# COMPREHENSIVE CLINICAL REASONING EXAMINATION ## Advanced Primary Care: Cardiovascular, Respiratory, and Multisystem Disorders (Part 3) --- **Target Question Count: 80** --- ### Question 1 A 72-year-old male with a history of hypertensi

# COMPREHENSIVE CLINICAL REASONING EXAMINATION ## Advanced Primary Care: Cardiovascular, Respiratory, and Multisystem Disorders (Part 3) --- **Target Question Count: 80** --- ### Question 1 A 72-year-old male with a history of hypertension, type 2 diabetes, and CKD stage 3 presents with a blood pressure of 168/94 mmHg. He is currently taking lisinopril 20 mg daily and hydrochlorothiazide 25 mg daily. His serum creatinine is 1.8 mg/dL. Which medication adjustment is most appropriate? A. Increase lisinopril to 40 mg daily B. Add amlodipine 5 mg daily C. Discontinue lisinopril and start amlodipine D. Increase hydrochlorothiazide to 50 mg daily RATIONALE️️: In a patient with elevated creatinine (suggesting renal impairment), adding a calcium channel blocker like amlodipine is safer than increasing the ACE inhibitor, which could further impair renal function. Thiazide diuretics may not be effective with GFR 30 mL/min, and his creatinine of 1.8 suggests moderate CKD. Calcium channel blockers are effective and safe in patients with renal impairment. ANSWER️️: B. Add amlodipine 5 mg daily --- ### Question 2 A 72-year-old female with heart failure with reduced ejection fraction (HFrEF) reports worsening dyspnea, weight gain of 5 pounds in 3 days, and increased ankle edema. Her current medications include lisinopril, carvedilol, and furosemide. Which action should the nurse take first? A. Increase the furosemide dose B. Assess for signs of fluid overload C. Notify the healthcare provider D. All of the above RATIONALE️️: The patient is experiencing signs of acute decompensated heart failure. The nurse should first assess for signs of fluid overload (jugular venous distension, crackles, edema), then notify the healthcare provider. Increasing the diuretic dose may be indicated but should be ordered by the provider. Comprehensive assessment and timely communication are essential. ANSWER️️: D. All of the above --- ### Question 3 A 68-year-old male with COPD presents with increased shortness of breath, cough, and purulent sputum. His oxygen saturation is 88% on room air. He has a history of frequent exacerbations. According to GOLD guidelines, which therapy is indicated for this patient? A. LAMA monotherapy B. LABA monotherapy C. LAMA + LABA + ICS combination therapy D. ICS monotherapy RATIONALE️️: Patients with COPD who have frequent exacerbations (≥ 2 per year) and high symptom burden are classified as Group E and should receive triple therapy with LAMA + LABA + ICS. This combination has been shown to reduce exacerbation risk and improve lung function compared to dual therapy or monotherapy. ANSWER️️: C. LAMA + LABA + ICS combination therapy --- ### Question 4 A 72-year-old female with a history of atrial fibrillation is on warfarin. Her INR today is 4.8. She reports no signs of bleeding. Which action is most appropriate? A. Administer vitamin K 5 mg orally B. Hold warfarin and monitor INR C. Decrease warfarin dose and recheck INR in 1 week D. Administer fresh frozen plasma RATIONALE️️: For an INR between 4.0 and 5.0 with no bleeding, the recommendation is to hold warfarin and monitor. Vitamin K is not typically indicated unless the INR is 5.0 or there is bleeding. The patient should be rechecked in 1-2 days. Fresh frozen plasma is reserved for life-threatening bleeding. ANSWER️️: B. Hold warfarin and monitor INR --- ### Question 5 A 65-year-old male with newly diagnosed hypertension has a blood pressure of 152/92 mmHg. His lab results show: creatinine 0.9 mg/dL, potassium 4.2 mEq/L, and glucose 110 mg/dL. Which medication is most appropriate for initial therapy? A. Hydrochlorothiazide 25 mg daily B. Lisinopril 10 mg daily C. Metoprolol 25 mg twice daily D. Amlodipine 5 mg daily RATIONALE️️: For a patient with hypertension and no comorbidities (e.g., diabetes, heart failure, CKD), thiazide diuretics are first-line therapy. Lisinopril and other ACE inhibitors are also options but are often recommended for patients with diabetes, CKD, or heart failure. The patient's lab values are within normal limits. ANSWER️️: A. Hydrochlorothiazide 25 mg daily --- ### Question 6 A 70-year-old female with type 2 diabetes and hypertension has a blood pressure of 138/82 mmHg. Her current medications include metformin 1,000 mg twice daily and lisinopril 20 mg daily. Her HbA1c is 7.2%. Which medication should be considered for additional cardiovascular and renal protection? A. Glipizide B. Pioglitazone C. Empagliflozin D. Insulin glargine RATIONALE️️: Empagliflozin (SGLT-2 inhibitor) has been shown to provide cardiovascular and renal benefits in patients with type 2 diabetes and established cardiovascular disease or multiple risk factors. It is preferred over sulfonylureas and thiazolidinediones in this population due to its proven benefits. ANSWER️️: C. Empagliflozin --- ### Question 7 A 58-year-old male with a history of hypertension and obesity presents with complaints of snoring, daytime sleepiness, and morning headaches. His wife reports that he stops breathing during sleep. Which condition should the nurse suspect? A. Narcolepsy B. Obstructive sleep apnea C. Restless leg syndrome D. Chronic insomnia RATIONALE️️: Obstructive sleep apnea is characterized by snoring, daytime sleepiness, and observed apneic episodes during sleep. Morning headaches are also common. Risk factors include obesity and hypertension. Diagnosis is confirmed with polysomnography. ANSWER️️: B. Obstructive sleep apnea --- ### Question 8 A 67-year-old male with suspected sleep apnea is referred for a sleep study. Which finding on physical examination supports the diagnosis? A. A narrowed oropharyngeal airway B. Decreased breath sounds C. Jugular venous distension D. Peripheral edema RATIONALE️️: A narrowed oropharyngeal airway is a common finding in patients with obstructive sleep apnea. Other findings may include obesity, hypertension, and a Mallampati score of III or IV. The physical exam can help identify patients at risk for OSA. ANSWER️️: