CMN 568 Family Nurse Practitioner Unit 4 Final
Exam Study Guide | Comprehensive Advanced
Integration & Mastery Review | 2026/2027
Domain 1: Complex Cardiovascular & Metabolic Integration (15 Questions)
Q1. A 68-year-old female with HFrEF (EF 35 %), type 2 DM (A1c 8.2 %), and stage 3a CKD
(eGFR 48 mL/min/1.73 m²) is seen in follow-up. Current meds: lisinopril 20 mg daily,
metformin 1 000 mg BID, atorvastatin 40 mg daily. BP 118/76 mmHg, HR 72 bpm, trace
pedal edema. Labs: Na 138 mmol/L, K 4.8 mmol/L, Cr 1.4 mg/dL. Which is the most
appropriate next step?
A. Increase lisinopril to 40 mg daily for better HF control
B. Add empagliflozin 10 mg daily
C. Switch metformin to sitagliptin 100 mg daily because of CKD
D. Prescribe furosemide 20 mg daily for pedal edema
Correct: B
Rationale: 2026 ACC/AHA HF guideline (class 1) and ADA Standards recommend SGLT2
inhibitors for HFrEF regardless of DM status and for renal protection down to eGFR ≥30.
Empagliflozin lowers A1c ~0.5 % and reduces HF hospitalization. Monitor for mycotic
infections and volume status; counsel hydration. Option A risks hyperkalemia (CKD).
Metformin is safe to eGFR 30 (C incorrect). No signs of volume overload (D
unnecessary).
,Q2. A 55-year-old male with resistant hypertension (BP 152/94 mmHg on maxed HCTZ
25 mg, amlodipine 10 mg, losartan 100 mg), CKD stage 3b (eGFR 34 mL/min), K 4.9
mmol/L. Which add-on therapy is best?
A. Spironolactone 25 mg daily
B. Hydralazine 25 mg BID
C. Clonidine 0.1 mg BID
D. Diltiazem 180 mg daily
Correct: B
Rationale: AHA 2026 resistant HTN algorithm: hydralazine (direct vasodilator) effective
with CKD and hyperkalemia risk. Spironolactone (A) contraindicated with K >4.5 and
eGFR <45. Clonidine (C) sedating; diltiazem (D) interacts with CKD. Monitor for reflex
tachycardia; add β-blocker if needed.
Q3. A 62-year-old female with type 2 DM, HFpEF (EF 55 %), BMI 34 kg/m², A1c 9.1 % on
metformin 2 g daily. Which agent addition provides greatest cardiometabolic benefit?
A. Insulin glargine 20 units nightly
B. Semaglutide 1 mg weekly SC
C. Glipizide 5 mg BID
D. Sitagliptin 100 mg daily
Correct: B
, Rationale: STEP-HFpEF trial 2026: GLP-1 RA reduces weight (~12 %), A1c (~1.2 %), and
HF symptoms. Semaglutide also CVD outcome proven. Insulin (A) causes weight gain;
glipizide (C) hypoglycemia risk; sitagliptin (D) weight-neutral, modest A1c reduction.
Q4. Patient with HFrEF (EF 30 %), on carvedilol 25 mg BID, lisinopril 20 mg,
spironolactone 25 mg, furosemide 40 mg BID. BNP 380 pg/mL (↓ from 550). Reports
fatigue, no edema, BP 96/62 mmHg, HR 52 bpm. Which change is most appropriate?
A. Reduce carvedilol to 12.5 mg BID
B. Increase lisinopril to 40 mg daily
C. Add digoxin 0.125 mg daily
D. Stop furosemide
Correct: A
Rationale: Guideline-directed beta-blockade target is maximally tolerated dose, not
absolute dose. Hypotension/bradycardia limit dose. Reduce carvedilol, reassess in 2
weeks. Digoxin (C) not first-line for asymptomatic low EF. Continue diuretic (D) for prior
fluid overload.
Q5. A 58-year-old male with T2DM, CKD 3a (eGFR 52), on atorvastatin 40 mg, reports
myalgia, CK 180 U/L (ULN 200). LDL 94 mg/dL. Which approach is best?
