,NSG555/NSG 555 Exam 1 Nurse Practitioners in
Primary Care II | Wilkes | 26/27 Updated (PDF)
1. A 72-year-old male with a 30-pack-year smoking history presents with progressive dyspnea on
exertion and a chronic productive cough. Spirometry reveals an FEV1/FVC ratio of 0.62. According to
the GOLD staging system, which parameter is most critical for determining the patient's disease
severity?
A) FEV1 percent predicted
B) FVC percent predicted
C) DLCO percent predicted
D) FEV1/FVC ratio
Correct Answer: FEV1 percent predicted
Rationale: GOLD staging of COPD is based on the FEV1 percent predicted, not the FEV1/FVC ratio,
which is used for diagnosis of airflow obstruction. Severity is classified as GOLD 1 (≥80%), GOLD 2 (50-
79%), GOLD 3 (30-49%), and GOLD 4 (<30%). DLCO assesses gas exchange but does not determine
GOLD stage.
2. A 68-year-old female with hypertension and type 2 diabetes has a blood pressure of 148/90 mmHg
on two separate visits. According to the JNC 8 guidelines, which is the most appropriate initial
pharmacologic strategy?
A) Initiate a thiazide diuretic
B) Initiate an ACE inhibitor
C) Initiate a calcium channel blocker
D) Initiate combination therapy with two agents
Correct Answer: Initiate an ACE inhibitor
Rationale: JNC 8 recommends starting an ACE inhibitor, ARB, thiazide diuretic, or calcium channel
blocker in non-black patients with hypertension, including those with diabetes. For patients with
diabetes, ACE inhibitors or ARBs are preferred due to renal protective effects. Combination therapy is
not recommended as initial therapy unless BP is >20/10 mmHg above goal.
3. A 55-year-old male with a history of heart failure with reduced ejection fraction (HFrEF) is being
managed on an ACE inhibitor and a beta-blocker. Which additional medication has been shown to
reduce mortality and hospitalizations in this population?
,A) Digoxin
B) Hydralazine and isosorbide dinitrate
C) Spironolactone
D) Ivabradine
Correct Answer: Spironolactone
Rationale: The RALES trial demonstrated that spironolactone (an aldosterone antagonist) reduces
mortality and hospitalizations in patients with NYHA class III-IV HFrEF when added to ACE inhibitors
and beta-blockers. Digoxin reduces symptoms but not mortality. Hydralazine/isosorbide dinitrate is
indicated in African American patients. Ivabradine reduces heart rate but is not first-line.
4. A 62-year-old female with persistent atrial fibrillation has a CHA₂DS₂-VASc score of 4. Which
anticoagulation strategy is most appropriate for stroke prevention?
A) Aspirin 81 mg daily
B) Aspirin 325 mg and clopidogrel
C) Warfarin with target INR 2.0-3.0
D) Direct oral anticoagulant (DOAC)
Correct Answer: Direct oral anticoagulant (DOAC)
Rationale: Patients with a CHA₂DS₂-VASc score ≥2 in males or ≥3 in females should receive oral
anticoagulation. DOACs (apixaban, rivaroxaban, dabigatran, edoxaban) are preferred over warfarin
for non-valvular atrial fibrillation due to comparable efficacy, lower bleeding risk, and no need for
routine INR monitoring. Aspirin is insufficient for stroke prevention at this risk level.
5. A 58-year-old male with long-standing type 2 diabetes has a urine albumin-to-creatinine ratio of
300 mg/g and an eGFR of 55 mL/min/1.73m². Which class of medication provides both glycemic
control and renal protection?
A) Metformin
B) Sulfonylurea
C) SGLT2 inhibitor
D) DPP-4 inhibitor
Correct Answer: SGLT2 inhibitor
Rationale: SGLT2 inhibitors (e.g., empagliflozin, dapagliflozin, canagliflozin) have been shown to
reduce progression of diabetic kidney disease and reduce cardiovascular events in patients with type 2
diabetes and established CKD. Metformin is first-line for glycemic control but does not provide the
, same renal protective effects. Sulfonylureas and DPP-4 inhibitors do not have proven renal protective
benefits.