A. A narrowed oropharyngeal airway --- ### Question 9 A 72-year-old female with COPD presents with increased shortness of breath and a cough productive of yellow sputum. She has a history of frequent exacerbations and is currently on triple therapy (LAMA + LABA + ICS). Which additional therapy should be considered? A. Azithromycin prophylaxis B. Theophylline C. Montelukast D. Oral corticosteroids long-term RATIONALE️️: In patients with COPD who have frequent exacerbations despite optimal inhaler therapy, low-dose azithromycin prophylaxis has been shown to reduce exacerbation frequency. Theophylline and montelukast are not first-line. Long-term oral corticosteroids are not recommended due to significant side effects. ANSWER️️: A. Azithromycin prophylaxis --- ### Question 10 A 60-year-old male presents with acute onset of sharp chest pain that worsens with inspiration. He is afebrile, and his ECG shows diffuse ST-segment elevation. Which condition is most likely? A. Acute myocardial infarction B. Pericarditis C. Pulmonary embolism D. Costochondritis RATIONALE️️: Pericarditis presents with sharp, pleuritic chest pain that worsens with inspiration and improves when leaning forward. Diffuse ST-segment elevation on ECG is characteristic. Myocardial infarction typically has localized ST-segment elevation and a different pain pattern. ANSWER️️: B. Pericarditis --- ### Question 11 A 65-year-old female with pericarditis is started on ibuprofen. Which finding indicates the treatment is effective? A. Resolution of chest pain B. Decrease in heart rate C. Improvement in ECG changes D. All of the above RATIONALE️️: Effective treatment of pericarditis is indicated by resolution of chest pain, normalization of heart rate, and resolution of ECG changes. NSAIDs are the mainstay of treatment, and colchicine may be added for recurrent cases. Symptom improvement is the most immediate indicator of effectiveness. ANSWER️️: D. All of the above --- ### Question 12 A 78-year-old male with a history of heart failure and CKD is started on spironolactone. Which laboratory value should be monitored closely? A. Serum potassium B. Serum sodium C. Serum creatinine D. Serum calcium RATIONALE️️: Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia, especially in patients with CKD or those on other potassium-sparing medications. Serum potassium should be monitored closely. Patients should be educated to avoid potassium-rich foods. ANSWER️️: A. Serum potassium --- ### Question 13 A 70-year-old male with a history of hypertension and hyperlipidemia presents with new onset of palpitations. His ECG shows atrial fibrillation with a ventricular rate of 130 beats per minute. He is hemodynamically stable. Which medication is most appropriate for rate control? A. Amiodarone B. Metoprolol C. Diltiazem D. Digoxin RATIONALE️️: In hemodynamically stable patients with atrial fibrillation, rate control is achieved with beta-blockers (metoprolol) or calcium channel blockers (diltiazem). Amiodarone is used for rhythm control, and digoxin is second-line. The choice depends on patient factors. ANSWER️️: B. Metoprolol --- ### Question 14 A 68-year-old male with atrial fibrillation is started on apixaban for stroke prevention. Which instruction should the nurse include? A. "Monitor for signs of bleeding." B. "Take the medication with food." C. "You will need monthly blood tests." D. "Avoid all green leafy vegetables." RATIONALE️️: Apixaban is a direct oral anticoagulant (DOAC) that increases the risk of bleeding. Patients should be monitored for signs of bleeding, including easy bruising, gum bleeding, and dark stools. Unlike warfarin, DOACs do not require routine INR monitoring or dietary restrictions. ANSWER️️: A. "Monitor for signs of bleeding." --- ### Question 15 A 62-year-old female with a history of asthma presents with a cough and wheezing that has worsened over the past month. She reports using her rescue inhaler more frequently. Her peak expiratory flow rate is 55% of personal best. Which step in asthma management should be considered? A. Step up therapy to a medium-dose ICS/LABA B. Add a leukotriene receptor antagonist C. Add a long-acting muscarinic antagonist (LAMA) D. Consider biologic therapy RATIONALE️️: For patients with asthma who are not controlled on low-dose ICS/LABA, stepping up to medium-dose ICS/LABA is the next step. Adding LAMA or biologic therapy may be considered in refractory cases. The patient's current symptoms indicate poor control. ANSWER️️: A. Step up therapy to a medium-dose ICS/LABA --- ### Question 16 A 55-year-old male with a history of hypertension and hyperlipidemia presents with chest discomfort that occurs with exertion and is relieved by rest. He has no history of coronary artery disease. His ECG is normal. Which test is most appropriate for further evaluation? A. Exercise stress test B. Coronary angiography C. Cardiac CT angiography D. Echocardiogram RATIONALE️️: For a patient with stable angina symptoms and no known CAD, an exercise stress test is the initial test of choice. If the patient cannot exercise, pharmacologic stress testing may be used. Coronary angiography is reserved for high-risk patients or those with abnormal stress tests. ANSWER️️: A. Exercise stress test --- ### Question 17 A 73-year-old female with COPD is prescribed a LAMA. Which medication is a LAMA? A. Tiotropium B. Formoterol C. Fluticasone D. Salmeterol RATIONALE️️: Tiotropium is a long-acting muscarinic antagonist (LAMA) used in the management of COPD. Formoterol and salmeterol are LABAs, and fluticasone is an ICS. LAMAs are first-line therapy for COPD and are preferred for their efficacy in reducing exacerbations. ANSWER️️: A. Tiotropium --- ### Question 18 A 66-year-old male with a history of heart failure presents with worsening dyspnea and an ejection fraction of 25%. His current medications include lisinopril, carvedilol, and furosemide. Which medication should be added for mortality benefit? A. Digoxin B. Spironolactone C. Hydralazine/isosorbide dinitrate D. Ivabradine RATIONALE️️: Spironolactone (an aldosterone antagonist) has been shown to reduce mortality in patients with HFrEF. Digoxin improves symptoms but not mortality. Hydralazine/isosorbide