial CBCs, broad-spectrum antibiotics if
febrile, and G-CSF if severe. Switching to PTU is contraindicated due to cross-
reactivity (~50%). Definitive treatment (radioactive iodine or surgery) should be
pursued once recovered.
