MN566 Final Exam - 2026/2027 | Integrative
Primary-Care Synthesis Questions | 100%
Correct Grade A Key Included | NP Competency
Assessment
Domain 1 – Chronic Disease Management & Comorbidity Integration (28 Qs)
Domain 2 – Preventive Care, Screening & Health Promotion Across Lifespan (24 Qs)
Domain 3 – Diagnostic & Therapeutic Reasoning in Ambiguity (20 Qs)
Domain 4 – Professional Role, Ethics & Practice Leadership (8 Qs)
DOMAIN 1 (28 QUESTIONS)
Q1: A 68-year-old male with HFrEF (EF 30 %), COPD GOLD-3, CKD-3b (eGFR 35), T2DM,
on lisinopril 10 mg, metoprolol succinate 25 mg, furosemide 40 mg, empagliflozin 10
mg, tiotropium. Dyspnea stable 2 blocks, worsening fatigue; BP 118/70, HR 62, SpO₂ 94
% RA, K⁺ 4.8, creatinine 1.8 mg/dL (stable). Next best step?
A. ↑ lisinopril to 20 mg → improve HF outcomes
B. ↑ metoprolol succinate to 50 mg → better HR control
C. Add dapagliflozin 10 mg daily
D. Add ivabradine 5 mg bid
,Correct: C
Rationale: 2022 AHA/ACC/HFSA Guideline: SGLT2-i now class-I for HFrEF regardless of
DM; dapagliflozin lowers HF-events & slows CKD progression without added hypoTN or
hyperK. Choice A risks AKI; B limited by HR 62; D requires HR ≥70 on max β-blocker.
Q2: 72-year-F with RA (MTX 20 mg/wk + prednisone 7.5 mg daily), CKD-3a, HTN, COPD
GOLD-2, BMI 24, recurrent UTIs. BP 136/82, eGFR 52. Which BP target & agent best?
A. <130/80—add lisinopril
B. <130/80—add amlodipine
C. <150/90—continue current, no add
D. <130/80—add chlorthalidone
Correct: B
Rationale: KDIGO/ACC 2024: CKD without albuminuria → target <130/80; ACE-i offers
no renal benefit here & ↑ MTX toxicity; thiazide with CKD-3a less effective; amlodipine
safe, steroid-friendly, no interaction.
Q3: 59-M T2DM, HFpEF, OSA on CPAP, BPH, depression. A1c 8.1 %, weight 118 kg, eGFR
48, NT-proBNP 650. Current metformin 1000 mg bid, glipizide 10 mg bid, sitagliptin 50
mg. Next pharmacologic move?
A. ↑ metformin to 2000 mg bid
B. Switch glipizide → once-weekly semaglutide
C. Add dapagliflozin
D. Add insulin glargine 20 u nightly
,Correct: B
Rationale: Semaglutide lowers A1c 1.5-1.8 %, promotes 5-7 kg loss, no hypoglycemia,
safe in HFpEF; dapagliflozin good but only modest A1c drop; insulin → weight gain;
metformin limited by eGFR <45.
(For brevity, stems are condensed; full vignette data implied.)
Q4: 64-F, T2DM 15 y, CKD-4 (eGFR 23), on insulin, omeprazole, atorvastatin 40 mg. K⁺
5.3, Hb 9.8 g/dL, TSAT 18 %, ferritin 280. Next best action?
A. Start IV iron sucrose
B. Start darbepoetin alfa
C. Hold ACE-i & ARB
D. Start sodium zirconium cyclosilicate
Correct: A
Rationale: KDIGO 2022 CKD anemia: TSAT <20 % → iron repletion first;
erythropoiesis-stimulating agents (ESAs) only after iron replete; ACE-i/ARB still
cardio-renal protective unless K⁺ >5.5; K⁺ binder not yet indicated.
Q5: 55-M HIV (CD4 480, VL <20), T2DM, HFrEF (EF 28 %), on bictegravir/TAF/FTC,
metformin 500 mg bid, dapagliflozin 10 mg, carvedilol 25 mg bid. A1c 7.9 %, weight 92
kg. Next?
A. ↑ metformin to 1000 mg bid
B. Switch TAF → abacavir/lamivudine
C. Add liraglutide
, D. Add insulin glargine
Correct: C
Rationale: TAF ↑ weight & LDL; liraglutide lowers A1c ~1 %, weight 3 kg, MACE benefit,
safe with HIV; metformin Tmax 1 g bid; insulin adds weight.
Q6: 67-F, systolic HF (EF 30 %), COPD on tiotropium/albuterol, paroxysmal AF
(CHA₂DS₂-VASc 4), CKD-3b, on apixaban 5 mg bid, metoprolol succinate 100 mg,
furosemide 40 mg. HR 84, BP 98/62. GDMT optimization?
A. ↑ apixaban to 7.5 mg bid
B. Add digoxin 0.25 mg daily
C. Add diltiazem for HR
D. Add atorvastatin 80 mg
Correct: B
Rationale: Digoxin controls HR in AF, improves symptoms & reduces HF-hospitalization
without hypoTN; diltiazem ↓ contractility; apixaban dose correct; statin no HF benefit.
Q7: 71-M, cirrhosis Child-A, COPD GOLD-3, HTN, CKD-3a. Spironolactone 25 mg daily
added for ascites. Two weeks later K⁺ 5.9, creatinine ↑0.3. Action?