dinitrate is indicated in African American patients with HFrEF. Ivabradine may be used in certain patients but is not first-line. ANSWER️️: B. Spironolactone --- ### Question 19 A 75-year-old female with hypertension and diabetes is started on an ACE inhibitor. Which finding requires the nurse to hold the medication? A. Serum potassium of 5.5 mEq/L B. Serum creatinine of 1.2 mg/dL C. Blood pressure of 130/80 mmHg D. Heart rate of 72 beats per minute RATIONALE️️: A serum potassium of 5.5 mEq/L is elevated and may indicate hyperkalemia, a potential side effect of ACE inhibitors. The nurse should hold the medication and notify the healthcare provider. Renal function should also be monitored. ANSWER️️: A. Serum potassium of 5.5 mEq/L --- ### Question 20 A 64-year-old male with a history of coronary artery disease is on aspirin and clopidogrel. He is scheduled for elective surgery. When should the clopidogrel be held? A. 5 days before surgery B. 7 days before surgery C. 10 days before surgery D. 14 days before surgery RATIONALE️️: Clopidogrel should be held for 5-7 days before elective surgery to reduce the risk of bleeding. Aspirin may be continued in some cases. The timing depends on the surgery and the patient's risk of thrombosis. Coordination with the surgical and cardiology teams is essential. ANSWER️️: A. 5 days before surgery --- ### Question 21 A 69-year-old female with heart failure with preserved ejection fraction (HFpEF) reports dyspnea on exertion and fatigue. Her blood pressure is 148/86 mmHg. Which medication is most appropriate for symptom management and blood pressure control? A. ACE inhibitor B. Beta-blocker C. Diuretic D. Aldosterone antagonist RATIONALE️️: In HFpEF, diuretics are the mainstay for symptom management to reduce fluid overload. Blood pressure control is also important, and ACE inhibitors or ARBs may be used if there is an indication (e.g., hypertension, diabetes). Beta-blockers are not specifically indicated in HFpEF. ANSWER️️: C. Diuretic --- ### Question 22 A 72-year-old male with COPD presents with an acute exacerbation. His oxygen saturation is 84% on room air. Which oxygen delivery device is most appropriate? A. Nasal cannula at 2-4 L/min B. Simple face mask at 6-10 L/min C. Non-rebreather mask at 10-15 L/min D. Venturi mask at 24-28% FiO₂ RATIONALE️️: In patients with COPD, oxygen should be titrated to maintain a target saturation of 88-92%. A Venturi mask provides the most precise oxygen delivery and is preferred for patients at risk of CO₂ retention. Nasal cannula may also be used but titration is less precise. ANSWER️️: D. Venturi mask at 24-28% FiO₂ --- ### Question 23 A 68-year-old male with a history of hypertension and hyperlipidemia presents with an acute onset of severe headache, nausea, and visual changes. His blood pressure is 210/120 mmHg. Which condition should the nurse suspect? A. Migraine headache B. Hypertensive urgency C. Hypertensive emergency D. Subarachnoid hemorrhage RATIONALE️️: Hypertensive emergency is defined as severe hypertension (typically 180/120 mmHg) with target organ damage, including neurologic symptoms, cardiac ischemia, or renal impairment. This patient is at risk for stroke and requires immediate intervention. ANSWER️️: C. Hypertensive emergency --- ### Question 24 A 67-year-old female with a history of hypertension and atrial fibrillation is on warfarin. Her INR today is 6.8, and she reports bleeding gums. Which action is most appropriate? A. Hold warfarin and give vitamin K 5 mg orally B. Hold warfarin and monitor C. Give fresh frozen plasma D. Give vitamin K 10 mg intravenously RATIONALE️️: For an INR 5.0 with bleeding, the recommendation is to hold warfarin and give vitamin K (1-5 mg orally or IV depending on the severity of bleeding). Fresh frozen plasma is reserved for life-threatening bleeding. The healthcare provider should be notified. ANSWER️️: A. Hold warfarin and give vitamin K 5 mg orally --- ### Question 25 A 70-year-old male with COPD reports increased shortness of breath and cough. His sputum is purulent. He has no fever. Which medication is indicated for this exacerbation? A. Antibiotics B. Oral corticosteroids C. Bronchodilators D. All of the above RATIONALE️️: COPD exacerbation is treated with bronchodilators (increase frequency and dose), corticosteroids (systemic), and antibiotics if there are signs of infection (purulent sputum). All of these interventions are appropriate for this patient. ANSWER️️: D. All of the above --- ### Question 26 A 62-year-old female with a history of coronary artery disease is started on atorvastatin. Which finding requires monitoring? A. Liver function tests B. Renal function C. Thyroid function D. Complete blood count RATIONALE️️: Liver function tests should be monitored in patients on statins due to the risk of hepatotoxicity. Statins can also cause myopathy, which should be assessed clinically. Routine monitoring of liver enzymes is recommended at baseline and as clinically indicated. ANSWER️️: A. Liver function tests --- ### Question 27 A 74-year-old male with heart failure and CKD is on furosemide. Which finding indicates the medication is effective? A. Weight loss B. Decreased edema C. Improved dyspnea D. All of the above RATIONALE️️: Effective diuretic therapy is indicated by weight loss, decreased edema, and improved dyspnea. All of these findings suggest that fluid overload is being addressed and that the patient is responding to treatment. ANSWER️️: D. All of the above --- ### Question 28 A 58-year-old male with a history of obesity and hypertension presents with complaints of daytime sleepiness, snoring, and gasping during sleep. His BMI is 36. Which diagnostic test is most appropriate? A. Polysomnography (sleep study) B. Arterial blood gas C. Chest x-ray D. Echocardiogram RATIONALE️️: Polysomnography (sleep study) is the gold standard for diagnosing obstructive sleep apnea. It records physiological parameters during sleep to assess for apneic events and guide treatment decisions. Obesity and hypertension are significant risk factors. ANSWER️️: A. Polysomnography (sleep study) --- ### Question 29 A 65-year-old female with a history of asthma is prescribed an inhaled corticosteroid. Which