NURS6540 Exam 2 | NURS 6540 / NRNP 6540
Advanced Practice Care of Frail Elders | Actual Q&A
with Rationale | Walden
1. An 82-year-old woman with chronic heart failure (HFpEF) presents with worsening dyspnea,
bilateral leg edema, and a weight gain of 4 lb over 2 days. Blood pressure is 148/82, heart rate
88, and oxygen saturation 91% on room air. Which intervention is the priority?
A. Increase oral furosemide from 40 mg to 80 mg daily
B. Administer intravenous furosemide 40 mg
C. Start metoprolol succinate 25 mg daily
D. Obtain a chest radiograph
[Answer] B
Rationale: Acute decompensated heart failure with significant fluid overload and hypoxia
requires prompt IV loop diuretic therapy for rapid decongestion. Oral furosemide absorption is
unreliable in the setting of gut edema. Beta-blockers should not be initiated during acute
decompensation.
2. A frail 87-year-old man with dementia, COPD, and hypertension is admitted with pneumonia.
He develops acute confusion, a heart rate of 110, and blood pressure 88/50. Which is the most
likely cause?
A. Delirium from infection
B. Septic shock
C. Adverse drug reaction
D. Hypoxia from pneumonia
[Answer] B
Rationale: Hypotension, tachycardia, and altered mental status in the setting of infection
indicate septic shock. Immediate management includes fluid resuscitation, vasopressors, and
broad-spectrum antibiotics. Delirium alone does not explain the hemodynamic instability.
3. A 78-year-old woman with type 2 diabetes on insulin glargine and lispro is found to have an
HbA1c of 7.8%. She has stage 3 chronic kidney disease (eGFR 42) and recurrent hypoglycemia.
Which is the most appropriate adjustment to her insulin regimen?
A. Increase glargine dose
B. Decrease glargine dose
C. Discontinue lispro
D. Switch to a sulfonylurea
[Answer] B
, Rationale: Recurrent hypoglycemia in a frail elder with CKD indicates insulin accumulation due
to reduced clearance. Reducing the basal insulin (glargine) is safer. Lispro adjustments may be
needed but the priority is to address the basal dose.
4. A frail 85-year-old man with HFrEF (LVEF 35%) on lisinopril, carvedilol, and furosemide
develops a dry cough. Which is the most likely cause?
A. Heart failure progression
B. Lisinopril-induced cough
C. Carvedilol side effect
D. Furosemide-induced cough
[Answer] B
Rationale: ACE inhibitor–induced cough is a common adverse effect, especially in older adults.
It is dry and nonproductive. Carvedilol and furosemide do not typically cause cough. The patient
should be switched to an angiotensin receptor blocker (ARB) if cough is intolerable.
5. A 79-year-old woman with osteoporosis and a history of hip fracture is started on
alendronate. She develops severe heartburn. Which is the most appropriate next step?
A. Discontinue alendronate and start denosumab
B. Reduce alendronate dose to half
C. Advise her to take alendronate with food
D. Prescribe a proton pump inhibitor
[Answer] A
Rationale: Alendronate can cause esophagitis and severe heartburn. If the patient cannot
tolerate oral bisphosphonates, denosumab (subcutaneous) is a good alternative. Dose
reduction is not recommended; taking with food reduces absorption.
6. A frail 90-year-old man with Alzheimer’s disease and hypertension is brought to the clinic
with a blood pressure of 96/58. He is on lisinopril 10 mg daily and amlodipine 5 mg daily. Which
is the most appropriate action?
A. Hold both medications and recheck in 1 week
B. Decrease lisinopril to 5 mg
C. Decrease amlodipine to 2.5 mg
D. Continue current doses and monitor
[Answer] A
Rationale: Symptomatic hypotension (BP 6.0 and ECG changes (or risk of arrhythmia) requires
immediate cardiac stabilization with intravenous calcium. Calcium gluconate protects the heart
while other measures (insulin, albuterol) lower potassium. Hemodialysis is reserved for
refractory cases.