6. A 45-year-old female with a body mass index of 34 kg/m², hypertension, and dyslipidemia has a
fasting glucose of 115 mg/dL. Which diagnosis best describes her metabolic status?
A) Type 2 diabetes mellitus
B) Prediabetes
C) Metabolic syndrome
D) Impaired fasting glucose
Correct Answer: Metabolic syndrome
Rationale: Metabolic syndrome is diagnosed when a patient meets three of five criteria: central
obesity (waist circumference ≥35 inches in women), elevated triglycerides (≥150 mg/dL), reduced HDL
(<50 mg/dL in women), elevated blood pressure (≥130/85 mmHg), and elevated fasting glucose (≥100
mg/dL). This patient meets criteria for obesity, hypertension, dyslipidemia, and impaired fasting
glucose, confirming metabolic syndrome.
7. A 72-year-old male with COPD GOLD stage 2 presents with increasing dyspnea and three
exacerbations in the past year. Which medication regimen is most appropriate for maintenance
therapy?
A) Short-acting beta-agonist (SABA) as needed
B) Long-acting muscarinic antagonist (LAMA) monotherapy
C) LAMA plus long-acting beta-agonist (LABA)
D) Inhaled corticosteroid (ICS) plus LABA
Correct Answer: LAMA plus LABA
Rationale: For patients with COPD GOLD stage 2-4 with frequent exacerbations (≥2 per year),
combination therapy with LAMA and LABA is recommended over monotherapy. ICS is added for
patients with a history of asthma or eosinophilia (e.g., eosinophil count ≥300 cells/μL). SABA alone is
insufficient for maintenance therapy.
8. A 66-year-old female with a history of osteoporosis and hypertension presents with a blood
pressure of 165/95 mmHg. Which antihypertensive class should be avoided due to potential
exacerbation of her underlying condition?
A) Thiazide diuretic
Primary Care II | Wilkes | 26/27 Updated (PDF)
1. A 72-year-old male with a 30-pack-year smoking history presents with progressive dyspnea on
exertion and a chronic productive cough. Spirometry reveals an FEV1/FVC ratio of 0.62. According to
the GOLD staging system, which parameter is most critical for determining the patient's disease
severity?
A) FEV1 percent predicted
B) FVC percent predicted
C) DLCO percent predicted
D) FEV1/FVC ratio
Correct Answer: FEV1 percent predicted
Rationale: GOLD staging of COPD is based on the FEV1 percent predicted, not the FEV1/FVC ratio,
which is used for diagnosis of airflow obstruction. Severity is classified as GOLD 1 (≥80%), GOLD 2 (50-
79%), GOLD 3 (30-49%), and GOLD 4 (<30%). DLCO assesses gas exchange but does not determine
GOLD stage.
2. A 68-year-old female with hypertension and type 2 diabetes has a blood pressure of 148/90 mmHg
on two separate visits. According to the JNC 8 guidelines, which is the most appropriate initial
pharmacologic strategy?
A) Initiate a thiazide diuretic
B) Initiate an ACE inhibitor
C) Initiate a calcium channel blocker
D) Initiate combination therapy with two agents
Correct Answer: Initiate an ACE inhibitor
Rationale: JNC 8 recommends starting an ACE inhibitor, ARB, thiazide diuretic, or calcium channel
blocker in non-black patients with hypertension, including those with diabetes. For patients with
diabetes, ACE inhibitors or ARBs are preferred due to renal protective effects. Combination therapy is
not recommended as initial therapy unless BP is >20/10 mmHg above goal.
3. A 55-year-old male with a history of heart failure with reduced ejection fraction (HFrEF) is being
managed on an ACE inhibitor and a beta-blocker. Which additional medication has been shown to
reduce mortality and hospitalizations in this population?
