KAPLAN USMLE STEP 3 EXAM PRACTICE | STUDY GUIDE | COMPREHENSIVE
TESTBANK | PRACTICE QUESTIONS & ANSWERS | EXAM PREPARATION | LATEST
UPDATE 2026/2027
i. Internal Medicine and Critical Care
ii. Pediatrics and Obstetrics/Gynecology
iii. Surgery and Perioperative Medicine
iv. Psychiatry, Neurology, and Behavioral Medicine
v. Emergency Medicine and Preventive Care
vi. Pharmacology, Ethics, and Patient Safety
vii. Biostatistics, Epidemiology, and Evidence-Based Medicine
viii. Clinical Decision-Making and Management*
INTRODUCTION
This comprehensive USMLE Step 3 practice examination emphasizes advanced clinical
decision-making across ambulatory, inpatient, emergency, and longitudinal care.
Questions integrate diagnosis, initial stabilization, definitive treatment, pharmacology,
preventive medicine, ethics, patient safety, epidemiology, and interpretation of clinical
data. The difficulty is designed for learners preparing for the physician-level reasoning
expected on Step 3, with emphasis on selecting the best next step rather than recalling
isolated facts. Students should expect realistic clinical vignettes requiring prioritization,
recognition of complications, interpretation of diagnostic findings, risk-benefit
assessment, and application of evidence-based management. The questions also
incorporate multidisciplinary considerations and situations in which an initially
reasonable intervention may be inappropriate.
Question 1
A 67-year-old man with a history of hypertension and hyperlipidemia presents with 90
minutes of substernal chest pressure radiating to the left arm. ECG shows ST-segment
elevation in leads II, III, and aVF. Blood pressure is 86/54 mm Hg, and jugular venous
pressure is elevated. Lung examination reveals clear breath sounds. He receives aspirin
and is transferred immediately for coronary angiography. Which additional intervention
is most appropriate while awaiting revascularization?
A. Intravenous nitroglycerin
B. Intravenous furosemide
C. Intravenous isotonic crystalloid
D. Intravenous metoprolol
,🔴 Correct Answer: C. Intravenous isotonic crystalloid
🔵 Explanation: Inferior STEMI with hypotension, elevated JVP, and clear lungs strongly
suggests right ventricular infarction. These patients are preload dependent, so cautious IV
fluid administration is appropriate. Nitrates and diuretics can worsen hypotension by
reducing preload, while beta-blockade is inappropriate during hemodynamic instability.
Question 2
A 29-year-old woman with type 1 diabetes mellitus presents with vomiting, abdominal
pain, and confusion. Laboratory studies show glucose 520 mg/dL, arterial pH 7.12,
bicarbonate 9 mEq/L, and markedly elevated serum β-hydroxybutyrate. Serum
potassium is 2.9 mEq/L. Which intervention should occur before initiating an insulin
infusion?
A. Intravenous sodium bicarbonate
B. Intravenous potassium replacement
C. Subcutaneous long-acting insulin
D. Intravenous phosphate replacement
🔴 Correct Answer: B. Intravenous potassium replacement
🔵 Explanation: In diabetic ketoacidosis, total-body potassium is depleted even when the
initial serum potassium is normal or elevated. If potassium is below 3.3 mEq/L, insulin
must be withheld temporarily because insulin drives potassium intracellularly and can
precipitate life-threatening hypokalemia. Potassium replacement should precede insulin.
Question 3
A 72-year-old woman with atrial fibrillation treated with warfarin presents with
headache and confusion after a fall. CT of the head shows an acute intracranial
hemorrhage. Her INR is 6.8. Which is the most appropriate immediate treatment?
