Barkley Adult-Gerontology Acute Care NP (AGACNP)
Review Practice Questions with Answers & Detailed
Rationales
1. A 68-year-old male with a history of hypertension and type 2
diabetes presents with substernal chest pressure radiating to the
jaw, diaphoresis, and nausea. ECG shows 2-mm ST-segment
elevation in leads V1–V4. What is the priority intervention?
A) Administer sublingual nitroglycerin
B) Obtain cardiac enzymes
C) Initiate immediate reperfusion therapy
D) Administer morphine sulfate
Answer: C) Initiate immediate reperfusion therapy
Explanation: ST-segment elevation in V1–V4 indicates an acute
anterior wall ST-elevation myocardial infarction (STEMI). The
priority is immediate reperfusion therapy (PCI or thrombolytics) to
restore blood flow and minimize myocardial damage. "Time is
muscle." Nitroglycerin and morphine are symptomatic treatments
but do not address the underlying occlusion. Cardiac enzymes
confirm the diagnosis but should not delay reperfusion.
2. A 72-year-old female with heart failure presents with worsening
dyspnea, orthopnea, and 3+ pitting edema. Her BNP is 1,200 pg/mL.
Which medication should be initiated first?
,A) Digoxin
B) Furosemide
C) Metoprolol succinate
D) Lisinopril
Answer: B) Furosemide
Explanation: The patient has acute decompensated heart failure with
fluid overload. A loop diuretic (furosemide) is the first-line
intervention to reduce preload and relieve congestion. Digoxin is
used for symptom control in HFrEF but is not first-line. Metoprolol
and lisinopril are chronic HF therapies and should not be initiated in
the acute decompensated state.
3. A 65-year-old male with atrial fibrillation is on warfarin. His INR is
5.2. He has no signs of bleeding. What is the most appropriate
management?
A) Administer vitamin K 2.5 mg PO
B) Hold warfarin and recheck INR tomorrow
C) Administer fresh frozen plasma
D) Administer prothrombin complex concentrate
Answer: B) Hold warfarin and recheck INR tomorrow
Explanation: For an INR of 5.0–9.0 without bleeding, the
recommended management is to hold warfarin and recheck INR the
next day. Vitamin K is indicated for INR >10 or with bleeding. FFP and
PCC are for life-threatening bleeding or emergent reversal.
,4. A 74-year-old male with a history of aortic stenosis presents with
syncope and exertional dyspnea. On auscultation, you hear a harsh,
crescendo-decrescendo systolic ejection murmur at the right upper
sternal border. What is the most appropriate next step?
A) Order a transthoracic echocardiogram
B) Prescribe a beta-blocker
C) Schedule for cardiac catheterization
D) Start an ACE inhibitor
Answer: A) Order a transthoracic echocardiogram
Explanation: This presentation is classic for severe aortic stenosis.
An echocardiogram is the gold standard for diagnosis, assessing
valve area, gradient, and left ventricular function. Beta-blockers and
ACE inhibitors are contraindicated in severe AS as they can
precipitate hypotension and syncope.
5. A 62-year-old female presents with acute onset of severe, tearing
chest pain radiating to the back. Blood pressure is 198/104 mmHg in
the right arm and 152/88 mmHg in the left arm. What is the most
likely diagnosis?
A) Acute myocardial infarction
B) Pulmonary embolism
C) Aortic dissection
D) Pericarditis
Answer: C) Aortic dissection
Explanation: The sudden onset of severe, tearing chest pain
, radiating to the back with a significant difference in blood pressure
between arms is classic for aortic dissection. Immediate diagnosis
with CT angiography or TEE is required.
6. A 55-year-old male with a history of cirrhosis presents with
confusion, asterixis, and a fruity breath odor. Which medication is
indicated for the treatment of hepatic encephalopathy?
A) Lactulose
B) Rifampin
C) Metronidazole
D) Ciprofloxacin
Answer: A) Lactulose
Explanation: Lactulose is the first-line treatment for hepatic
encephalopathy. It reduces ammonia absorption by acidifying the
colon and promoting catharsis. Rifaximin may be added for
recurrent episodes.
7. A 45-year-old female presents with severe epigastric pain
radiating to the back, nausea, and vomiting. Serum lipase is 3 times
the upper limit of normal. What is the most likely diagnosis?
