NR-509 — 2025_2026 Practice Questions
with Answers & Rationales
1
A 68-year-old man with COPD presents with increased dyspnea, productive cough with purulent
sputum, and fever (38.5°C). His usual O₂ saturation is 90% on room air; today it is 84%. Which
is the most appropriate next step?
A. Start high-dose oral corticosteroids and discharge home.
B. Obtain a chest x-ray and start empiric antibiotics; consider supplemental oxygen.
C. Send him home with increased inhaler use and follow-up in 1 week.
D. Begin IV furosemide for presumed heart failure.
Answer: B
Rationale: Acute COPD exacerbation with hypoxemia and purulent sputum suggests possible
pneumonia or bacterial exacerbation — chest x-ray and empiric antibiotics plus oxygen are
appropriate. Steroids may be used but not sole step; IV diuretics not indicated without signs of
heart failure.
2
A 25-year-old woman presents with sudden onset right lower quadrant pain, nausea, and
low-grade fever. On exam: guarding and rebound at McBurney’s point. Pregnancy test is
negative. Best next diagnostic step?
A. Pelvic ultrasound.
B. CT abdomen/pelvis with IV contrast.
C. Plain abdominal x-ray.
D. MRI abdomen.
Answer: B
Rationale: In adult nonpregnant women with suspected appendicitis, CT abdomen/pelvis with
IV contrast has high sensitivity/specificity and is appropriate.
3
A 54-year-old with type 2 diabetes reports a painless ulcer on the plantar surface of his foot for
3 weeks. It probes to bone. According to standard management, what should you suspect?
,A. Superficial cellulitis only.
B. Osteomyelitis; obtain MRI or bone biopsy/culture.
C. Viral infection; begin antivirals.
D. Autoimmune ulceration; refer to rheumatology.
Answer: B
Rationale: Ulcers that probe to bone are highly suspicious for osteomyelitis; imaging (MRI) and
bone culture/biopsy are appropriate.
4
A 35-year-old with new-onset atrial fibrillation of unknown duration presents asymptomatic.
Which is correct regarding anticoagulation before cardioversion?
A. No anticoagulation is needed if asymptomatic.
B. Anticoagulate for 3 weeks prior to elective cardioversion if AF duration >48 hours or
unknown.
C. Anticoagulate only if CHA₂DS₂-VASc ≥2.
D. Immediate cardioversion without anticoagulation is safe.
Answer: B
Rationale: For AF >48 hours or unknown duration, anticoagulate for 3 weeks prior to elective
cardioversion (or do TEE-guided strategy).
5
A 22-year-old presents with severe sore throat, fever, anterior cervical adenopathy, and
exudative tonsillitis. Rapid strep test is negative. Next best step?
A. Start empiric TMP-SMX.
B. No antibiotics; supportive care only.
C. Throat culture or consider empiric penicillin if high Centor score.
D. Start antiviral therapy for influenza.
Answer: C
Rationale: Negative rapid test may need confirmatory throat culture if suspicion high (or
empiric penicillin when bacterial pharyngitis is likely). TMP-SMX not first-line.
6
A patient with heart failure with reduced EF (HFrEF) remains symptomatic on ACE inhibitor and
beta-blocker. Which agent provides mortality benefit and should be added?
A. Hydralazine alone.
B. Spironolactone (an MRA).
, C. High-dose loop diuretic only.
D. Verapamil.
Answer: B
Rationale: Mineralocorticoid receptor antagonists (spironolactone/eplerenone) reduce mortality
in HFrEF when added to ACEi/ARB and beta-blocker (if kidney function and K permit).
7
A 45-year-old with suspected stable angina—exercise stress test is nondiagnostic. Next best
diagnostic test to evaluate ischemia?
A. Coronary CT angiography (if low–intermediate pretest probability).
B. Repeat the same exercise test.
C. Immediate CABG.
D. No further testing.
Answer: A
Rationale: If exercise stress test is nondiagnostic, coronary CT angiography is useful in
appropriate patients; further testing is guided by pretest probability and ability to exercise.
8
Which antibiotic is contraindicated in pregnancy for treatment of uncomplicated UTI?
A. Nitrofurantoin (first trimester caution).
B. Trimethoprim-sulfamethoxazole (avoid in 1st trimester and near term).
C. Amoxicillin.
D. Cephalexin.
Answer: B
Rationale: TMP-SMX has teratogenic risk and is generally avoided in first trimester and near
term; nitrofurantoin is often used except near term; cephalosporins and amoxicillin are safer.
9
A patient with new diagnosis of primary hypothyroidism (TSH elevated, low free T4). Best initial
therapy?
