NUR 6130 - Exam and Answers | Newest 2026 | 100% Correct -
William Paterson University. - 149 Questions
Section 1: Cardiovascular Disorders (Questions 1-15)
1 A patient with chronic heart failure (HFrEF, NYHA class II) is currently on lisinopril, metoprolol succinate, and
furosemide. Recent labs show serum potassium 5.2 mEq/L, creatinine 1.4 mg/dL, and BNP 350 pg/mL. The
patient reports persistent dyspnea on exertion. Which medication adjustment is most appropriate based on
current guidelines?
A) Add spironolactone 12.5 mg daily
B) Increase lisinopril to maximum tolerated dose
C) Add sacubitril/valsartan in place of lisinopril
D) Add digoxin 0.125 mg daily
Answer: C
Rationale: In HFrEF, sacubitril/valsartan is recommended to replace ACE inhibitors to further reduce morbidity and
mortality, especially in patients with persistent symptoms despite standard therapy. Spironolactone is relatively
contraindicated with K+ >5.0. Increasing lisinopril could worsen hyperkalemia. Digoxin is second-line for
symptom control but not first for mortality reduction.
2 A patient presents with acute-onset chest pain and dyspnea. ECG shows sinus tachycardia with S1Q3T3 pattern.
D-dimer is elevated. CT pulmonary angiography reveals a filling defect in the left main pulmonary artery. Vital
signs: BP 90/60 mmHg, HR 110 bpm, RR 24, SpO2 89% on room air. Which intervention is most appropriate?
A) Initiate therapeutic heparin infusion and admit for monitoring
B) Administer alteplase 100 mg IV over 2 hours
C) Perform catheter-directed thrombolysis
D) Start oral rivaroxaban 15 mg twice daily
Answer: B
Rationale: This patient has massive PE with hemodynamic instability (hypotension, hypoxia) and right heart strain.
Guidelines recommend systemic thrombolysis for massive PE unless contraindicated. Heparin alone is insufficient.
Catheter-directed thrombolysis is an alternative if systemic lysis contraindicated. Rivaroxaban is not first-line in
acute massive PE.
3 A patient with a history of hypertension and type 2 diabetes mellitus is found to have a blood pressure of 152/96
mmHg on three separate occasions. Serum creatinine is 0.9 mg/dL, and urine albumin-to-creatinine ratio is 45
mg/g. Which antihypertensive regimen is most appropriate to reduce cardiovascular and renal risk?
A) Amlodipine 5 mg daily + hydrochlorothiazide 12.5 mg daily
B) Lisinopril 10 mg daily + amlodipine 5 mg daily
C) Metoprolol tartrate 50 mg twice daily + chlorthalidone 25 mg daily
D) Spironolactone 25 mg daily + furosemide 20 mg daily
Answer: B
Rationale: ACE inhibitors (or ARBs) are first-line for patients with hypertension and albuminuria (UACR >30
mg/g) to slow progression of CKD and reduce cardiovascular events. Combination with a calcium channel blocker
(like amlodipine) is recommended for better BP control and additive benefit. Thiazides and beta-blockers are less
preferred in this setting.
,4 A patient with hypertrophic cardiomyopathy (HCM) presents with syncope during exercise. Echocardiography
shows left ventricular outflow tract (LVOT) gradient of 70 mmHg at rest, which increases with Valsalva. The
patient is not on any medications. Which initial pharmacotherapy is most appropriate?
A) Metoprolol tartrate 25 mg twice daily
B) Verapamil 120 mg daily
C) Disopyramide 100 mg three times daily
D) Lisinopril 5 mg daily
Answer: A
Rationale: Beta-blockers (e.g., metoprolol) are first-line to reduce LVOT gradient by decreasing heart rate and
contractility, improving symptoms. Verapamil is an alternative but caution in severe obstruction. Disopyramide is
second-line. ACE inhibitors are contraindicated as they reduce afterload and worsen obstruction.
5 A patient with atrial fibrillation (AF) and a CHA2DS2-VASc score of 3 is started on apixaban 5 mg twice daily.
Three months later, the patient develops a transient ischemic attack. Which of the following is the most likely
explanation for the failure of anticoagulation?
