NR661 Advanced Clinical
Practicum Exam 2025/2026 –
Verified Questions & Correct
Answers | Chamberlain
Section 1: Cardiovascular Management (Questions 1–20)
1. A 58-year-old female with hypertension presents for follow-up, reporting fatigue and leg
swelling. BP 148/92 mmHg, HR 88 bpm. Labs show K+ 5.2 mEq/L. She is on lisinopril 20
mg daily. What is the priority intervention? A. Increase lisinopril to 40 mg B. Switch to
losartan 50 mg and add spironolactone 25 mg C. Add hydrochlorothiazide 25 mg D. Order
echocardiogram only
Rationale: Per JNC 2025 guidelines and AANP primary care standards, hyperkalemia (>5.0
mEq/L) with fatigue/swelling suggests ACEI intolerance; switching to ARB (losartan) maintains
RAAS inhibition while adding MRA (spironolactone) for resistant HTN, prioritizing patient
safety by avoiding K+ elevation; coordinate with cardiology for echo if HF suspected.
2. A 72-year-old male with stable angina (post-PCI 2 years ago) has LDL 95 mg/dL on
atorvastatin 20 mg. He reports muscle aches. What is the best next step? A. Increase to 40
mg B. Switch to rosuvastatin 10 mg and add ezetimibe 10 mg C. Discontinue statin D. Add
niacin
Rationale: ACC/AHA 2025 lipid guidelines target LDL <70 mg/dL in post-PCI; myalgia
indicates statin intolerance—switch to hydrophilic rosuvastatin reduces muscle risk, adding
ezetimibe for PCSK9-independent lowering enhances safety; refer to cardiologist for care
coordination.
3. A 45-year-old obese female (BMI 32) with new-onset AFib (CHA2DS2-VASc 2) is
asymptomatic. What is the initial pharmacologic management? A. Aspirin 81 mg daily B.
Apixaban 5 mg BID C. Metoprolol 25 mg BID D. Warfarin INR 2–3
Rationale: AHA/ACC/HRS 2025 AF guidelines recommend DOACs like apixaban for stroke
prevention in non-valvular AFib (score ≥2); aspirin insufficient—prioritizes safety over bleeding
risk; coordinate with cardiology for rate control if symptomatic.
4. A 68-year-old with HFrEF (EF 35%) on lisinopril, metoprolol, and furosemide reports
worsening dyspnea. What adjustment improves outcomes? A. Increase furosemide to BID B.
,Add sacubitril/valsartan titrated from 24/26 mg BID C. Switch to amlodipine D. Add digoxin
0.125 mg
Rationale: ACC 2025 HF guidelines endorse ARNI (sacubitril/valsartan) over ACEI for
symptomatic HFrEF, reducing hospitalizations via neprilysin inhibition; slow titration ensures
BP stability; interprofessional referral to HF clinic for monitoring.
5. A 55-year-old smoker with PAD (ABI 0.65) complains of claudication. What is first-line
therapy? A. Cilostazol 100 mg BID B. Cilostazol 100 mg BID C. Pentoxifylline D. Statin only
Rationale: AHA 2025 PAD guidelines recommend cilostazol for intermittent claudication
(PDE3 inhibitor improves walking distance); contraindicated in HF—safety first; coordinate with
vascular surgery for revascularization if severe.
6. A 62-year-old diabetic with CKD (eGFR 45) has BP 142/88 mmHg on amlodipine 10 mg.
What addition aligns with guidelines? A. Add clonidine B. Add lisinopril 5 mg daily C.
Switch to hydralazine D. Increase amlodipine to 20 mg
Rationale: KDIGO 2025 HTN in CKD recommends ACEI for proteinuria protection in DM;
low starting dose minimizes AKI risk; monitor eGFR monthly for safety and nephrology
coordination.
7. A 78-year-old frail female with osteoporosis and recent hip fracture is on alendronate.
She reports dysphagia. What is the priority action? A. Continue with water B. Switch to
denosumab 60 mg SQ q6 months C. Add calcium D. Order endoscopy
Rationale: NOF 2025 guidelines advise switching to denosumab for esophagitis risk in frail
elders; rapid BMD gains; monitor hypocalcemia and coordinate with endocrinology for fracture
prevention.