instruction should the nurse include? A. "Rinse your mouth after each use." B. "Use the inhaler for immediate relief." C. "Take the medication only when you have symptoms." D. "Use the medication once daily for prevention." RATIONALE️️: Inhaled corticosteroids should be used regularly for prevention, not for immediate relief. Rinsing the mouth after each use helps prevent oral thrush. The patient should use the medication as prescribed, typically twice daily. ANSWER️️: A. "Rinse your mouth after each use." --- ### Question 30 A 71-year-old male with hypertension is on lisinopril. He reports a new cough. Which action is most appropriate? A. Increase lisinopril dose B. Add a cough suppressant C. Switch to an ARB (e.g., losartan) D. Discontinue all antihypertensive medications RATIONALE️️: A dry, persistent cough is a common side effect of ACE inhibitors. If the cough is bothersome, switching to an ARB is the appropriate action. ARBs provide similar cardiovascular benefits without affecting bradykinin levels. ANSWER️️: C. Switch to an ARB (e.g., losartan) --- ### Question 31 A 68-year-old female with a history of heart failure is on digoxin. Which finding indicates digoxin toxicity? A. Yellow-green halos around visual objects B. Nausea and vomiting C. Bradycardia D. All of the above RATIONALE️️: Digoxin toxicity can cause visual disturbances (yellow-green halos), gastrointestinal symptoms (nausea, vomiting), and cardiac manifestations (bradycardia, arrhythmias). Any of these findings should prompt a digoxin level check and evaluation. ANSWER️️: D. All of the above --- ### Question 32 A 66-year-old male with COPD is on tiotropium. Which side effect should the nurse monitor for? A. Dry mouth B. Cough C. Tachycardia D. Hyperglycemia RATIONALE️️: Tiotropium is a LAMA that can cause dry mouth due to its anticholinergic effects. Other side effects include urinary retention and constipation. It is generally well-tolerated and is a first-line treatment for COPD. ANSWER️️: A. Dry mouth --- ### Question 33 A 70-year-old male with a history of hypertension and hyperlipidemia presents with an acute onset of chest pain at rest. His ECG shows ST-segment depression. Which action is most appropriate? A. Administer aspirin, nitroglycerin, and oxygen B. Refer for a stress test C. Schedule for coronary angiography D. Discharge with follow-up RATIONALE️️: The patient is experiencing unstable angina or a non-ST-elevation myocardial infarction (NSTEMI). Immediate management includes aspirin, nitroglycerin, and oxygen. The patient should be admitted for further evaluation and management. ANSWER️️: A. Administer aspirin, nitroglycerin, and oxygen --- ### Question 34 A 75-year-old female with hypertension and diabetes is on lisinopril. Her serum creatinine increases from 1.0 to 1.4 mg/dL after starting therapy. Which action is most appropriate? A. Discontinue lisinopril B. Continue lisinopril and monitor renal function C. Decrease the lisinopril dose D. Switch to an ARB RATIONALE️️: A rise in serum creatinine of up to 30% after starting an ACE inhibitor or ARB is acceptable and usually stabilizes within 1-2 weeks. The nurse should continue the medication and monitor renal function. Discontinuation is not indicated unless the creatinine rises significantly. ANSWER️️: B. Continue lisinopril and monitor renal function --- ### Question 35 A 63-year-old male with a history of atrial fibrillation is started on dabigatran. Which instruction should the nurse include? A. "Take the medication with food." B. "Do not crush or chew the capsule." C. "You will need monthly monitoring of renal function." D. "All of the above." RATIONALE️️: Dabigatran capsules should not be crushed or chewed, as this can increase the risk of bleeding. Renal function should be monitored, especially in patients with renal impairment. The medication can be taken with or without food. ANSWER️️: B. "Do not crush or chew the capsule." --- ### Question 36 A 72-year-old male with COPD is on inhaled corticosteroids and a LABA. He reports a cough and hoarseness. Which intervention is most appropriate? A. Discontinue the ICS B. Rinse mouth after using the inhaler C. Add a leukotriene receptor antagonist D. Increase the ICS dose RATIONALE️️: Hoarseness and cough are common side effects of inhaled corticosteroids due to deposition of the medication in the oropharynx. Rinsing the mouth after each use can help prevent these side effects. If symptoms persist, the technique should be evaluated. ANSWER️️: B. Rinse mouth after using the inhaler --- ### Question 37 A 78-year-old female with heart failure and CKD is on furosemide and spironolactone. Which finding requires immediate action? A. Serum potassium of 5.8 mEq/L B. Serum creatinine of 1.8 mg/dL C. Blood pressure of 130/80 mmHg D. Heart rate of 68 beats per minute RATIONALE️️: A serum potassium of 5.8 mEq/L is elevated and may indicate hyperkalemia, a risk with spironolactone especially in patients with CKD. The nurse should hold the spironolactone and notify the healthcare provider. Elevated potassium can lead to life-threatening arrhythmias. ANSWER️️: A. Serum potassium of 5.8 mEq/L --- ### Question 38 A 69-year-old male with a history of coronary artery disease is on atorvastatin. He reports muscle aches. Which action is most appropriate? A. Stop the statin immediately B. Check creatine kinase (CK) levels C. Reassure the patient and continue therapy D. Switch to a different statin RATIONALE️️: Muscle aches in a patient on a statin should be evaluated for statin-induced myopathy. Checking CK levels can help differentiate between benign myalgia and myopathy. If CK is elevated, the statin may need to be adjusted or switched. ANSWER️️: B. Check creatine kinase (CK) levels --- ### Question 39 A 76-year-old female with COPD presents with an exacerbation. She is started on prednisone. Which instruction should the nurse include? A. "Do not stop the medication abruptly." B. "Take the medication with food." C. "Monitor for hyperglycemia." D. "All of the above." RATIONALE️️: Prednisone should not be stopped abruptly due to the risk of adrenal insufficiency. Taking it with food minimizes gastrointestinal upset. It can cause hyperglycemia, especially