A. Oral vitamin K alone
B. Intravenous unfractionated heparin
C. Intravenous vitamin K plus 4-factor prothrombin complex concentrate
D. Fresh frozen plasma alone
E. Protamine sulfate
🔴 Correct Answer: C. Intravenous vitamin K plus 4-factor prothrombin complex
concentrate
🔵 Explanation: Life-threatening warfarin-associated bleeding requires rapid reversal. IV
vitamin K provides sustained reversal, while 4-factor PCC rapidly replaces vitamin K–
,dependent clotting factors. FFP can be used when PCC is unavailable but is slower and
requires larger infusion volumes. Protamine reverses heparin, not warfarin.
Question 4
A 41-year-old man presents with fever, agitation, diaphoresis, diarrhea, and
tremulousness. He has a history of Graves disease but stopped taking his medications
several weeks ago. Temperature is 40.2°C, heart rate is 158/min, and he has atrial
fibrillation. Which treatment sequence is most appropriate?
A. Radioactive iodine followed by levothyroxine
B. Methimazole, iodine after thionamide administration, and beta-blockade
C. Iodine immediately followed by methimazole
D. Levothyroxine and propranolol
E. Thyroidectomy without medical stabilization
🔴 Correct Answer: B. Methimazole, iodine after thionamide administration, and
beta-blockade
🔵 Explanation: This presentation is thyroid storm. Treatment includes a thionamide to
inhibit new hormone synthesis, followed at least shortly afterward by iodine to inhibit
hormone release, plus beta-blockade and supportive therapy. Iodine should not precede
thionamide because it can otherwise provide substrate for thyroid hormone synthesis.
Question 5
A 56-year-old man with cirrhosis presents with hematemesis and hypotension. After
airway stabilization and IV access, which combination most appropriately addresses the
likely source of bleeding while definitive endoscopy is arranged?
A. IV proton pump inhibitor alone
B. Octreotide plus prophylactic antibiotics
C. Aspirin plus IV heparin
D. Tranexamic acid plus oral propranolol
E. Sucralfate plus misoprostol
🔴 Correct Answer: B. Octreotide plus prophylactic antibiotics
🔵 Explanation: In a patient with cirrhosis and suspected variceal hemorrhage, vasoactive
therapy such as octreotide reduces portal pressure, while antibiotic prophylaxis decreases
infectious complications and mortality. Urgent endoscopy with variceal ligation is
definitive therapy when esophageal varices are identified.
, Question 6
A 63-year-old man develops sudden aphasia and right hemiparesis 75 minutes after
symptom onset. CT shows no hemorrhage. Blood pressure is 178/102 mm Hg, and
there are no contraindications to thrombolysis. Which is the most appropriate next
step?
A. Lower blood pressure below 120/80 mm Hg before any reperfusion treatment
B. Administer IV thrombolytic therapy after appropriate eligibility assessment
C. Begin therapeutic heparin immediately
D. Delay treatment until MRI confirms infarction
E. Administer aspirin and reassess after 24 hours
🔴 Correct Answer: B. Administer IV thrombolytic therapy after appropriate
eligibility assessment
🔵 Explanation: This patient has an acute ischemic stroke within the standard
thrombolytic treatment window and a blood pressure below the threshold requiring
reduction before IV thrombolysis. Treatment should not be delayed for MRI when
noncontrast CT has excluded hemorrhage and the clinical criteria are satisfied.
Question 7
A 34-year-old woman at 32 weeks' gestation presents with severe headache, visual
disturbances, and right upper-quadrant pain. Blood pressure is 172/114 mm Hg on
repeat measurement. Platelets are 82,000/mm³ and AST/ALT are markedly elevated.
Which management is most appropriate?
A. Outpatient observation until 37 weeks
B. Immediate delivery after maternal stabilization
C. Betamethasone alone followed by discharge
D. Magnesium sulfate without delivery
E. ACE inhibitor therapy
🔴 Correct Answer: B. Immediate delivery after maternal stabilization
🔵 Explanation: Severe hypertension with neurologic symptoms, thrombocytopenia, and
hepatic injury represents severe preeclampsia with features consistent with HELLP
syndrome. At 32 weeks, expectant management is not appropriate when there is
significant maternal deterioration. Stabilization includes seizure prophylaxis with
magnesium sulfate and blood-pressure management, followed by delivery.