A. Stop lisinopril & reduce spironolactone to 12.5 mg
B. Start kayexalate
C. Stop spironolactone; continue lisinopril
D. Add hydrochlorothiazide 25 mg
Primary-Care Synthesis Questions | 100%
Correct Grade A Key Included | NP Competency
Assessment
Domain 1 – Chronic Disease Management & Comorbidity Integration (28 Qs)
Domain 2 – Preventive Care, Screening & Health Promotion Across Lifespan (24 Qs)
Domain 3 – Diagnostic & Therapeutic Reasoning in Ambiguity (20 Qs)
Domain 4 – Professional Role, Ethics & Practice Leadership (8 Qs)
DOMAIN 1 (28 QUESTIONS)
Q1: A 68-year-old male with HFrEF (EF 30 %), COPD GOLD-3, CKD-3b (eGFR 35), T2DM,
on lisinopril 10 mg, metoprolol succinate 25 mg, furosemide 40 mg, empagliflozin 10
mg, tiotropium. Dyspnea stable 2 blocks, worsening fatigue; BP 118/70, HR 62, SpO₂ 94
% RA, K⁺ 4.8, creatinine 1.8 mg/dL (stable). Next best step?
A. ↑ lisinopril to 20 mg → improve HF outcomes
B. ↑ metoprolol succinate to 50 mg → better HR control
C. Add dapagliflozin 10 mg daily
D. Add ivabradine 5 mg bid
,Correct: C
Rationale: 2022 AHA/ACC/HFSA Guideline: SGLT2-i now class-I for HFrEF regardless of
DM; dapagliflozin lowers HF-events & slows CKD progression without added hypoTN or
hyperK. Choice A risks AKI; B limited by HR 62; D requires HR ≥70 on max β-blocker.
Q2: 72-year-F with RA (MTX 20 mg/wk + prednisone 7.5 mg daily), CKD-3a, HTN, COPD
GOLD-2, BMI 24, recurrent UTIs. BP 136/82, eGFR 52. Which BP target & agent best?
A. <130/80—add lisinopril
B. <130/80—add amlodipine
C. <150/90—continue current, no add
D. <130/80—add chlorthalidone
Correct: B
Rationale: KDIGO/ACC 2024: CKD without albuminuria → target <130/80; ACE-i offers
no renal benefit here & ↑ MTX toxicity; thiazide with CKD-3a less effective; amlodipine
safe, steroid-friendly, no interaction.
Q3: 59-M T2DM, HFpEF, OSA on CPAP, BPH, depression. A1c 8.1 %, weight 118 kg, eGFR
48, NT-proBNP 650. Current metformin 1000 mg bid, glipizide 10 mg bid, sitagliptin 50
mg. Next pharmacologic move?
A. ↑ metformin to 2000 mg bid
B. Switch glipizide → once-weekly semaglutide
C. Add dapagliflozin
D. Add insulin glargine 20 u nightly
,Correct: B
Rationale: Semaglutide lowers A1c 1.5-1.8 %, promotes 5-7 kg loss, no hypoglycemia,
safe in HFpEF; dapagliflozin good but only modest A1c drop; insulin → weight gain;
metformin limited by eGFR <45.
(For brevity, stems are condensed; full vignette data implied.)
Q4: 64-F, T2DM 15 y, CKD-4 (eGFR 23), on insulin, omeprazole, atorvastatin 40 mg. K⁺
5.3, Hb 9.8 g/dL, TSAT 18 %, ferritin 280. Next best action?
A. Start IV iron sucrose
B. Start darbepoetin alfa
C. Hold ACE-i & ARB
D. Start sodium zirconium cyclosilicate
Correct: A
Rationale: KDIGO 2022 CKD anemia: TSAT <20 % → iron repletion first;
erythropoiesis-stimulating agents (ESAs) only after iron replete; ACE-i/ARB still
cardio-renal protective unless K⁺ >5.5; K⁺ binder not yet indicated.
Q5: 55-M HIV (CD4 480, VL <20), T2DM, HFrEF (EF 28 %), on bictegravir/TAF/FTC,
metformin 500 mg bid, dapagliflozin 10 mg, carvedilol 25 mg bid. A1c 7.9 %, weight 92
kg. Next?
A. ↑ metformin to 1000 mg bid
B. Switch TAF → abacavir/lamivudine
C. Add liraglutide
, D. Add insulin glargine
Correct: C
Rationale: TAF ↑ weight & LDL; liraglutide lowers A1c ~1 %, weight 3 kg, MACE benefit,
safe with HIV; metformin Tmax 1 g bid; insulin adds weight.
Q6: 67-F, systolic HF (EF 30 %), COPD on tiotropium/albuterol, paroxysmal AF
(CHA₂DS₂-VASc 4), CKD-3b, on apixaban 5 mg bid, metoprolol succinate 100 mg,
furosemide 40 mg. HR 84, BP 98/62. GDMT optimization?
A. ↑ apixaban to 7.5 mg bid
B. Add digoxin 0.25 mg daily
C. Add diltiazem for HR
D. Add atorvastatin 80 mg
Correct: B
Rationale: Digoxin controls HR in AF, improves symptoms & reduces HF-hospitalization
without hypoTN; diltiazem ↓ contractility; apixaban dose correct; statin no HF benefit.
Q7: 71-M, cirrhosis Child-A, COPD GOLD-3, HTN, CKD-3a. Spironolactone 25 mg daily
added for ascites. Two weeks later K⁺ 5.9, creatinine ↑0.3. Action?
A. Stop lisinopril & reduce spironolactone to 12.5 mg
B. Start kayexalate
C. Stop spironolactone; continue lisinopril
D. Add hydrochlorothiazide 25 mg
