GACNP BOARD EXAM PREP:
PRACTICE QUESTIONS WITH
RATIONALES FOR ACUTE CARE
CERTIFICATION
Cardiovascular
1. A 68-year-old male presents with acute substernal chest pain
radiating to the jaw. ECG shows 3-mm ST-segment elevation in leads
V1-V4. BP is 145/90, HR 96. Which intervention is the priority?
Answer: A. Immediate PCI or fibrinolysis per protocol
Rationale: ST-segment elevation in V1-V4 indicates an anterior STEMI.
Time to reperfusion is critical—PCI is preferred within 90 minutes of arrival;
fibrinolysis if PCI not available within 120 minutes. Aspirin, nitroglycerin,
and morphine are adjunctive but do not replace reperfusion therapy.
2. A patient with new-onset atrial fibrillation has a ventricular rate of
140, BP 110/70, and is asymptomatic. Which is the first-line agent for
rate control?
Answer: A. Beta-blocker (e.g., metoprolol)
Rationale: Beta-blockers are first-line for rate control in stable AF with
preserved LV function. Non-dihydropyridine calcium channel blockers
,(diltiazem, verapamil) are alternatives. Digoxin is less effective acutely and
reserved for patients with heart failure or those who cannot tolerate beta-
blockers or CCBs .
3. A 72-year-old with CHF exacerbation has JVD, peripheral edema,
and crackles. Which diuretic is preferred for rapid volume removal in
acute decompensated heart failure?
Answer: A. IV furosemide
Rationale: IV loop diuretics (furosemide, bumetanide) are first-line for
acute volume overload. IV administration ensures bioavailability in patients
with intestinal edema. Initial dose should be based on home oral dose—
typically 1-2.5 times the oral dose.
4. A patient with a hypertensive emergency has acute aortic dissection.
What is the target BP management?
Answer: A. Rapid SBP reduction to 100-120 mmHg using IV beta-blocker
Rationale: Acute aortic dissection requires rapid SBP reduction to 100-120
mmHg using IV beta-blockers (e.g., esmolol, labetalol) to decrease shear
stress on the aortic wall. Too rapid or too slow reduction may worsen
outcomes. Pain control is adjunctive, not primary .
,5. A patient in septic shock requires vasopressor support. Which is the
first-line vasopressor?
Answer: A. Norepinephrine
Rationale: Norepinephrine is the first-line vasopressor in septic shock per
Surviving Sepsis Campaign guidelines. It increases MAP through
vasoconstriction with minimal chronotropic effect. Vasopressin and
epinephrine are second-line or adjunctive agents.
6. An ECG shows prolonged PR interval (>200 ms) with a dropped QRS
complex every third beat. What is the diagnosis?
Answer: A. Second-degree AV block, Mobitz Type II
Rationale: Mobitz Type II AV block is characterized by intermittent non-
conducted P waves without PR interval prolongation before the dropped
beat. This pattern is often infranodal and may progress to complete heart
block, requiring close monitoring and possible pacemaker placement.
7. A patient with CHF and a history of COPD exacerbations is being
treated for acute bronchitis. Which medication should be avoided?
Answer: A. High-dose beta-blocker
Rationale: Non-selective beta-blockers can cause bronchospasm in COPD
patients. If beta-blockers are needed for heart failure, cardioselective
, agents (metoprolol, bisoprolol) are preferred but should be used cautiously.
Consider alternative rate control in acute settings.
8. A 65-year-old with a history of DVT presents with sudden-onset
dyspnea, tachycardia, and hypotension. What is the most appropriate
next step?
Answer: A. CT pulmonary angiography
Rationale: This presentation suggests massive PE with hemodynamic
instability. CT pulmonary angiography is the diagnostic study of choice for
suspected PE. If unavailable, V/Q scan or bedside echocardiography (for RV
strain) may be used. Anticoagulation should not be delayed if clinical
suspicion is high.
9. Which finding on a stress test is most concerning for significant
coronary artery disease?
Answer: A. ST-segment depression ≥2 mm with chest pain
Rationale: Horizontal or downsloping ST-segment depression ≥2 mm
accompanied by chest pain is highly suggestive of significant CAD. The
depth and duration of ST changes, along with symptoms, determine risk
stratification.