in patients with diabetes or prediabetes. All of these instructions are important. ANSWER️️: D. "All of the above." --- ### Question 40 A 64-year-old male with a history of hypertension presents with a blood pressure of 142/88 mmHg. He reports no symptoms. Which lifestyle modification is most important? A. Sodium restriction B. Weight loss C. Physical activity D. All of the above RATIONALE️️: Lifestyle modifications for hypertension include sodium restriction, weight loss (if overweight), and physical activity. All of these interventions contribute to blood pressure reduction and cardiovascular risk reduction. ANSWER️️: D. All of the above --- ### Question 41 A 73-year-old male with heart failure is on carvedilol. Which side effect should the nurse monitor for? A. Bradycardia B. Hypotension C. Fatigue D. All of the above RATIONALE️️: Carvedilol is a beta-blocker that can cause bradycardia, hypotension, and fatigue. These side effects should be monitored, especially during dose titration. The patient should be educated to report any concerning symptoms. ANSWER️️: D. All of the above --- ### Question 42 A 67-year-old female with a history of asthma is prescribed an ICS/LABA combination inhaler. Which instruction is most important? A. "Use the inhaler for immediate relief of symptoms." B. "Rinse your mouth after using the inhaler." C. "Use the inhaler only when you have symptoms." D. "Shake the inhaler vigorously before each use." RATIONALE️️: Rinsing the mouth after using an ICS/LABA inhaler helps prevent oral thrush. The inhaler should be used regularly for prevention, not for immediate symptom relief. Rescue inhalers (SABAs) are used for acute symptoms. ANSWER️️: B. "Rinse your mouth after using the inhaler." --- ### Question 43 A 71-year-old male with a history of hypertension is on amlodipine. He reports ankle swelling. Which action is most appropriate? A. Discontinue amlodipine B. Add a diuretic C. Reduce the dose of amlodipine D. Switch to a different calcium channel blocker RATIONALE️️: Ankle swelling is a common side effect of calcium channel blockers. Adding a diuretic can help reduce edema. If symptoms persist, switching to another class of antihypertensive may be considered. ANSWER️️: B. Add a diuretic --- ### Question 44 A 66-year-old female with COPD and a history of frequent exacerbations is started on roflumilast. Which side effect should the nurse monitor for? A. Nausea and diarrhea B. Cough C. Tachycardia D. Hyperglycemia RATIONALE️️: Roflumilast is a phosphodiesterase-4 inhibitor used in COPD. Nausea and diarrhea are common side effects. It is used for patients with frequent exacerbations, especially those with chronic bronchitis. The dose should be titrated to reduce gastrointestinal side effects. ANSWER️️: A. Nausea and diarrhea --- ### Question 45 A 79-year-old male with heart failure and CKD is on digoxin. His digoxin level is 2.2 ng/mL. Which finding is most concerning? A. Nausea B. Bradycardia C. Visual changes D. All of the above RATIONALE️️: Digoxin toxicity is associated with levels 2.0 ng/mL. Symptoms include nausea, vomiting, bradycardia, and visual disturbances (yellow-green halos). All of these findings are concerning and indicate toxicity requiring evaluation. ANSWER️️: D. All of the above --- ### Question 46 A 68-year-old male with a history of coronary artery disease is on aspirin and clopidogrel. He is scheduled for a colonoscopy with polypectomy. Which action is most appropriate? A. Continue both medications B. Hold clopidogrel 5 days before the procedure C. Hold aspirin 7 days before the procedure D. Hold both medications 5 days before the procedure RATIONALE️️: For procedures with a high risk of bleeding (e.g., polypectomy), antiplatelet agents should be held. Clopidogrel is typically held for 5-7 days, while aspirin may be continued in some cases. The decision depends on the patient's thrombotic risk and the procedure's bleeding risk. ANSWER️️: B. Hold clopidogrel 5 days before the procedure --- ### Question 47 A 74-year-old female with COPD is on an ICS/LABA combination. She reports a cough and hoarseness. Which action is most appropriate? A. Discontinue the ICS B. Rinse mouth after using the inhaler C. Add a leukotriene receptor antagonist D. Increase the ICS dose RATIONALE️️: Hoarseness and cough are common side effects of inhaled corticosteroids due to deposition in the oropharynx. Rinsing the mouth after each use can help prevent these side effects. If symptoms persist, the technique should be evaluated. ANSWER️️: B. Rinse mouth after using the inhaler --- ### Question 48 A 62-year-old male with hypertension and diabetes is on lisinopril and metformin. Which finding requires monitoring? A. Serum potassium B. Serum creatinine C. Blood glucose D. All of the above RATIONALE️️: Lisinopril can affect potassium and renal function, and metformin can affect blood glucose and renal function. All of these parameters should be monitored regularly to ensure safe and effective therapy. ANSWER️️: D. All of the above --- ### Question 49 A 77-year-old male with heart failure is on sacubitril/valsartan (Entresto). Which side effect should the nurse monitor for? A. Hypotension B. Hyperkalemia C. Angioedema D. All of the above RATIONALE️️: Sacubitril/valsartan can cause hypotension, hyperkalemia, and angioedema. It should not be used with ACE inhibitors due to the risk of angioedema. Blood pressure, potassium, and renal function should be monitored regularly. ANSWER️️: D. All of the above --- ### Question 50 A 65-year-old female with a history of hypertension is on lisinopril. She reports a new onset of swelling of the lips and tongue. Which action is most appropriate? A. Continue lisinopril and monitor B. Discontinue lisinopril and seek emergency care C. Add an antihistamine D. Switch to an ARB RATIONALE️️: Swelling of the lips and tongue indicates angioedema, a potentially life-threatening allergic reaction to ACE inhibitors. The medication should be discontinued immediately, and emergency care should be sought. Angioedema requires immediate intervention. ANSWER️️: B. Discontinue lisinopril and seek emergency care --- ### Question 51 A 68-year-old male with a history of hypertension and