A) Acute cholecystitis
B) Acute pancreatitis
C) Peptic ulcer disease
D) Gastroenteritis
Review Practice Questions with Answers & Detailed
Rationales
1. A 68-year-old male with a history of hypertension and type 2
diabetes presents with substernal chest pressure radiating to the
jaw, diaphoresis, and nausea. ECG shows 2-mm ST-segment
elevation in leads V1–V4. What is the priority intervention?
A) Administer sublingual nitroglycerin
B) Obtain cardiac enzymes
C) Initiate immediate reperfusion therapy
D) Administer morphine sulfate
Answer: C) Initiate immediate reperfusion therapy
Explanation: ST-segment elevation in V1–V4 indicates an acute
anterior wall ST-elevation myocardial infarction (STEMI). The
priority is immediate reperfusion therapy (PCI or thrombolytics) to
restore blood flow and minimize myocardial damage. "Time is
muscle." Nitroglycerin and morphine are symptomatic treatments
but do not address the underlying occlusion. Cardiac enzymes
confirm the diagnosis but should not delay reperfusion.
2. A 72-year-old female with heart failure presents with worsening
dyspnea, orthopnea, and 3+ pitting edema. Her BNP is 1,200 pg/mL.
Which medication should be initiated first?
,A) Digoxin
B) Furosemide
C) Metoprolol succinate
D) Lisinopril
Answer: B) Furosemide
Explanation: The patient has acute decompensated heart failure with
fluid overload. A loop diuretic (furosemide) is the first-line
intervention to reduce preload and relieve congestion. Digoxin is
used for symptom control in HFrEF but is not first-line. Metoprolol
and lisinopril are chronic HF therapies and should not be initiated in
the acute decompensated state.
3. A 65-year-old male with atrial fibrillation is on warfarin. His INR is
5.2. He has no signs of bleeding. What is the most appropriate
management?
A) Administer vitamin K 2.5 mg PO
B) Hold warfarin and recheck INR tomorrow
C) Administer fresh frozen plasma
D) Administer prothrombin complex concentrate
Answer: B) Hold warfarin and recheck INR tomorrow
Explanation: For an INR of 5.0–9.0 without bleeding, the
recommended management is to hold warfarin and recheck INR the
next day. Vitamin K is indicated for INR >10 or with bleeding. FFP and
PCC are for life-threatening bleeding or emergent reversal.
,4. A 74-year-old male with a history of aortic stenosis presents with
syncope and exertional dyspnea. On auscultation, you hear a harsh,
crescendo-decrescendo systolic ejection murmur at the right upper
sternal border. What is the most appropriate next step?
A) Order a transthoracic echocardiogram
B) Prescribe a beta-blocker
C) Schedule for cardiac catheterization
D) Start an ACE inhibitor
Answer: A) Order a transthoracic echocardiogram
Explanation: This presentation is classic for severe aortic stenosis.
An echocardiogram is the gold standard for diagnosis, assessing
valve area, gradient, and left ventricular function. Beta-blockers and
ACE inhibitors are contraindicated in severe AS as they can
precipitate hypotension and syncope.
5. A 62-year-old female presents with acute onset of severe, tearing
chest pain radiating to the back. Blood pressure is 198/104 mmHg in
the right arm and 152/88 mmHg in the left arm. What is the most
likely diagnosis?
A) Acute myocardial infarction
B) Pulmonary embolism
C) Aortic dissection
D) Pericarditis
Answer: C) Aortic dissection
Explanation: The sudden onset of severe, tearing chest pain
, radiating to the back with a significant difference in blood pressure
between arms is classic for aortic dissection. Immediate diagnosis
with CT angiography or TEE is required.
6. A 55-year-old male with a history of cirrhosis presents with
confusion, asterixis, and a fruity breath odor. Which medication is
indicated for the treatment of hepatic encephalopathy?
A) Lactulose
B) Rifampin
C) Metronidazole
D) Ciprofloxacin
Answer: A) Lactulose
Explanation: Lactulose is the first-line treatment for hepatic
encephalopathy. It reduces ammonia absorption by acidifying the
colon and promoting catharsis. Rifaximin may be added for
recurrent episodes.
7. A 45-year-old female presents with severe epigastric pain
radiating to the back, nausea, and vomiting. Serum lipase is 3 times
the upper limit of normal. What is the most likely diagnosis?
A) Acute cholecystitis
B) Acute pancreatitis
C) Peptic ulcer disease
D) Gastroenteritis