,A) Digoxin
B) Hydralazine and isosorbide dinitrate
C) Spironolactone
D) Ivabradine
Correct Answer: Spironolactone
Rationale: The RALES trial demonstrated that spironolactone (an aldosterone antagonist) reduces
mortality and hospitalizations in patients with NYHA class III-IV HFrEF when added to ACE inhibitors
and beta-blockers. Digoxin reduces symptoms but not mortality. Hydralazine/isosorbide dinitrate is
indicated in African American patients. Ivabradine reduces heart rate but is not first-line.
4. A 62-year-old female with persistent atrial fibrillation has a CHA₂DS₂-VASc score of 4. Which
anticoagulation strategy is most appropriate for stroke prevention?
A) Aspirin 81 mg daily
B) Aspirin 325 mg and clopidogrel
C) Warfarin with target INR 2.0-3.0
D) Direct oral anticoagulant (DOAC)
Correct Answer: Direct oral anticoagulant (DOAC)
Rationale: Patients with a CHA₂DS₂-VASc score ≥2 in males or ≥3 in females should receive oral
anticoagulation. DOACs (apixaban, rivaroxaban, dabigatran, edoxaban) are preferred over warfarin
for non-valvular atrial fibrillation due to comparable efficacy, lower bleeding risk, and no need for
routine INR monitoring. Aspirin is insufficient for stroke prevention at this risk level.
5. A 58-year-old male with long-standing type 2 diabetes has a urine albumin-to-creatinine ratio of
300 mg/g and an eGFR of 55 mL/min/1.73m². Which class of medication provides both glycemic
control and renal protection?
A) Metformin
B) Sulfonylurea
C) SGLT2 inhibitor
D) DPP-4 inhibitor
Correct Answer: SGLT2 inhibitor
Rationale: SGLT2 inhibitors (e.g., empagliflozin, dapagliflozin, canagliflozin) have been shown to
reduce progression of diabetic kidney disease and reduce cardiovascular events in patients with type 2
diabetes and established CKD. Metformin is first-line for glycemic control but does not provide the
, same renal protective effects. Sulfonylureas and DPP-4 inhibitors do not have proven renal protective
benefits.
6. A 45-year-old female with a body mass index of 34 kg/m², hypertension, and dyslipidemia has a
fasting glucose of 115 mg/dL. Which diagnosis best describes her metabolic status?
A) Type 2 diabetes mellitus
B) Prediabetes
C) Metabolic syndrome
D) Impaired fasting glucose
Correct Answer: Metabolic syndrome
Rationale: Metabolic syndrome is diagnosed when a patient meets three of five criteria: central
obesity (waist circumference ≥35 inches in women), elevated triglycerides (≥150 mg/dL), reduced HDL
(<50 mg/dL in women), elevated blood pressure (≥130/85 mmHg), and elevated fasting glucose (≥100
mg/dL). This patient meets criteria for obesity, hypertension, dyslipidemia, and impaired fasting
glucose, confirming metabolic syndrome.
7. A 72-year-old male with COPD GOLD stage 2 presents with increasing dyspnea and three
exacerbations in the past year. Which medication regimen is most appropriate for maintenance
therapy?
A) Short-acting beta-agonist (SABA) as needed
B) Long-acting muscarinic antagonist (LAMA) monotherapy
C) LAMA plus long-acting beta-agonist (LABA)
D) Inhaled corticosteroid (ICS) plus LABA
Correct Answer: LAMA plus LABA
Rationale: For patients with COPD GOLD stage 2-4 with frequent exacerbations (≥2 per year),
combination therapy with LAMA and LABA is recommended over monotherapy. ICS is added for
patients with a history of asthma or eosinophilia (e.g., eosinophil count ≥300 cells/μL). SABA alone is
insufficient for maintenance therapy.
8. A 66-year-old female with a history of osteoporosis and hypertension presents with a blood
pressure of 165/95 mmHg. Which antihypertensive class should be avoided due to potential
exacerbation of her underlying condition?
A) Thiazide diuretic