Question 8
TESTBANK | PRACTICE QUESTIONS & ANSWERS | EXAM PREPARATION | LATEST
UPDATE 2026/2027
i. Internal Medicine and Critical Care
ii. Pediatrics and Obstetrics/Gynecology
iii. Surgery and Perioperative Medicine
iv. Psychiatry, Neurology, and Behavioral Medicine
v. Emergency Medicine and Preventive Care
vi. Pharmacology, Ethics, and Patient Safety
vii. Biostatistics, Epidemiology, and Evidence-Based Medicine
viii. Clinical Decision-Making and Management*
INTRODUCTION
This comprehensive USMLE Step 3 practice examination emphasizes advanced clinical
decision-making across ambulatory, inpatient, emergency, and longitudinal care.
Questions integrate diagnosis, initial stabilization, definitive treatment, pharmacology,
preventive medicine, ethics, patient safety, epidemiology, and interpretation of clinical
data. The difficulty is designed for learners preparing for the physician-level reasoning
expected on Step 3, with emphasis on selecting the best next step rather than recalling
isolated facts. Students should expect realistic clinical vignettes requiring prioritization,
recognition of complications, interpretation of diagnostic findings, risk-benefit
assessment, and application of evidence-based management. The questions also
incorporate multidisciplinary considerations and situations in which an initially
reasonable intervention may be inappropriate.
Question 1
A 67-year-old man with a history of hypertension and hyperlipidemia presents with 90
minutes of substernal chest pressure radiating to the left arm. ECG shows ST-segment
elevation in leads II, III, and aVF. Blood pressure is 86/54 mm Hg, and jugular venous
pressure is elevated. Lung examination reveals clear breath sounds. He receives aspirin
and is transferred immediately for coronary angiography. Which additional intervention
is most appropriate while awaiting revascularization?
A. Intravenous nitroglycerin
B. Intravenous furosemide
C. Intravenous isotonic crystalloid
D. Intravenous metoprolol
,🔴 Correct Answer: C. Intravenous isotonic crystalloid
🔵 Explanation: Inferior STEMI with hypotension, elevated JVP, and clear lungs strongly
suggests right ventricular infarction. These patients are preload dependent, so cautious IV
fluid administration is appropriate. Nitrates and diuretics can worsen hypotension by
reducing preload, while beta-blockade is inappropriate during hemodynamic instability.
Question 2
A 29-year-old woman with type 1 diabetes mellitus presents with vomiting, abdominal
pain, and confusion. Laboratory studies show glucose 520 mg/dL, arterial pH 7.12,
bicarbonate 9 mEq/L, and markedly elevated serum β-hydroxybutyrate. Serum
potassium is 2.9 mEq/L. Which intervention should occur before initiating an insulin
infusion?
A. Intravenous sodium bicarbonate
B. Intravenous potassium replacement
C. Subcutaneous long-acting insulin
D. Intravenous phosphate replacement
🔴 Correct Answer: B. Intravenous potassium replacement
🔵 Explanation: In diabetic ketoacidosis, total-body potassium is depleted even when the
initial serum potassium is normal or elevated. If potassium is below 3.3 mEq/L, insulin
must be withheld temporarily because insulin drives potassium intracellularly and can
precipitate life-threatening hypokalemia. Potassium replacement should precede insulin.
Question 3
A 72-year-old woman with atrial fibrillation treated with warfarin presents with
headache and confusion after a fall. CT of the head shows an acute intracranial
hemorrhage. Her INR is 6.8. Which is the most appropriate immediate treatment?
A. Oral vitamin K alone
B. Intravenous unfractionated heparin
C. Intravenous vitamin K plus 4-factor prothrombin complex concentrate
D. Fresh frozen plasma alone
E. Protamine sulfate
🔴 Correct Answer: C. Intravenous vitamin K plus 4-factor prothrombin complex
concentrate
🔵 Explanation: Life-threatening warfarin-associated bleeding requires rapid reversal. IV
vitamin K provides sustained reversal, while 4-factor PCC rapidly replaces vitamin K–
,dependent clotting factors. FFP can be used when PCC is unavailable but is slower and
requires larger infusion volumes. Protamine reverses heparin, not warfarin.