type 2 diabetes has a HbA1c of 8.5% on metformin and glipizide. He has CKD (eGFR 35 mL/min). Which medication adjustment is most appropriate? A. Increase glipizide dose B. Start insulin therapy C. Consider an SGLT-2 inhibitor D. Add a DPP-4 inhibitor RATIONALE️️: SGLT-2 inhibitors have shown renal and cardiovascular benefits in patients with type 2 diabetes and CKD. They are preferred in this population due to their proven benefits. DPP-4 inhibitors are also options but do not have the same level of evidence for renal protection. Metformin is contraindicated at this GFR. ANSWER️️: C. Consider an SGLT-2 inhibitor --- ### Question 52 A 72-year-old female with heart failure and CKD is on furosemide 80 mg daily. She reports muscle cramps and fatigue. Her potassium is 3.2 mEq/L. Which action is most appropriate? A. Increase furosemide dose B. Add a potassium-sparing diuretic C. Start oral potassium supplementation D. Decrease furosemide dose RATIONALE️️: The patient is experiencing hypokalemia (potassium 3.2 mEq/L), a side effect of furosemide. Oral potassium supplementation is indicated to correct the deficit. The dose of furosemide may need to be adjusted, but potassium supplementation is the priority. ANSWER️️: C. Start oral potassium supplementation --- ### Question 53 A 66-year-old male with a history of hypertension and hyperlipidemia presents with a new onset of lower extremity edema. His blood pressure is 148/86 mmHg. He has no signs of heart failure. Which medication is most likely causing the edema? A. Lisinopril B. Amlodipine C. Metoprolol D. Hydrochlorothiazide RATIONALE️️: Amlodipine is a calcium channel blocker that can cause peripheral edema due to vasodilation. ACE inhibitors, beta-blockers, and thiazide diuretics are less likely to cause peripheral edema. The edema is often dose-dependent. ANSWER️️: B. Amlodipine --- ### Question 54 A 70-year-old male with a history of hypertension and diabetes is on lisinopril 20 mg daily and metformin 1,000 mg twice daily. His blood pressure is 132/80 mmHg, and his HbA1c is 6.8%. Which medication should be added for additional cardiovascular protection? A. Atorvastatin 20 mg daily B. Glipizide 5 mg daily C. Pioglitazone 15 mg daily D. Aspirin 81 mg daily RATIONALE️️: Atorvastatin is indicated for patients with diabetes and hypertension for cardiovascular risk reduction. Statin therapy is recommended for patients with diabetes regardless of baseline LDL levels. Aspirin may be considered for primary prevention in select patients. ANSWER️️: A. Atorvastatin 20 mg daily --- ### Question 55 A 68-year-old female with COPD is on tiotropium and salmeterol. She reports worsening dyspnea and increased sputum production. Her oxygen saturation is 90% on room air. Which action is most appropriate? A. Increase the dose of tiotropium B. Add an inhaled corticosteroid C. Start antibiotics and oral corticosteroids D. Refer for pulmonary rehabilitation RATIONALE️️: The patient is experiencing a COPD exacerbation requiring treatment with antibiotics (if signs of infection) and systemic corticosteroids. Adding an ICS may be indicated for long-term management but not for acute exacerbation. Pulmonary rehabilitation is for stable COPD. ANSWER️️: C. Start antibiotics and oral corticosteroids --- ### Question 56 A 75-year-old male with a history of hypertension and heart failure is on carvedilol and lisinopril. He reports dizziness and lightheadedness. His blood pressure is 100/60 mmHg. Which action is most appropriate? A. Increase carvedilol dose B. Decrease lisinopril dose C. Hold carvedilol and notify the healthcare provider D. Add a diuretic RATIONALE️️: The patient is experiencing hypotension, likely due to the combination of carvedilol and lisinopril. The nurse should hold the carvedilol and notify the healthcare provider. The provider may adjust the dose of one or both medications. ANSWER️️: C. Hold carvedilol and notify the healthcare provider --- ### Question 57 A 64-year-old female with a history of asthma is on an ICS/LABA combination. She reports that her symptoms are well-controlled. Which finding indicates good asthma control? A. Use of rescue inhaler more than twice per week B. No limitation in daily activities C. Nocturnal awakenings due to asthma D. Peak flow 80% of personal best RATIONALE️️: Well-controlled asthma is characterized by symptoms less than twice per week, no nocturnal awakenings, no limitation in daily activities, and peak flow 80% of personal best. The patient's report of good control should be confirmed with objective measures. ANSWER️️: B. No limitation in daily activities --- ### Question 58 A 71-year-old male with a history of hypertension is on hydrochlorothiazide. He reports muscle weakness and fatigue. His potassium is 3.0 mEq/L. Which action is most appropriate? A. Increase hydrochlorothiazide dose B. Add a potassium-sparing diuretic C. Start oral potassium supplementation D. Discontinue hydrochlorothiazide RATIONALE️️: The patient is experiencing hypokalemia, a side effect of thiazide diuretics. Oral potassium supplementation is indicated to correct the deficit. The dose of hydrochlorothiazide may need to be adjusted, but potassium supplementation is the priority. ANSWER️️: C. Start oral potassium supplementation --- ### Question 59 A 69-year-old female with a history of heart failure is on digoxin. She reports nausea and visual changes. Which action is most appropriate? A. Increase digoxin dose B. Check digoxin level C. Add a diuretic D. Start antiemetic RATIONALE️️: Nausea and visual changes are signs of digoxin toxicity. The nurse should check the digoxin level and notify the healthcare provider. Digoxin toxicity is a serious condition that requires dose adjustment or discontinuation. ANSWER️️: B. Check digoxin level --- ### Question 60 A 67-year-old male with a history of COPD is on an ICS/LABA combination. He reports a cough and sore throat. Which intervention is most appropriate? A. Discontinue the ICS B. Rinse mouth after using the inhaler C. Add a leukotriene receptor antagonist D. Increase the ICS dose RATIONALE️️: Sore throat and cough are common side effects of inhaled corticosteroids due to deposition in the oropharynx. Rinsing the mouth after