8. A 50-year-old with familial hypercholesterolemia (LDL 190 mg/dL) on max statin. What
adjunct reduces CV risk? A. Ezetimibe 10 mg B. Ezetimibe 10 mg C. Niacin D. Fibrates
Rationale: AHA 2025 FH guidelines add ezetimibe for LDL >100 despite statin; 20% further
reduction; safety via LFT monitoring; refer to lipid clinic for PCSK9i if needed.
9. A 65-year-old with OSA and uncontrolled HTN (BP 155/95) on CPAP compliance 70%.
What pharmacologic adjustment? A. Add losartan 50 mg B. Optimize CPAP and add
chlorthalidone 12.5 mg C. Switch to ARB D. Increase CPAP pressure only
Rationale: AHA 2025 resistant HTN in OSA recommends diuretic addition after adherence
confirmation; thiazide-like enhances RAAS control; coordinate with sleep specialist for titration.
10. A 70-year-old with aortic stenosis (AS, AVA 1.0 cm²) has syncope. Echo confirms severe
AS. What is urgent referral? A. Medical management only B. Cardiology for TAVR
evaluation C. Beta-blocker increase D. Annual echo
, Rationale: ACC/AHA 2025 valve guidelines prioritize TAVR in symptomatic severe AS for
elders; reduces mortality vs. medical therapy; safety via frailty assessment pre-procedure.
11. A 55-year-old with ACS discharged on ticagrelor 90 mg BID and aspirin 81 mg. At 1
month, dyspnea noted. What is priority? A. Continue DAPT B. Check CBC for dyspnea
(bleed?); consider clopidogrel switch C. Stop aspirin D. Add PPI only
Rationale: ACC 2025 DAPT guidelines require monitoring for ticagrelor dyspnea (10–15%,
benign); rule out bleed; switch if persistent for safety.
12. A 68-year-old with T2DM and eGFR 35 on metformin 1000 mg BID. What is the
action? A. Continue B. Discontinue metformin; start linagliptin 5 mg C. Reduce to 500 mg D.
Add insulin
Rationale: ADA 2025 contraindicates metformin at eGFR <30; DPP-4i linagliptin renal-safe;
prevents lactic acidosis while maintaining glycemic control.
13. A 60-year-old with RA (DAS28 5.1) on MTX 15 mg weekly. Labs: CrCl 50 mL/min,
LFT normal. What adjustment? A. Increase to 20 mg B. Continue with folic acid 1 mg daily
C. Switch to leflunomide D. Add steroid
Rationale: ACR 2025 MTX dosing caps at 25 mg/week; folic acid mitigates GI/hepatic toxicity;
monitor q1–3 months for safety in chronic RA management.
14. A 75-year-old with CLL on ibrutinib 420 mg daily develops atrial fibrillation. What is
the management? A. Continue ibrutinib B. Hold ibrutinib; consult hematology for dose
reduction or alternative C. Add beta-blocker D. Anticoagulate only
Rationale: NCCN 2025 BTK inhibitors like ibrutinib carry 10% AF risk; hold for new-onset,
evaluate for alternative like venetoclax; coordinate multidisciplinary.
15. A 52-year-old with psoriasis (PASI 12) on adalimumab 40 mg SQ q2 weeks. TB test
negative. What monitoring? A. None B. Annual CBC, LFT, TB skin test C. Monthly lipids D.
ECG q6 months
Rationale: AAD 2025 TNF-alpha monitoring for infection/malignancy; latent TB screening
essential for safety in biologic therapy.
16. A 80-year-old with Parkinson's (UPDRS 40) on carbidopa/levodopa 25/100 mg TID
"wearing off". What addition? A. Increase to QID B. Add entacapone 200 mg with each dose
C. Switch to pramipexole D. Deep brain stimulation
Rationale: MDS 2025 COMT inhibitor entacapone extends levodopa duration; dyskinesia risk;
refer neurology for advanced therapy if progresses.