A) The patient has a mechanical heart valve
B) The patient has antiphospholipid syndrome (APS)
C) The apixaban dose is too low for the patient's weight
D) The patient has a patent foramen ovale (PFO)
Answer: B
Rationale: APS is associated with a high risk of thromboembolism despite adequate anticoagulation with direct oral
anticoagulants (DOACs); vitamin K antagonists (warfarin) are preferred. DOACs are contraindicated in APS
patients with triple positivity. Mechanical valves and PFO could cause stroke but are less likely given the scenario.
Dose adjustment is weight-based, but standard dose is appropriate unless weight <60 kg or age >80.
6 A patient with acute ST-elevation myocardial infarction (STEMI) undergoes primary percutaneous coronary
intervention (PCI) with a drug-eluting stent to the left anterior descending artery. Which dual antiplatelet
therapy (DAPT) regimen is most appropriate for the first year?
A) Aspirin 81 mg daily + clopidogrel 75 mg daily
B) Aspirin 325 mg daily + ticagrelor 90 mg twice daily
C) Aspirin 81 mg daily + ticagrelor 90 mg twice daily
D) Aspirin 81 mg daily + warfarin 2.5 mg daily
Answer: C
Rationale: Current guidelines recommend DAPT with aspirin (81 mg daily) and a P2Y12 inhibitor (ticagrelor or
prasugrel) for at least 12 months after STEMI with DES. Ticagrelor is preferred over clopidogrel due to superior
efficacy. High-dose aspirin (325 mg) is not recommended long-term due to increased bleeding risk. Warfarin is not
indicated unless additional indication.
7 A patient with dilated cardiomyopathy (LVEF 30%) and no significant coronary artery disease is being
evaluated for implantable cardioverter-defibrillator (ICD) placement. Which of the following findings would
most strongly support ICD implantation for primary prevention?
A) Left ventricular end-diastolic diameter 6.5 cm
B) Non-sustained ventricular tachycardia on 24-hour Holter monitor
C) QRS duration 150 ms with left bundle branch block
D) New York Heart Association (NYHA) functional class III symptoms despite optimal medical therapy
Answer: D
,Rationale: I C D f o r p r i m a r y p r e v e n t i o n i s i n d i c a t e d
symptoms on optimal medical therapy. Non-sustained VT alone is not an indication. QRS duration and LBBB are
criteria for cardiac resynchronization therapy, not ICD alone. LV end-diastolic diameter is not a primary criterion.
8 A patient with aortic stenosis (valve area 0.8 cm², mean gradient 50 mmHg, peak velocity 4.5 m/s) is
asymptomatic. Which of the following findings would be an indication for aortic valve replacement?
A) Left ventricular ejection fraction 55%
B) Abnormal exercise test with development of symptoms
C) Presence of moderate aortic regurgitation
D) Left atrial enlargement (volume index 40 mL/m²)
Answer: B
Rationale: In severe asymptomatic aortic stenosis, valve replacement is indicated if exercise testing provokes
symptoms. LVEF <50% is a Class I indication, but 55% is normal. Moderate aortic regurgitation and left atrial
enlargement are not standalone indications for surgery.
9 A patient with a history of coronary artery disease presents with chest pain and dyspnea. ECG shows ST
depression in leads V3-V5. High-sensitivity troponin I is elevated at 0.5 ng/mL (upper reference limit 0.04
ng/mL). Which of the following best describes the underlying pathophysiology?
A) Complete occlusion of a coronary artery with transmural ischemia
B) Subendocardial ischemia due to reduced oxygen supply or increased demand
C) Myocardial injury due to catecholamine surge without coronary obstruction
D) Microvascular spasm leading to focal necrosis
Answer: B
Rationale: Non-ST-elevation myocardial infarction (NSTEMI) typically results from incomplete occlusion or
transient occlusion of a coronary artery, causing subendocardial ischemia. ST depression and troponin elevation
confirm injury. Complete occlusion would cause STEMI. Takotsubo (catecholamine) and microvascular spasm are
less common and not the classic pathophysiology.
10 A patient with chronic pericarditis is being treated with colchicine 0.6 mg twice daily. Which of the following
laboratory findings would require discontinuation of colchicine?
