Barkley AGACNP DRT Exam | 100 Acute Care NP Practice
Questions with Rationales
SECTION 1: CARDIOVASCULAR EMERGENCIES & CRITICAL CARE
(Questions 1-20)
Question 1
A 65-year-old man with a history of hypertension and diabetes presents with substernal
chest pressure, diaphoresis, and nausea for 2 hours. ECG shows ST-segment elevation in
leads II, III, and aVF. Which coronary artery is most likely occluded?
A) Left anterior descending artery (LAD)
B) Left circumflex artery (LCx)
C) Right coronary artery (RCA)
D) Left main coronary artery
Answer: C) Right coronary artery (RCA)
Rationale: ST elevation in leads II, III, and aVF indicates an inferior wall myocardial
infarction . The RCA supplies the inferior wall in the majority of patients (right-dominant
circulation). The LAD supplies the anterior wall (V1-V4), the LCx supplies the lateral wall
(I, aVL, V5-V6), and the left main supplies large territories and is often rapidly fatal .
Question 2
A patient with an acute anterior STEMI undergoes percutaneous coronary intervention
,(PCI) and receives a drug-eluting stent. Dual antiplatelet therapy (DAPT) with aspirin and
a P2Y12 inhibitor should be continued for at least:
A) 1 month
B) 3 months
C) 6-12 months
D) Indefinitely, only aspirin after the first year
Answer: C) 6-12 months
Rationale: For patients with acute coronary syndrome treated with a drug-eluting stent,
current guidelines recommend DAPT (aspirin plus ticagrelor, prasugrel, or clopidogrel)
for at least 6-12 months . After that, aspirin alone continues indefinitely. Shorter
durations may be considered in high bleeding risk patients .
Question 3
A 60-year-old man with a known history of heart failure with reduced ejection fraction
(HFrEF, EF 30%) presents with worsening dyspnea, orthopnea, and 3+ pitting edema.
BNP is 1,500 pg/mL. Which of the following medication classes has been shown to
reduce mortality in HFrEF?
A) Digoxin
B) Loop diuretics
C) Mineralocorticoid receptor antagonists (eplerenone)
D) Calcium channel blockers
Answer: C) Mineralocorticoid receptor antagonists (eplerenone)
Rationale: Guideline-directed medical therapy for HFrEF includes ACE inhibitors/ARBs,
beta-blockers, mineralocorticoid receptor antagonists (spironolactone, eplerenone), and
SGLT2 inhibitors . These medications reduce mortality in HFrEF. Digoxin reduces
,hospitalizations but not mortality. Loop diuretics control symptoms but do not affect
mortality. Calcium channel blockers (except amlodipine) are generally avoided in HFrEF .
Question 4
A patient with a temporary transvenous pacemaker develops sudden onset of chest
pain, hypotension, and a pericardial friction rub. ECG shows ST elevation in all leads.
What is the most likely complication?
A) Pneumothorax
B) Cardiac tamponade
C) Acute pericarditis from lead perforation
D) Pacemaker malfunction
Answer: C) Acute pericarditis from lead perforation
Rationale: A transvenous pacemaker lead can perforate the right ventricular wall,
causing acute pericarditis with diffuse ST elevation and a pericardial friction rub .
Tamponade would present with Beck's triad (hypotension, muffled heart sounds, JVD).
Pneumothorax would present with absent breath sounds. Pacemaker malfunction would
typically present with pacing or sensing abnormalities .
Question 5
A 55-year-old woman with acute decompensated heart failure has a blood pressure of
85/50 mmHg, cold extremities, and a cardiac index of 1.8 L/min/m². Which inotropic
agent is most appropriate?
A) Dobutamine
B) Milrinone
, C) Norepinephrine
D) Dopamine
Answer: A) Dobutamine
Rationale: Cardiogenic shock with low cardiac index and signs of hypoperfusion
requires an inotrope . Dobutamine is a beta-1 agonist that increases contractility and
may cause mild vasodilation. Milrinone is a phosphodiesterase inhibitor also used but
may cause more hypotension. Norepinephrine is a vasopressor for vasodilatory shock.
Dobutamine is first-line for low cardiac output without severe hypotension; if BP
remains low, norepinephrine may be added .
Question 6
A 74-year-old male with a history of CHF presents with an audible S3 gallop and
increased jugular venous distention. This finding most likely indicates:
A) Decreased cardiac output
B) Fluid volume overload
C) Pericardial effusion
D) Valvular stenosis
Answer: B) Fluid volume overload
Rationale: The S3 heart sound is a classic sign of fluid volume overload in heart failure
patients, caused by blood rushing into a distended ventricle during early diastole . This
finding, combined with JVD, indicates elevated filling pressures and volume overload .