Practicum Exam 2025/2026 –
Verified Questions & Correct
Answers | Chamberlain
Section 1: Cardiovascular Management (Questions 1–20)
1. A 58-year-old female with hypertension presents for follow-up, reporting fatigue and leg
swelling. BP 148/92 mmHg, HR 88 bpm. Labs show K+ 5.2 mEq/L. She is on lisinopril 20
mg daily. What is the priority intervention? A. Increase lisinopril to 40 mg B. Switch to
losartan 50 mg and add spironolactone 25 mg C. Add hydrochlorothiazide 25 mg D. Order
echocardiogram only
Rationale: Per JNC 2025 guidelines and AANP primary care standards, hyperkalemia (>5.0
mEq/L) with fatigue/swelling suggests ACEI intolerance; switching to ARB (losartan) maintains
RAAS inhibition while adding MRA (spironolactone) for resistant HTN, prioritizing patient
safety by avoiding K+ elevation; coordinate with cardiology for echo if HF suspected.
2. A 72-year-old male with stable angina (post-PCI 2 years ago) has LDL 95 mg/dL on
atorvastatin 20 mg. He reports muscle aches. What is the best next step? A. Increase to 40
mg B. Switch to rosuvastatin 10 mg and add ezetimibe 10 mg C. Discontinue statin D. Add
niacin
Rationale: ACC/AHA 2025 lipid guidelines target LDL <70 mg/dL in post-PCI; myalgia
indicates statin intolerance—switch to hydrophilic rosuvastatin reduces muscle risk, adding
ezetimibe for PCSK9-independent lowering enhances safety; refer to cardiologist for care
coordination.
3. A 45-year-old obese female (BMI 32) with new-onset AFib (CHA2DS2-VASc 2) is
asymptomatic. What is the initial pharmacologic management? A. Aspirin 81 mg daily B.
Apixaban 5 mg BID C. Metoprolol 25 mg BID D. Warfarin INR 2–3
Rationale: AHA/ACC/HRS 2025 AF guidelines recommend DOACs like apixaban for stroke
prevention in non-valvular AFib (score ≥2); aspirin insufficient—prioritizes safety over bleeding
risk; coordinate with cardiology for rate control if symptomatic.
4. A 68-year-old with HFrEF (EF 35%) on lisinopril, metoprolol, and furosemide reports
worsening dyspnea. What adjustment improves outcomes? A. Increase furosemide to BID B.
,Add sacubitril/valsartan titrated from 24/26 mg BID C. Switch to amlodipine D. Add digoxin
0.125 mg
Rationale: ACC 2025 HF guidelines endorse ARNI (sacubitril/valsartan) over ACEI for
symptomatic HFrEF, reducing hospitalizations via neprilysin inhibition; slow titration ensures
BP stability; interprofessional referral to HF clinic for monitoring.
5. A 55-year-old smoker with PAD (ABI 0.65) complains of claudication. What is first-line
therapy? A. Cilostazol 100 mg BID B. Cilostazol 100 mg BID C. Pentoxifylline D. Statin only
Rationale: AHA 2025 PAD guidelines recommend cilostazol for intermittent claudication
(PDE3 inhibitor improves walking distance); contraindicated in HF—safety first; coordinate with
vascular surgery for revascularization if severe.
6. A 62-year-old diabetic with CKD (eGFR 45) has BP 142/88 mmHg on amlodipine 10 mg.
What addition aligns with guidelines? A. Add clonidine B. Add lisinopril 5 mg daily C.
Switch to hydralazine D. Increase amlodipine to 20 mg
Rationale: KDIGO 2025 HTN in CKD recommends ACEI for proteinuria protection in DM;
low starting dose minimizes AKI risk; monitor eGFR monthly for safety and nephrology
coordination.
7. A 78-year-old frail female with osteoporosis and recent hip fracture is on alendronate.
She reports dysphagia. What is the priority action? A. Continue with water B. Switch to
denosumab 60 mg SQ q6 months C. Add calcium D. Order endoscopy
Rationale: NOF 2025 guidelines advise switching to denosumab for esophagitis risk in frail
elders; rapid BMD gains; monitor hypocalcemia and coordinate with endocrinology for fracture
prevention.