A) Serum creatinine 1.2 mg/dL
B) Alanine aminotransferase 45 U/L
C) Platelet count 150,000/L
D) Creatine kinase 300 U/L
Answer: D
Rationale: Colchicine can cause myotoxicity, especially in patients with renal impairment. Elevated creatine kinase
(CK) suggests myopathy, which may progress to rhabdomyolysis. Mild elevations in creatinine, ALT, or mild
thrombocytopenia are not contraindications. Colchicine dose should be reduced in renal impairment, but CK >5
times upper limit warrants discontinuation.
11 A 68-year-old individual with a history of hypertension and type 2 diabetes presents with acute-onset chest
pressure radiating to the left arm, diaphoresis, and nausea. ECG shows ST-segment elevation in leads V2-V4.
Immediate management includes aspirin, oxygen, nitroglycerin, and morphine. Which of the following best
explains the paradoxical decrease in coronary perfusion pressure that may occur with nitroglycerin
administration in this setting?
A) Nitroglycerin causes reflex tachycardia, increasing myocardial oxygen demand and reducing diastolic filling
time.
, B) Nitroglycerin preferentially dilates epicardial coronary arteries, but in acute myocardial infarction, the culprit
lesion is already fully occluded, so no net benefit occurs.
C) Nitroglycerin reduces preload and afterload, but in the presence of right ventricular infarction, it can cause
profound hypotension and reduce coronary perfusion pressure.
D) Nitroglycerin induces coronary steal phenomenon by dilating resistance vessels in non-ischemic zones,
diverting flow away from the ischemic area.
Answer: C
Rationale: In acute inferior wall MI, right ventricular infarction may coexist. Nitroglycerin's venodilation reduces
preload, which can cause severe hypotension if right ventricular function is compromised, decreasing coronary
perfusion pressure. Options A and B are less specific: reflex tachycardia is not paradoxical, and epicardial dilation
is not detrimental. Option D describes coronary steal, but this is more relevant with vasodilators like adenosine, not
nitroglycerin.
12 A 55-year-old patient with chronic kidney disease (stage 3) and hypertension is being evaluated for resistant
hypertension (office BP 158/92 mmHg on three medications including an ACE inhibitor, a calcium channel
blocker, and a thiazide diuretic). Ambulatory blood pressure monitoring confirms lack of white-coat effect.
Which of the following additional diagnostic tests would be most appropriate to guide further management?
A) Plasma renin activity and aldosterone concentration to screen for primary hyperaldosteronism.
B) Renal artery duplex ultrasound to screen for renal artery stenosis.
C) 24-hour urinary metanephrines to rule out pheochromocytoma.
D) Polysomnography to evaluate for obstructive sleep apnea.
Answer: A
Rationale: Resistant hypertension, especially with hypokalemia (though not mentioned), warrants screening for
primary hyperaldosteronism. With CKD, renin-angiotensin-aldosterone system evaluation is crucial because
aldosterone excess is a common cause. Renal artery stenosis (B) is possible but less common in the absence of
flash pulmonary edema or bruit. Pheochromocytoma (C) is rare. Sleep apnea (D) is associated but not the next best
test in this context; aldosterone evaluation is more directly actionable.
13 A 72-year-old patient with atrial fibrillation (CHADS-VASc score 4) is on warfarin with a therapeutic INR of
2.5. The patient develops acute chest pain and dyspnea. ECG shows new left bundle branch block.
High-sensitivity troponin is elevated. Which of the following is the most appropriate immediate management
step?
A) Administer intravenous thrombolytics for suspected ST-elevation myocardial infarction.
B) Perform emergent coronary angiography with primary percutaneous coronary intervention (PCI).
C) Start intravenous unfractionated heparin and schedule urgent coronary angiography within 24 hours.
D) Obtain a computed tomography pulmonary angiogram (CTPA) to rule out pulmonary embolism before
proceeding with anticoagulation adjustment.
Answer: B
Rationale: New left bundle branch block and elevated troponin in the setting of chest pain is suggestive of acute
coronary occlusion (STEMI equivalent). Guidelines recommend emergent reperfusion with primary PCI, regardless
of anticoagulation status. Thrombolytics (A) are contraindicated due to risk of bleeding on warfarin. Heparin (C) is
not sufficient for acute occlusion. CTPA (D) may delay life-saving PCI; the presentation is more consistent with MI
than PE.