A. Levothyroxine replacement, dose based on weight and cardiac status.
B. Liothyronine (T3) alone.
C. Methimazole.
D. No treatment required.
Answer: A
with Answers & Rationales
1
A 68-year-old man with COPD presents with increased dyspnea, productive cough with purulent
sputum, and fever (38.5°C). His usual O₂ saturation is 90% on room air; today it is 84%. Which
is the most appropriate next step?
A. Start high-dose oral corticosteroids and discharge home.
B. Obtain a chest x-ray and start empiric antibiotics; consider supplemental oxygen.
C. Send him home with increased inhaler use and follow-up in 1 week.
D. Begin IV furosemide for presumed heart failure.
Answer: B
Rationale: Acute COPD exacerbation with hypoxemia and purulent sputum suggests possible
pneumonia or bacterial exacerbation — chest x-ray and empiric antibiotics plus oxygen are
appropriate. Steroids may be used but not sole step; IV diuretics not indicated without signs of
heart failure.
2
A 25-year-old woman presents with sudden onset right lower quadrant pain, nausea, and
low-grade fever. On exam: guarding and rebound at McBurney’s point. Pregnancy test is
negative. Best next diagnostic step?
A. Pelvic ultrasound.
B. CT abdomen/pelvis with IV contrast.
C. Plain abdominal x-ray.
D. MRI abdomen.
Answer: B
Rationale: In adult nonpregnant women with suspected appendicitis, CT abdomen/pelvis with
IV contrast has high sensitivity/specificity and is appropriate.
3
A 54-year-old with type 2 diabetes reports a painless ulcer on the plantar surface of his foot for
3 weeks. It probes to bone. According to standard management, what should you suspect?
,A. Superficial cellulitis only.
B. Osteomyelitis; obtain MRI or bone biopsy/culture.
C. Viral infection; begin antivirals.
D. Autoimmune ulceration; refer to rheumatology.
Answer: B
Rationale: Ulcers that probe to bone are highly suspicious for osteomyelitis; imaging (MRI) and
bone culture/biopsy are appropriate.
4
A 35-year-old with new-onset atrial fibrillation of unknown duration presents asymptomatic.
Which is correct regarding anticoagulation before cardioversion?
A. No anticoagulation is needed if asymptomatic.
B. Anticoagulate for 3 weeks prior to elective cardioversion if AF duration >48 hours or
unknown.
C. Anticoagulate only if CHA₂DS₂-VASc ≥2.
D. Immediate cardioversion without anticoagulation is safe.
Answer: B
Rationale: For AF >48 hours or unknown duration, anticoagulate for 3 weeks prior to elective
cardioversion (or do TEE-guided strategy).
5
A 22-year-old presents with severe sore throat, fever, anterior cervical adenopathy, and
exudative tonsillitis. Rapid strep test is negative. Next best step?
A. Start empiric TMP-SMX.
B. No antibiotics; supportive care only.
C. Throat culture or consider empiric penicillin if high Centor score.
D. Start antiviral therapy for influenza.
Answer: C
Rationale: Negative rapid test may need confirmatory throat culture if suspicion high (or
empiric penicillin when bacterial pharyngitis is likely). TMP-SMX not first-line.
6
A patient with heart failure with reduced EF (HFrEF) remains symptomatic on ACE inhibitor and
beta-blocker. Which agent provides mortality benefit and should be added?
A. Hydralazine alone.
B. Spironolactone (an MRA).
, C. High-dose loop diuretic only.
D. Verapamil.
Answer: B
Rationale: Mineralocorticoid receptor antagonists (spironolactone/eplerenone) reduce mortality
in HFrEF when added to ACEi/ARB and beta-blocker (if kidney function and K permit).
7
A 45-year-old with suspected stable angina—exercise stress test is nondiagnostic. Next best
diagnostic test to evaluate ischemia?
A. Coronary CT angiography (if low–intermediate pretest probability).
B. Repeat the same exercise test.
C. Immediate CABG.
D. No further testing.
Answer: A
Rationale: If exercise stress test is nondiagnostic, coronary CT angiography is useful in
appropriate patients; further testing is guided by pretest probability and ability to exercise.
8
Which antibiotic is contraindicated in pregnancy for treatment of uncomplicated UTI?
A. Nitrofurantoin (first trimester caution).
B. Trimethoprim-sulfamethoxazole (avoid in 1st trimester and near term).
C. Amoxicillin.
D. Cephalexin.
Answer: B
Rationale: TMP-SMX has teratogenic risk and is generally avoided in first trimester and near
term; nitrofurantoin is often used except near term; cephalosporins and amoxicillin are safer.
9
A patient with new diagnosis of primary hypothyroidism (TSH elevated, low free T4). Best initial
therapy?
A. Levothyroxine replacement, dose based on weight and cardiac status.
B. Liothyronine (T3) alone.
C. Methimazole.
D. No treatment required.
Answer: A