Advanced Practice Care of Frail Elders | Actual Q&A
with Rationale | Walden
1. An 82-year-old woman with chronic heart failure (HFpEF) presents with worsening dyspnea,
bilateral leg edema, and a weight gain of 4 lb over 2 days. Blood pressure is 148/82, heart rate
88, and oxygen saturation 91% on room air. Which intervention is the priority?
A. Increase oral furosemide from 40 mg to 80 mg daily
B. Administer intravenous furosemide 40 mg
C. Start metoprolol succinate 25 mg daily
D. Obtain a chest radiograph
[Answer] B
Rationale: Acute decompensated heart failure with significant fluid overload and hypoxia
requires prompt IV loop diuretic therapy for rapid decongestion. Oral furosemide absorption is
unreliable in the setting of gut edema. Beta-blockers should not be initiated during acute
decompensation.
2. A frail 87-year-old man with dementia, COPD, and hypertension is admitted with pneumonia.
He develops acute confusion, a heart rate of 110, and blood pressure 88/50. Which is the most
likely cause?
A. Delirium from infection
B. Septic shock
C. Adverse drug reaction
D. Hypoxia from pneumonia
[Answer] B
Rationale: Hypotension, tachycardia, and altered mental status in the setting of infection
indicate septic shock. Immediate management includes fluid resuscitation, vasopressors, and
broad-spectrum antibiotics. Delirium alone does not explain the hemodynamic instability.
3. A 78-year-old woman with type 2 diabetes on insulin glargine and lispro is found to have an
HbA1c of 7.8%. She has stage 3 chronic kidney disease (eGFR 42) and recurrent hypoglycemia.
Which is the most appropriate adjustment to her insulin regimen?
A. Increase glargine dose
B. Decrease glargine dose
C. Discontinue lispro
D. Switch to a sulfonylurea
[Answer] B
, Rationale: Recurrent hypoglycemia in a frail elder with CKD indicates insulin accumulation due
to reduced clearance. Reducing the basal insulin (glargine) is safer. Lispro adjustments may be
needed but the priority is to address the basal dose.
4. A frail 85-year-old man with HFrEF (LVEF 35%) on lisinopril, carvedilol, and furosemide
develops a dry cough. Which is the most likely cause?
A. Heart failure progression
B. Lisinopril-induced cough
C. Carvedilol side effect
D. Furosemide-induced cough
[Answer] B
Rationale: ACE inhibitor–induced cough is a common adverse effect, especially in older adults.
It is dry and nonproductive. Carvedilol and furosemide do not typically cause cough. The patient
should be switched to an angiotensin receptor blocker (ARB) if cough is intolerable.
5. A 79-year-old woman with osteoporosis and a history of hip fracture is started on
alendronate. She develops severe heartburn. Which is the most appropriate next step?
A. Discontinue alendronate and start denosumab
B. Reduce alendronate dose to half
C. Advise her to take alendronate with food
D. Prescribe a proton pump inhibitor
[Answer] A
Rationale: Alendronate can cause esophagitis and severe heartburn. If the patient cannot
tolerate oral bisphosphonates, denosumab (subcutaneous) is a good alternative. Dose
reduction is not recommended; taking with food reduces absorption.
6. A frail 90-year-old man with Alzheimer’s disease and hypertension is brought to the clinic
with a blood pressure of 96/58. He is on lisinopril 10 mg daily and amlodipine 5 mg daily. Which
is the most appropriate action?
A. Hold both medications and recheck in 1 week
B. Decrease lisinopril to 5 mg
C. Decrease amlodipine to 2.5 mg
D. Continue current doses and monitor
[Answer] A
Rationale: Symptomatic hypotension (BP 6.0 and ECG changes (or risk of arrhythmia) requires
immediate cardiac stabilization with intravenous calcium. Calcium gluconate protects the heart
while other measures (insulin, albuterol) lower potassium. Hemodialysis is reserved for
refractory cases.