A. Switch to rosuvastatin 20 mg every other day
B. Add ezetimibe 10 mg daily and stop statin
C. Add bempedoic acid 180 mg daily
Exam Study Guide | Comprehensive Advanced
Integration & Mastery Review | 2026/2027
Domain 1: Complex Cardiovascular & Metabolic Integration (15 Questions)
Q1. A 68-year-old female with HFrEF (EF 35 %), type 2 DM (A1c 8.2 %), and stage 3a CKD
(eGFR 48 mL/min/1.73 m²) is seen in follow-up. Current meds: lisinopril 20 mg daily,
metformin 1 000 mg BID, atorvastatin 40 mg daily. BP 118/76 mmHg, HR 72 bpm, trace
pedal edema. Labs: Na 138 mmol/L, K 4.8 mmol/L, Cr 1.4 mg/dL. Which is the most
appropriate next step?
A. Increase lisinopril to 40 mg daily for better HF control
B. Add empagliflozin 10 mg daily
C. Switch metformin to sitagliptin 100 mg daily because of CKD
D. Prescribe furosemide 20 mg daily for pedal edema
Correct: B
Rationale: 2026 ACC/AHA HF guideline (class 1) and ADA Standards recommend SGLT2
inhibitors for HFrEF regardless of DM status and for renal protection down to eGFR ≥30.
Empagliflozin lowers A1c ~0.5 % and reduces HF hospitalization. Monitor for mycotic
infections and volume status; counsel hydration. Option A risks hyperkalemia (CKD).
Metformin is safe to eGFR 30 (C incorrect). No signs of volume overload (D
unnecessary).
,Q2. A 55-year-old male with resistant hypertension (BP 152/94 mmHg on maxed HCTZ
25 mg, amlodipine 10 mg, losartan 100 mg), CKD stage 3b (eGFR 34 mL/min), K 4.9
mmol/L. Which add-on therapy is best?
A. Spironolactone 25 mg daily
B. Hydralazine 25 mg BID
C. Clonidine 0.1 mg BID
D. Diltiazem 180 mg daily
Correct: B
Rationale: AHA 2026 resistant HTN algorithm: hydralazine (direct vasodilator) effective
with CKD and hyperkalemia risk. Spironolactone (A) contraindicated with K >4.5 and
eGFR <45. Clonidine (C) sedating; diltiazem (D) interacts with CKD. Monitor for reflex
tachycardia; add β-blocker if needed.
Q3. A 62-year-old female with type 2 DM, HFpEF (EF 55 %), BMI 34 kg/m², A1c 9.1 % on
metformin 2 g daily. Which agent addition provides greatest cardiometabolic benefit?
A. Insulin glargine 20 units nightly
B. Semaglutide 1 mg weekly SC
C. Glipizide 5 mg BID
D. Sitagliptin 100 mg daily
Correct: B
, Rationale: STEP-HFpEF trial 2026: GLP-1 RA reduces weight (~12 %), A1c (~1.2 %), and
HF symptoms. Semaglutide also CVD outcome proven. Insulin (A) causes weight gain;
glipizide (C) hypoglycemia risk; sitagliptin (D) weight-neutral, modest A1c reduction.
Q4. Patient with HFrEF (EF 30 %), on carvedilol 25 mg BID, lisinopril 20 mg,
spironolactone 25 mg, furosemide 40 mg BID. BNP 380 pg/mL (↓ from 550). Reports
fatigue, no edema, BP 96/62 mmHg, HR 52 bpm. Which change is most appropriate?
A. Reduce carvedilol to 12.5 mg BID
B. Increase lisinopril to 40 mg daily
C. Add digoxin 0.125 mg daily
D. Stop furosemide
Correct: A
Rationale: Guideline-directed beta-blockade target is maximally tolerated dose, not
absolute dose. Hypotension/bradycardia limit dose. Reduce carvedilol, reassess in 2
weeks. Digoxin (C) not first-line for asymptomatic low EF. Continue diuretic (D) for prior
fluid overload.
Q5. A 58-year-old male with T2DM, CKD 3a (eGFR 52), on atorvastatin 40 mg, reports
myalgia, CK 180 U/L (ULN 200). LDL 94 mg/dL. Which approach is best?
A. Switch to rosuvastatin 20 mg every other day
B. Add ezetimibe 10 mg daily and stop statin
C. Add bempedoic acid 180 mg daily