each use can help prevent these side effects. If symptoms persist, the technique should be evaluated. ANSWER️️: B. Rinse mouth after using the inhaler --- ### Question 61 A 73-year-old female with a history of hypertension is on lisinopril. She reports a cough that has persisted for 3 weeks. Which action is most appropriate? A. Continue lisinopril and monitor B. Switch to an ARB C. Add a cough suppressant D. Discontinue lisinopril RATIONALE️️: A dry, persistent cough is a common side effect of ACE inhibitors. If the cough is bothersome, switching to an ARB is appropriate. ARBs provide similar cardiovascular benefits without affecting bradykinin levels. ANSWER️️: B. Switch to an ARB --- ### Question 62 A 68-year-old male with a history of hypertension and diabetes is on metformin and lisinopril. His serum creatinine is 1.6 mg/dL. Which medication should be held? A. Metformin B. Lisinopril C. Both metformin and lisinopril D. Neither medication RATIONALE️️: Metformin is contraindicated in patients with severe renal impairment (eGFR 30 mL/min) and should be used with caution in patients with eGFR 30-45 mL/min. A serum creatinine of 1.6 mg/dL may indicate moderate renal impairment, and metformin should be held or the dose adjusted. Lisinopril may be continued with monitoring. ANSWER️️: A. Metformin --- ### Question 63 A 70-year-old female with COPD is on tiotropium. She reports dry mouth. Which intervention is most appropriate? A. Discontinue tiotropium B. Increase fluid intake C. Add a bronchodilator D. Use sugar-free candy or gum RATIONALE️️: Dry mouth is a common side effect of tiotropium (a LAMA) due to its anticholinergic effects. Increasing fluid intake and using sugar-free candy or gum can help relieve symptoms. The medication should not be discontinued without consulting the healthcare provider. ANSWER️️: D. Use sugar-free candy or gum --- ### Question 64 A 66-year-old male with a history of coronary artery disease is on aspirin and clopidogrel. He reports dark, tarry stools. Which action is most appropriate? A. Continue medications and monitor B. Hold clopidogrel and notify the healthcare provider C. Hold aspirin and notify the healthcare provider D. Hold both medications and notify the healthcare provider RATIONALE️️: Dark, tarry stools indicate gastrointestinal bleeding, a serious complication of antiplatelet therapy. The nurse should hold both medications and notify the healthcare provider immediately. The patient may need further evaluation and treatment. ANSWER️️: D. Hold both medications and notify the healthcare provider --- ### Question 65 A 72-year-old female with heart failure and CKD is on furosemide. She reports a weight gain of 4 pounds in 3 days. Which action is most appropriate? A. Increase furosemide dose B. Assess for signs of fluid overload C. Notify the healthcare provider D. All of the above RATIONALE️️: Weight gain of 4 pounds in 3 days indicates fluid retention and worsening heart failure. The nurse should assess for signs of fluid overload, notify the healthcare provider, and prepare to increase the diuretic dose as ordered. ANSWER️️: D. All of the above --- ### Question 66 A 68-year-old male with a history of hypertension and hyperlipidemia presents with a new onset of chest pain that is relieved by rest. His ECG is normal. Which test is most appropriate for further evaluation? A. Exercise stress test B. Coronary angiography C. Cardiac CT angiography D. Echocardiogram RATIONALE️️: For a patient with stable angina symptoms and no known CAD, an exercise stress test is the initial test of choice. If the patient cannot exercise, pharmacologic stress testing may be used. Coronary angiography is reserved for high-risk patients or those with abnormal stress tests. ANSWER️️: A. Exercise stress test --- ### Question 67 A 75-year-old female with a history of hypertension is on hydrochlorothiazide. She reports increased urination and nocturia. Which instruction is most appropriate? A. "Take the medication at bedtime." B. "Take the medication in the morning." C. "Reduce your fluid intake." D. "Skip the medication if you have nocturia." RATIONALE️️: Thiazide diuretics should be taken in the morning to avoid nighttime urination. The patient should be advised to take the medication as prescribed and to report any concerning symptoms. Reducing fluid intake is not recommended without consulting the healthcare provider. ANSWER️️: B. "Take the medication in the morning." --- ### Question 68 A 64-year-old female with a history of asthma is on an ICS/LABA combination. She reports that her symptoms are worse at night. Which action is most appropriate? A. Increase the dose of the ICS/LABA B. Add a leukotriene receptor antagonist C. Evaluate for GERD or sinusitis D. Switch to a different ICS/LABA RATIONALE️️: Nocturnal asthma symptoms may indicate poor asthma control. GERD and sinusitis are common causes of nocturnal symptoms and should be evaluated. The nurse should also assess adherence and inhaler technique before adjusting therapy. ANSWER️️: C. Evaluate for GERD or sinusitis --- ### Question 69 A 71-year-old male with a history of heart failure is on carvedilol and lisinopril. He reports fatigue and dizziness. His blood pressure is 104/62 mmHg. Which action is most appropriate? A. Increase carvedilol dose B. Decrease lisinopril dose C. Hold carvedilol and notify the healthcare provider D. Add a diuretic RATIONALE️️: The patient is experiencing hypotension, likely due to the combination of carvedilol and lisinopril. The nurse should hold the carvedilol and notify the healthcare provider. The provider may adjust the dose of one or both medications. ANSWER️️: C. Hold carvedilol and notify the healthcare provider --- ### Question 70 A 67-year-old female with a history of COPD is on an ICS/LABA combination. She reports a cough and hoarseness. Which intervention is most appropriate? A. Discontinue the ICS B. Rinse mouth after using the inhaler C. Add a leukotriene receptor antagonist D. Increase the ICS dose RATIONALE️️: Hoarseness and cough are common side effects of inhaled corticosteroids due to deposition in the oropharynx. Rinsing the mouth after each use can help prevent these side effects. If symptoms