PRACTICE QUESTIONS WITH
RATIONALES FOR ACUTE CARE
CERTIFICATION
Cardiovascular
1. A 68-year-old male presents with acute substernal chest pain
radiating to the jaw. ECG shows 3-mm ST-segment elevation in leads
V1-V4. BP is 145/90, HR 96. Which intervention is the priority?
Answer: A. Immediate PCI or fibrinolysis per protocol
Rationale: ST-segment elevation in V1-V4 indicates an anterior STEMI.
Time to reperfusion is critical—PCI is preferred within 90 minutes of arrival;
fibrinolysis if PCI not available within 120 minutes. Aspirin, nitroglycerin,
and morphine are adjunctive but do not replace reperfusion therapy.
2. A patient with new-onset atrial fibrillation has a ventricular rate of
140, BP 110/70, and is asymptomatic. Which is the first-line agent for
rate control?
Answer: A. Beta-blocker (e.g., metoprolol)
Rationale: Beta-blockers are first-line for rate control in stable AF with
preserved LV function. Non-dihydropyridine calcium channel blockers
,(diltiazem, verapamil) are alternatives. Digoxin is less effective acutely and
reserved for patients with heart failure or those who cannot tolerate beta-
blockers or CCBs .
3. A 72-year-old with CHF exacerbation has JVD, peripheral edema,
and crackles. Which diuretic is preferred for rapid volume removal in
acute decompensated heart failure?
Answer: A. IV furosemide
Rationale: IV loop diuretics (furosemide, bumetanide) are first-line for
acute volume overload. IV administration ensures bioavailability in patients
with intestinal edema. Initial dose should be based on home oral dose—
typically 1-2.5 times the oral dose.
4. A patient with a hypertensive emergency has acute aortic dissection.
What is the target BP management?
Answer: A. Rapid SBP reduction to 100-120 mmHg using IV beta-blocker
Rationale: Acute aortic dissection requires rapid SBP reduction to 100-120
mmHg using IV beta-blockers (e.g., esmolol, labetalol) to decrease shear
stress on the aortic wall. Too rapid or too slow reduction may worsen
outcomes. Pain control is adjunctive, not primary .
,5. A patient in septic shock requires vasopressor support. Which is the
first-line vasopressor?
Answer: A. Norepinephrine
Rationale: Norepinephrine is the first-line vasopressor in septic shock per
Surviving Sepsis Campaign guidelines. It increases MAP through
vasoconstriction with minimal chronotropic effect. Vasopressin and
epinephrine are second-line or adjunctive agents.
6. An ECG shows prolonged PR interval (>200 ms) with a dropped QRS
complex every third beat. What is the diagnosis?
Answer: A. Second-degree AV block, Mobitz Type II
Rationale: Mobitz Type II AV block is characterized by intermittent non-
conducted P waves without PR interval prolongation before the dropped
beat. This pattern is often infranodal and may progress to complete heart
block, requiring close monitoring and possible pacemaker placement.
7. A patient with CHF and a history of COPD exacerbations is being
treated for acute bronchitis. Which medication should be avoided?
Answer: A. High-dose beta-blocker
Rationale: Non-selective beta-blockers can cause bronchospasm in COPD
patients. If beta-blockers are needed for heart failure, cardioselective
, agents (metoprolol, bisoprolol) are preferred but should be used cautiously.
Consider alternative rate control in acute settings.
8. A 65-year-old with a history of DVT presents with sudden-onset
dyspnea, tachycardia, and hypotension. What is the most appropriate
next step?
Answer: A. CT pulmonary angiography
Rationale: This presentation suggests massive PE with hemodynamic
instability. CT pulmonary angiography is the diagnostic study of choice for
suspected PE. If unavailable, V/Q scan or bedside echocardiography (for RV
strain) may be used. Anticoagulation should not be delayed if clinical
suspicion is high.
9. Which finding on a stress test is most concerning for significant
coronary artery disease?
Answer: A. ST-segment depression ≥2 mm with chest pain
Rationale: Horizontal or downsloping ST-segment depression ≥2 mm
accompanied by chest pain is highly suggestive of significant CAD. The
depth and duration of ST changes, along with symptoms, determine risk
stratification.