8. A 50-year-old with familial hypercholesterolemia (LDL 190 mg/dL) on max statin. What
adjunct reduces CV risk? A. Ezetimibe 10 mg B. Ezetimibe 10 mg C. Niacin D. Fibrates
Rationale: AHA 2025 FH guidelines add ezetimibe for LDL >100 despite statin; 20% further
reduction; safety via LFT monitoring; refer to lipid clinic for PCSK9i if needed.
9. A 65-year-old with OSA and uncontrolled HTN (BP 155/95) on CPAP compliance 70%.
What pharmacologic adjustment? A. Add losartan 50 mg B. Optimize CPAP and add
chlorthalidone 12.5 mg C. Switch to ARB D. Increase CPAP pressure only
Rationale: AHA 2025 resistant HTN in OSA recommends diuretic addition after adherence
confirmation; thiazide-like enhances RAAS control; coordinate with sleep specialist for titration.
10. A 70-year-old with aortic stenosis (AS, AVA 1.0 cm²) has syncope. Echo confirms severe
AS. What is urgent referral? A. Medical management only B. Cardiology for TAVR
evaluation C. Beta-blocker increase D. Annual echo
, Rationale: ACC/AHA 2025 valve guidelines prioritize TAVR in symptomatic severe AS for
elders; reduces mortality vs. medical therapy; safety via frailty assessment pre-procedure.
11. A 55-year-old with ACS discharged on ticagrelor 90 mg BID and aspirin 81 mg. At 1
month, dyspnea noted. What is priority? A. Continue DAPT B. Check CBC for dyspnea
(bleed?); consider clopidogrel switch C. Stop aspirin D. Add PPI only
Rationale: ACC 2025 DAPT guidelines require monitoring for ticagrelor dyspnea (10–15%,
benign); rule out bleed; switch if persistent for safety.
12. A 68-year-old with T2DM and eGFR 35 on metformin 1000 mg BID. What is the
action? A. Continue B. Discontinue metformin; start linagliptin 5 mg C. Reduce to 500 mg D.
Add insulin
Rationale: ADA 2025 contraindicates metformin at eGFR <30; DPP-4i linagliptin renal-safe;
prevents lactic acidosis while maintaining glycemic control.
13. A 60-year-old with RA (DAS28 5.1) on MTX 15 mg weekly. Labs: CrCl 50 mL/min,
LFT normal. What adjustment? A. Increase to 20 mg B. Continue with folic acid 1 mg daily
C. Switch to leflunomide D. Add steroid
Rationale: ACR 2025 MTX dosing caps at 25 mg/week; folic acid mitigates GI/hepatic toxicity;
monitor q1–3 months for safety in chronic RA management.
14. A 75-year-old with CLL on ibrutinib 420 mg daily develops atrial fibrillation. What is
the management? A. Continue ibrutinib B. Hold ibrutinib; consult hematology for dose
reduction or alternative C. Add beta-blocker D. Anticoagulate only
Rationale: NCCN 2025 BTK inhibitors like ibrutinib carry 10% AF risk; hold for new-onset,
evaluate for alternative like venetoclax; coordinate multidisciplinary.
15. A 52-year-old with psoriasis (PASI 12) on adalimumab 40 mg SQ q2 weeks. TB test
negative. What monitoring? A. None B. Annual CBC, LFT, TB skin test C. Monthly lipids D.
ECG q6 months
Rationale: AAD 2025 TNF-alpha monitoring for infection/malignancy; latent TB screening
essential for safety in biologic therapy.
16. A 80-year-old with Parkinson's (UPDRS 40) on carbidopa/levodopa 25/100 mg TID
"wearing off". What addition? A. Increase to QID B. Add entacapone 200 mg with each dose
C. Switch to pramipexole D. Deep brain stimulation
Rationale: MDS 2025 COMT inhibitor entacapone extends levodopa duration; dyskinesia risk;
refer neurology for advanced therapy if progresses.