persist, the technique should be evaluated. ANSWER️️: B. Rinse mouth after using the inhaler --- ### Question 71 A 72-year-old male with a history of hypertension is on amlodipine. He reports ankle swelling. Which action is most appropriate? A. Discontinue amlodipine B. Add a diuretic C. Reduce the dose of amlodipine D. Switch to a different calcium channel blocker RATIONALE️️: Ankle swelling is a common side effect of calcium channel blockers. Adding a diuretic can help reduce edema. If symptoms persist, switching to another class of antihypertensive may be considered. ANSWER️️: B. Add a diuretic --- ### Question 72 A 69-year-old female with a history of heart failure is on digoxin. She reports nausea and visual changes. Which action is most appropriate? A. Increase digoxin dose B. Check digoxin level C. Add a diuretic D. Start antiemetic RATIONALE️️: Nausea and visual changes are signs of digoxin toxicity. The nurse should check the digoxin level and notify the healthcare provider. Digoxin toxicity is a serious condition that requires dose adjustment or discontinuation. ANSWER️️: B. Check digoxin level --- ### Question 73 A 66-year-old male with a history of hypertension and hyperlipidemia presents with a new onset of chest pain that is relieved by rest. His ECG is normal. Which test is most appropriate for further evaluation? A. Exercise stress test B. Coronary angiography C. Cardiac CT angiography D. Echocardiogram RATIONALE️️: For a patient with stable angina symptoms and no known CAD, an exercise stress test is the initial test of choice. If the patient cannot exercise, pharmacologic stress testing may be used. Coronary angiography is reserved for high-risk patients or those with abnormal stress tests. ANSWER️️: A. Exercise stress test --- ### Question 74 A 75-year-old female with a history of hypertension is on hydrochlorothiazide. She reports increased urination and nocturia. Which instruction is most appropriate? A. "Take the medication at bedtime." B. "Take the medication in the morning." C. "Reduce your fluid intake." D. "Skip the medication if you have nocturia." RATIONALE️️: Thiazide diuretics should be taken in the morning to avoid nighttime urination. The patient should be advised to take the medication as prescribed and to report any concerning symptoms. Reducing fluid intake is not recommended without consulting the healthcare provider. ANSWER️️: B. "Take the medication in the morning." --- ### Question 75 A 64-year-old female with a history of asthma is on an ICS/LABA combination. She reports that her symptoms are worse at night. Which action is most appropriate? A. Increase the dose of the ICS/LABA B. Add a leukotriene receptor antagonist C. Evaluate for GERD or sinusitis D. Switch to a different ICS/LABA RATIONALE️️: Nocturnal asthma symptoms may indicate poor asthma control. GERD and sinusitis are common causes of nocturnal symptoms and should be evaluated. The nurse should also assess adherence and inhaler technique before adjusting therapy. ANSWER️️: C. Evaluate for GERD or sinusitis --- ### Question 76 A 68-year-old male with a history of hypertension and hyperlipidemia presents with an acute onset of chest pain at rest. His ECG shows ST-segment depression. Which action is most appropriate? A. Administer aspirin, nitroglycerin, and oxygen B. Refer for a stress test C. Schedule for coronary angiography D. Discharge with follow-up RATIONALE️️: The patient is experiencing unstable angina or a non-ST-elevation myocardial infarction (NSTEMI). Immediate management includes aspirin, nitroglycerin, and oxygen. The patient should be admitted for further evaluation and management. ANSWER️️: A. Administer aspirin, nitroglycerin, and oxygen --- ### Question 77 A 75-year-old female with hypertension and diabetes is on lisinopril. Her serum creatinine increases from 1.0 to 1.4 mg/dL after starting therapy. Which action is most appropriate? A. Discontinue lisinopril B. Continue lisinopril and monitor renal function C. Decrease the lisinopril dose D. Switch to an ARB RATIONALE️️: A rise in serum creatinine of up to 30% after starting an ACE inhibitor or ARB is acceptable and usually stabilizes within 1-2 weeks. The nurse should continue the medication and monitor renal function. Discontinuation is not indicated unless the creatinine rises significantly. ANSWER️️: B. Continue lisinopril and monitor renal function --- ### Question 78 A 63-year-old male with a history of atrial fibrillation is started on dabigatran. Which instruction should the nurse include? A. "Take the medication with food." B. "Do not crush or chew the capsule." C. "You will need monthly monitoring of renal function." D. "All of the above." RATIONALE️️: Dabigatran capsules should not be crushed or chewed, as this can increase the risk of bleeding. Renal function should be monitored, especially in patients with renal impairment. The medication can be taken with or without food. ANSWER️️: B. "Do not crush or chew the capsule." --- ### Question 79 A 72-year-old male with COPD is on inhaled corticosteroids and a LABA. He reports a cough and hoarseness. Which intervention is most appropriate? A. Discontinue the ICS B. Rinse mouth after using the inhaler C. Add a leukotriene receptor antagonist D. Increase the ICS dose RATIONALE️️: Hoarseness and cough are common side effects of inhaled corticosteroids due to deposition of the medication in the oropharynx. Rinsing the mouth after each use can help prevent these side effects. If symptoms persist, the technique should be evaluated. ANSWER️️: B. Rinse mouth after using the inhaler --- ### Question 80 A 78-year-old female with heart failure and CKD is on furosemide and spironolactone. Which finding requires immediate action? A. Serum potassium of 5.8 mEq/L B. Serum creatinine of 1.8 mg/dL C. Blood pressure of 130/80 mmHg D. Heart rate of 68 beats per minute RATIONALE️️: A serum potassium of 5.8 mEq/L is elevated and may indicate hyperkalemia, a risk with spironolactone especially in patients with CKD. The nurse should hold the spironolactone and notify the healthcare provider. Elevated potassium can lead to life-threatening arrhythmias. ANSWER️️: A. Serum potassium of 5.8 mEq/L --- **END OF EXAMINATION**