William Paterson University. - 149 Questions
Section 1: Cardiovascular Disorders (Questions 1-15)
1 A patient with chronic heart failure (HFrEF, NYHA class II) is currently on lisinopril, metoprolol succinate, and
furosemide. Recent labs show serum potassium 5.2 mEq/L, creatinine 1.4 mg/dL, and BNP 350 pg/mL. The
patient reports persistent dyspnea on exertion. Which medication adjustment is most appropriate based on
current guidelines?
A) Add spironolactone 12.5 mg daily
B) Increase lisinopril to maximum tolerated dose
C) Add sacubitril/valsartan in place of lisinopril
D) Add digoxin 0.125 mg daily
Answer: C
Rationale: In HFrEF, sacubitril/valsartan is recommended to replace ACE inhibitors to further reduce morbidity and
mortality, especially in patients with persistent symptoms despite standard therapy. Spironolactone is relatively
contraindicated with K+ >5.0. Increasing lisinopril could worsen hyperkalemia. Digoxin is second-line for
symptom control but not first for mortality reduction.
2 A patient presents with acute-onset chest pain and dyspnea. ECG shows sinus tachycardia with S1Q3T3 pattern.
D-dimer is elevated. CT pulmonary angiography reveals a filling defect in the left main pulmonary artery. Vital
signs: BP 90/60 mmHg, HR 110 bpm, RR 24, SpO2 89% on room air. Which intervention is most appropriate?
A) Initiate therapeutic heparin infusion and admit for monitoring
B) Administer alteplase 100 mg IV over 2 hours
C) Perform catheter-directed thrombolysis
D) Start oral rivaroxaban 15 mg twice daily
Answer: B
Rationale: This patient has massive PE with hemodynamic instability (hypotension, hypoxia) and right heart strain.
Guidelines recommend systemic thrombolysis for massive PE unless contraindicated. Heparin alone is insufficient.
Catheter-directed thrombolysis is an alternative if systemic lysis contraindicated. Rivaroxaban is not first-line in
acute massive PE.
3 A patient with a history of hypertension and type 2 diabetes mellitus is found to have a blood pressure of 152/96
mmHg on three separate occasions. Serum creatinine is 0.9 mg/dL, and urine albumin-to-creatinine ratio is 45
mg/g. Which antihypertensive regimen is most appropriate to reduce cardiovascular and renal risk?
A) Amlodipine 5 mg daily + hydrochlorothiazide 12.5 mg daily
B) Lisinopril 10 mg daily + amlodipine 5 mg daily
C) Metoprolol tartrate 50 mg twice daily + chlorthalidone 25 mg daily
D) Spironolactone 25 mg daily + furosemide 20 mg daily
Answer: B
Rationale: ACE inhibitors (or ARBs) are first-line for patients with hypertension and albuminuria (UACR >30
mg/g) to slow progression of CKD and reduce cardiovascular events. Combination with a calcium channel blocker
(like amlodipine) is recommended for better BP control and additive benefit. Thiazides and beta-blockers are less
preferred in this setting.
,4 A patient with hypertrophic cardiomyopathy (HCM) presents with syncope during exercise. Echocardiography
shows left ventricular outflow tract (LVOT) gradient of 70 mmHg at rest, which increases with Valsalva. The
patient is not on any medications. Which initial pharmacotherapy is most appropriate?
A) Metoprolol tartrate 25 mg twice daily
B) Verapamil 120 mg daily
C) Disopyramide 100 mg three times daily
D) Lisinopril 5 mg daily
Answer: A
Rationale: Beta-blockers (e.g., metoprolol) are first-line to reduce LVOT gradient by decreasing heart rate and
contractility, improving symptoms. Verapamil is an alternative but caution in severe obstruction. Disopyramide is
second-line. ACE inhibitors are contraindicated as they reduce afterload and worsen obstruction.
5 A patient with atrial fibrillation (AF) and a CHA2DS2-VASc score of 3 is started on apixaban 5 mg twice daily.
Three months later, the patient develops a transient ischemic attack. Which of the following is the most likely
explanation for the failure of anticoagulation?