Questions with Rationales
SECTION 1: CARDIOVASCULAR EMERGENCIES & CRITICAL CARE
(Questions 1-20)
Question 1
A 65-year-old man with a history of hypertension and diabetes presents with substernal
chest pressure, diaphoresis, and nausea for 2 hours. ECG shows ST-segment elevation in
leads II, III, and aVF. Which coronary artery is most likely occluded?
A) Left anterior descending artery (LAD)
B) Left circumflex artery (LCx)
C) Right coronary artery (RCA)
D) Left main coronary artery
Answer: C) Right coronary artery (RCA)
Rationale: ST elevation in leads II, III, and aVF indicates an inferior wall myocardial
infarction . The RCA supplies the inferior wall in the majority of patients (right-dominant
circulation). The LAD supplies the anterior wall (V1-V4), the LCx supplies the lateral wall
(I, aVL, V5-V6), and the left main supplies large territories and is often rapidly fatal .
Question 2
A patient with an acute anterior STEMI undergoes percutaneous coronary intervention
,(PCI) and receives a drug-eluting stent. Dual antiplatelet therapy (DAPT) with aspirin and
a P2Y12 inhibitor should be continued for at least:
A) 1 month
B) 3 months
C) 6-12 months
D) Indefinitely, only aspirin after the first year
Answer: C) 6-12 months
Rationale: For patients with acute coronary syndrome treated with a drug-eluting stent,
current guidelines recommend DAPT (aspirin plus ticagrelor, prasugrel, or clopidogrel)
for at least 6-12 months . After that, aspirin alone continues indefinitely. Shorter
durations may be considered in high bleeding risk patients .
Question 3
A 60-year-old man with a known history of heart failure with reduced ejection fraction
(HFrEF, EF 30%) presents with worsening dyspnea, orthopnea, and 3+ pitting edema.
BNP is 1,500 pg/mL. Which of the following medication classes has been shown to
reduce mortality in HFrEF?
A) Digoxin
B) Loop diuretics
C) Mineralocorticoid receptor antagonists (eplerenone)
D) Calcium channel blockers
Answer: C) Mineralocorticoid receptor antagonists (eplerenone)
Rationale: Guideline-directed medical therapy for HFrEF includes ACE inhibitors/ARBs,
beta-blockers, mineralocorticoid receptor antagonists (spironolactone, eplerenone), and
SGLT2 inhibitors . These medications reduce mortality in HFrEF. Digoxin reduces
,hospitalizations but not mortality. Loop diuretics control symptoms but do not affect
mortality. Calcium channel blockers (except amlodipine) are generally avoided in HFrEF .
Question 4
A patient with a temporary transvenous pacemaker develops sudden onset of chest
pain, hypotension, and a pericardial friction rub. ECG shows ST elevation in all leads.
What is the most likely complication?
A) Pneumothorax
B) Cardiac tamponade
C) Acute pericarditis from lead perforation
D) Pacemaker malfunction
Answer: C) Acute pericarditis from lead perforation
Rationale: A transvenous pacemaker lead can perforate the right ventricular wall,
causing acute pericarditis with diffuse ST elevation and a pericardial friction rub .
Tamponade would present with Beck's triad (hypotension, muffled heart sounds, JVD).
Pneumothorax would present with absent breath sounds. Pacemaker malfunction would
typically present with pacing or sensing abnormalities .
Question 5
A 55-year-old woman with acute decompensated heart failure has a blood pressure of
85/50 mmHg, cold extremities, and a cardiac index of 1.8 L/min/m². Which inotropic
agent is most appropriate?
A) Dobutamine
B) Milrinone
, C) Norepinephrine
D) Dopamine
Answer: A) Dobutamine
Rationale: Cardiogenic shock with low cardiac index and signs of hypoperfusion
requires an inotrope . Dobutamine is a beta-1 agonist that increases contractility and
may cause mild vasodilation. Milrinone is a phosphodiesterase inhibitor also used but
may cause more hypotension. Norepinephrine is a vasopressor for vasodilatory shock.
Dobutamine is first-line for low cardiac output without severe hypotension; if BP
remains low, norepinephrine may be added .
Question 6
A 74-year-old male with a history of CHF presents with an audible S3 gallop and
increased jugular venous distention. This finding most likely indicates:
A) Decreased cardiac output
B) Fluid volume overload
C) Pericardial effusion
D) Valvular stenosis
Answer: B) Fluid volume overload
Rationale: The S3 heart sound is a classic sign of fluid volume overload in heart failure
patients, caused by blood rushing into a distended ventricle during early diastole . This
finding, combined with JVD, indicates elevated filling pressures and volume overload .