Question 4
A 41-year-old man presents with fever, agitation, diaphoresis, diarrhea, and
tremulousness. He has a history of Graves disease but stopped taking his medications
several weeks ago. Temperature is 40.2°C, heart rate is 158/min, and he has atrial
fibrillation. Which treatment sequence is most appropriate?
A. Radioactive iodine followed by levothyroxine
B. Methimazole, iodine after thionamide administration, and beta-blockade
C. Iodine immediately followed by methimazole
D. Levothyroxine and propranolol
E. Thyroidectomy without medical stabilization
🔴 Correct Answer: B. Methimazole, iodine after thionamide administration, and
beta-blockade
🔵 Explanation: This presentation is thyroid storm. Treatment includes a thionamide to
inhibit new hormone synthesis, followed at least shortly afterward by iodine to inhibit
hormone release, plus beta-blockade and supportive therapy. Iodine should not precede
thionamide because it can otherwise provide substrate for thyroid hormone synthesis.
Question 5
A 56-year-old man with cirrhosis presents with hematemesis and hypotension. After
airway stabilization and IV access, which combination most appropriately addresses the
likely source of bleeding while definitive endoscopy is arranged?
A. IV proton pump inhibitor alone
B. Octreotide plus prophylactic antibiotics
C. Aspirin plus IV heparin
D. Tranexamic acid plus oral propranolol
E. Sucralfate plus misoprostol
🔴 Correct Answer: B. Octreotide plus prophylactic antibiotics
🔵 Explanation: In a patient with cirrhosis and suspected variceal hemorrhage, vasoactive
therapy such as octreotide reduces portal pressure, while antibiotic prophylaxis decreases
infectious complications and mortality. Urgent endoscopy with variceal ligation is
definitive therapy when esophageal varices are identified.
, Question 6
A 63-year-old man develops sudden aphasia and right hemiparesis 75 minutes after
symptom onset. CT shows no hemorrhage. Blood pressure is 178/102 mm Hg, and
there are no contraindications to thrombolysis. Which is the most appropriate next
step?
A. Lower blood pressure below 120/80 mm Hg before any reperfusion treatment
B. Administer IV thrombolytic therapy after appropriate eligibility assessment
C. Begin therapeutic heparin immediately
D. Delay treatment until MRI confirms infarction
E. Administer aspirin and reassess after 24 hours
🔴 Correct Answer: B. Administer IV thrombolytic therapy after appropriate
eligibility assessment
🔵 Explanation: This patient has an acute ischemic stroke within the standard
thrombolytic treatment window and a blood pressure below the threshold requiring
reduction before IV thrombolysis. Treatment should not be delayed for MRI when
noncontrast CT has excluded hemorrhage and the clinical criteria are satisfied.
Question 7
A 34-year-old woman at 32 weeks' gestation presents with severe headache, visual
disturbances, and right upper-quadrant pain. Blood pressure is 172/114 mm Hg on
repeat measurement. Platelets are 82,000/mm³ and AST/ALT are markedly elevated.
Which management is most appropriate?
A. Outpatient observation until 37 weeks
B. Immediate delivery after maternal stabilization
C. Betamethasone alone followed by discharge
D. Magnesium sulfate without delivery
E. ACE inhibitor therapy
🔴 Correct Answer: B. Immediate delivery after maternal stabilization
🔵 Explanation: Severe hypertension with neurologic symptoms, thrombocytopenia, and
hepatic injury represents severe preeclampsia with features consistent with HELLP
syndrome. At 32 weeks, expectant management is not appropriate when there is
significant maternal deterioration. Stabilization includes seizure prophylaxis with
magnesium sulfate and blood-pressure management, followed by delivery.
Question 8