A) The patient has a mechanical heart valve
B) The patient has antiphospholipid syndrome (APS)
C) The apixaban dose is too low for the patient's weight
D) The patient has a patent foramen ovale (PFO)
Answer: B
Rationale: APS is associated with a high risk of thromboembolism despite adequate anticoagulation with direct oral
anticoagulants (DOACs); vitamin K antagonists (warfarin) are preferred. DOACs are contraindicated in APS
patients with triple positivity. Mechanical valves and PFO could cause stroke but are less likely given the scenario.
Dose adjustment is weight-based, but standard dose is appropriate unless weight <60 kg or age >80.
6 A patient with acute ST-elevation myocardial infarction (STEMI) undergoes primary percutaneous coronary
intervention (PCI) with a drug-eluting stent to the left anterior descending artery. Which dual antiplatelet
therapy (DAPT) regimen is most appropriate for the first year?
A) Aspirin 81 mg daily + clopidogrel 75 mg daily
B) Aspirin 325 mg daily + ticagrelor 90 mg twice daily
C) Aspirin 81 mg daily + ticagrelor 90 mg twice daily
D) Aspirin 81 mg daily + warfarin 2.5 mg daily
Answer: C
Rationale: Current guidelines recommend DAPT with aspirin (81 mg daily) and a P2Y12 inhibitor (ticagrelor or
prasugrel) for at least 12 months after STEMI with DES. Ticagrelor is preferred over clopidogrel due to superior
efficacy. High-dose aspirin (325 mg) is not recommended long-term due to increased bleeding risk. Warfarin is not
indicated unless additional indication.
7 A patient with dilated cardiomyopathy (LVEF 30%) and no significant coronary artery disease is being
evaluated for implantable cardioverter-defibrillator (ICD) placement. Which of the following findings would
most strongly support ICD implantation for primary prevention?
A) Left ventricular end-diastolic diameter 6.5 cm
B) Non-sustained ventricular tachycardia on 24-hour Holter monitor
C) QRS duration 150 ms with left bundle branch block
D) New York Heart Association (NYHA) functional class III symptoms despite optimal medical therapy
Answer: D
,Rationale: I C D f o r p r i m a r y p r e v e n t i o n i s i n d i c a t e d
symptoms on optimal medical therapy. Non-sustained VT alone is not an indication. QRS duration and LBBB are
criteria for cardiac resynchronization therapy, not ICD alone. LV end-diastolic diameter is not a primary criterion.
8 A patient with aortic stenosis (valve area 0.8 cm², mean gradient 50 mmHg, peak velocity 4.5 m/s) is
asymptomatic. Which of the following findings would be an indication for aortic valve replacement?
A) Left ventricular ejection fraction 55%
B) Abnormal exercise test with development of symptoms
C) Presence of moderate aortic regurgitation
D) Left atrial enlargement (volume index 40 mL/m²)
Answer: B
Rationale: In severe asymptomatic aortic stenosis, valve replacement is indicated if exercise testing provokes
symptoms. LVEF <50% is a Class I indication, but 55% is normal. Moderate aortic regurgitation and left atrial
enlargement are not standalone indications for surgery.
9 A patient with a history of coronary artery disease presents with chest pain and dyspnea. ECG shows ST
depression in leads V3-V5. High-sensitivity troponin I is elevated at 0.5 ng/mL (upper reference limit 0.04
ng/mL). Which of the following best describes the underlying pathophysiology?
A) Complete occlusion of a coronary artery with transmural ischemia
B) Subendocardial ischemia due to reduced oxygen supply or increased demand
C) Myocardial injury due to catecholamine surge without coronary obstruction
D) Microvascular spasm leading to focal necrosis
Answer: B
Rationale: Non-ST-elevation myocardial infarction (NSTEMI) typically results from incomplete occlusion or
transient occlusion of a coronary artery, causing subendocardial ischemia. ST depression and troponin elevation
confirm injury. Complete occlusion would cause STEMI. Takotsubo (catecholamine) and microvascular spasm are
less common and not the classic pathophysiology.
10 A patient with chronic pericarditis is being treated with colchicine 0.6 mg twice daily. Which of the following
laboratory findings would require discontinuation of colchicine?
A) Serum creatinine 1.2 mg/dL
B) Alanine aminotransferase 45 U/L
C) Platelet count 150,000/L
D) Creatine kinase 300 U/L
Answer: D
Rationale: Colchicine can cause myotoxicity, especially in patients with renal impairment. Elevated creatine kinase
(CK) suggests myopathy, which may progress to rhabdomyolysis. Mild elevations in creatinine, ALT, or mild
thrombocytopenia are not contraindications. Colchicine dose should be reduced in renal impairment, but CK >5
times upper limit warrants discontinuation.
11 A 68-year-old individual with a history of hypertension and type 2 diabetes presents with acute-onset chest
pressure radiating to the left arm, diaphoresis, and nausea. ECG shows ST-segment elevation in leads V2-V4.
Immediate management includes aspirin, oxygen, nitroglycerin, and morphine. Which of the following best
explains the paradoxical decrease in coronary perfusion pressure that may occur with nitroglycerin
administration in this setting?
A) Nitroglycerin causes reflex tachycardia, increasing myocardial oxygen demand and reducing diastolic filling
time.
, B) Nitroglycerin preferentially dilates epicardial coronary arteries, but in acute myocardial infarction, the culprit
lesion is already fully occluded, so no net benefit occurs.
C) Nitroglycerin reduces preload and afterload, but in the presence of right ventricular infarction, it can cause
profound hypotension and reduce coronary perfusion pressure.
D) Nitroglycerin induces coronary steal phenomenon by dilating resistance vessels in non-ischemic zones,
diverting flow away from the ischemic area.
Answer: C
Rationale: In acute inferior wall MI, right ventricular infarction may coexist. Nitroglycerin's venodilation reduces
preload, which can cause severe hypotension if right ventricular function is compromised, decreasing coronary
perfusion pressure. Options A and B are less specific: reflex tachycardia is not paradoxical, and epicardial dilation
is not detrimental. Option D describes coronary steal, but this is more relevant with vasodilators like adenosine, not
nitroglycerin.
12 A 55-year-old patient with chronic kidney disease (stage 3) and hypertension is being evaluated for resistant
hypertension (office BP 158/92 mmHg on three medications including an ACE inhibitor, a calcium channel
blocker, and a thiazide diuretic). Ambulatory blood pressure monitoring confirms lack of white-coat effect.
Which of the following additional diagnostic tests would be most appropriate to guide further management?
A) Plasma renin activity and aldosterone concentration to screen for primary hyperaldosteronism.
B) Renal artery duplex ultrasound to screen for renal artery stenosis.
C) 24-hour urinary metanephrines to rule out pheochromocytoma.
D) Polysomnography to evaluate for obstructive sleep apnea.
Answer: A
Rationale: Resistant hypertension, especially with hypokalemia (though not mentioned), warrants screening for
primary hyperaldosteronism. With CKD, renin-angiotensin-aldosterone system evaluation is crucial because
aldosterone excess is a common cause. Renal artery stenosis (B) is possible but less common in the absence of
flash pulmonary edema or bruit. Pheochromocytoma (C) is rare. Sleep apnea (D) is associated but not the next best
test in this context; aldosterone evaluation is more directly actionable.
13 A 72-year-old patient with atrial fibrillation (CHADS-VASc score 4) is on warfarin with a therapeutic INR of
2.5. The patient develops acute chest pain and dyspnea. ECG shows new left bundle branch block.
High-sensitivity troponin is elevated. Which of the following is the most appropriate immediate management
step?
A) Administer intravenous thrombolytics for suspected ST-elevation myocardial infarction.
B) Perform emergent coronary angiography with primary percutaneous coronary intervention (PCI).
C) Start intravenous unfractionated heparin and schedule urgent coronary angiography within 24 hours.
D) Obtain a computed tomography pulmonary angiogram (CTPA) to rule out pulmonary embolism before
proceeding with anticoagulation adjustment.
Answer: B
Rationale: New left bundle branch block and elevated troponin in the setting of chest pain is suggestive of acute
coronary occlusion (STEMI equivalent). Guidelines recommend emergent reperfusion with primary PCI, regardless
of anticoagulation status. Thrombolytics (A) are contraindicated due to risk of bleeding on warfarin. Heparin (C) is
not sufficient for acute occlusion. CTPA (D) may delay life-saving PCI; the presentation is more consistent with MI
than PE.
