NURS 5434 Final Exam 2026: Family Nurse
Practitioner III (Family III) Test Bank | University of
Texas at Arlington (UTA) - Verified Questions,
Answers & Detailed Rationales
1. A 45-year-old patient with a history of hypertension and type 2 diabetes presents with a blood
pressure of 148/92 mmHg, serum creatinine of 1.3 mg/dL, and urine albumin-to-creatinine ratio of
45 mg/g. Current medications include lisinopril 20 mg daily, metformin 1000 mg twice daily, and
atorvastatin 20 mg daily. Which of the following is the most appropriate modification to the
antihypertensive regimen to optimize renoprotection?
A. Add amlodipine 5 mg daily
B. Increase lisinopril to 40 mg daily
C. Discontinue lisinopril and start losartan 50 mg daily
D. Add hydrochlorothiazide 12.5 mg daily
Answer: B
Rationale: The patient has stage 2 hypertension with albuminuria indicating chronic kidney disease
(CKD) stage 3a. The KDIGO guidelines recommend maximizing the dose of ACE inhibitors (or ARBs) as
first-line renoprotective therapy before adding other agents. Increasing lisinopril to the maximum
tolerated dose (40 mg) is preferred over adding amlodipine or thiazide, which are second-line.
Switching to losartan is not indicated if ACE inhibitor is tolerated.
2. A 30-year-old patient presents with acute onset of unilateral, throbbing headache associated with
nausea, photophobia, and phonophobia, lasting 6 hours. The patient reports similar episodes 2-3
times per month for the past year. Neurological exam is normal. Which of the following is the most
appropriate acute treatment recommendation?
A. Sumatriptan 50 mg oral tablet at onset, may repeat after 2 hours if no response
B. Rizatriptan 10 mg oral disintegrating tablet at onset, may repeat once after 2 hours
C. Ibuprofen 800 mg oral at onset, with metoclopramide 10 mg for nausea
D. Sumatriptan 6 mg subcutaneous injection at onset, may repeat once after 1 hour
Answer: D
Rationale: The presentation is consistent with migraine without aura. Given the severity (throbbing,
nausea, photophobia) and failure to respond to simple analgesics (implied by frequent episodes), a
triptan is indicated. Subcutaneous sumatriptan provides the fastest and most effective relief for acute
migraine, especially when nausea limits oral intake. Oral triptans (A, B) are appropriate for
mild-to-moderate attacks but are less effective with significant nausea. Ibuprofen with metoclopramide
(C) is a reasonable first-line but may be insufficient for this severity.
Page 1
,3. A 55-year-old patient with a 30-pack-year smoking history and a body mass index of 32 kg/m²
presents with a persistent cough and dyspnea on exertion. Spirometry shows FEV/FVC ratio of
0.65 and FEV 55% of predicted. The patient has had two exacerbations in the past year requiring
antibiotics and oral corticosteroids. Which of the following pharmacologic interventions is most
likely to reduce exacerbation frequency?
A. Initiate tiotropium monotherapy
B. Initiate fluticasone/salmeterol combination
C. Initiate budesonide/formoterol as maintenance and reliever therapy
D. Initiate roflumilast 500 mcg daily
Answer: B
Rationale: The patient has GOLD stage 2 COPD (FEV • 50-79%) with frequent exacerbations ("e2/year)
and symptoms. According to GOLD 2024 guidelines, for group E patients (high exacerbation risk),
initial therapy with LABA/LAMA is recommended, but if blood eosinophils 300 cells/µL (likely given
smoking history), ICS/LABA is preferred. Fluticasone/salmeterol (ICS/LABA) reduces exacerbation risk
in patients with eosinophilic phenotype. Tiotropium monotherapy (A) is for group B.
Budesonide/formoterol SMART (C) is not first-line in COPD. Roflumilast (D) is reserved for severe
COPD with chronic bronchitis and frequent exacerbations despite optimal therapy.
4. A 28-year-old patient with no significant medical history presents with a 3-day history of
dysuria, urinary frequency, and suprapubic discomfort. Urinalysis shows positive nitrites and
leukocyte esterase, with >50 WBCs/hpf and moderate bacteria. The patient is not pregnant and has
no known drug allergies. Which of the following is the most appropriate empiric antibiotic
regimen?
A. Nitrofurantoin 100 mg twice daily for 5 days
B. Ciprofloxacin 250 mg twice daily for 3 days
C. Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days
D. Amoxicillin-clavulanate 875/125 mg twice daily for 7 days
Answer: A
Rationale: The patient has uncomplicated acute cystitis. The IDSA guidelines recommend nitrofurantoin
(5 days), trimethoprim-sulfamethoxazole (3 days if local resistance <20%), or fosfomycin as first-line.
However, given the high prevalence of TMP-SMX resistance in many regions, nitrofurantoin is
preferred. Ciprofloxacin (B) is reserved for complicated UTI or pyelonephritis due to
fluoroquinolone-sparing strategies. Amoxicillin-clavulanate (D) is less effective for E. coli and has
higher resistance rates.
5. A 62-year-old patient with a history of coronary artery disease and heart failure with reduced
ejection fraction (HFrEF, LVEF 35%) is on optimal medical therapy including lisinopril 40 mg,
carvedilol 25 mg twice daily, and spironolactone 25 mg daily. The patient has persistent NYHA
class II symptoms and a heart rate of 72 bpm. Which of the following additional therapies has been
shown to reduce mortality in this population?
A. Ivabradine 5 mg twice daily
B. Sacubitril/valsartan 24/26 mg twice daily
C. Digoxin 0.125 mg daily
Page 2
,D. Dapagliflozin 10 mg daily
Answer: D
Rationale: In HFrEF patients on optimal medical therapy (ACEi/ARB, beta-blocker, MRA), the addition
of an SGLT2 inhibitor (dapagliflozin or empagliflozin) is now a Class I recommendation based on
DAPA-HF and EMPEROR-Reduced trials showing reduced cardiovascular death and HF
hospitalization. Sacubitril/valsartan (B) is indicated if ACEi/ARB is tolerated but patient remains
symptomatic, but it would replace lisinopril, not be added. Ivabradine (A) is for patients with heart rate
70 bpm on beta-blocker; here HR is 72, but dapagliflozin has stronger mortality benefit. Digoxin (C)
reduces hospitalizations but not mortality.
6. A 50-year-old patient with type 2 diabetes (HbA1c 8.2%) and established atherosclerotic
cardiovascular disease (ASCVD) is currently on metformin 1000 mg twice daily and empagliflozin
10 mg daily. The patient has a BMI of 31 kg/m² and eGFR 65 mL/min/1.73 m². Which of the
following agents, when added, has demonstrated cardiovascular benefit in this population?
A. Liraglutide 1.8 mg subcutaneously daily
B. Glipizide 5 mg daily
C. Sitagliptin 100 mg daily
D. Insulin glargine 10 units at bedtime
Answer: A
Rationale: For patients with type 2 diabetes and ASCVD on metformin and an SGLT2 inhibitor, adding a
GLP-1 receptor agonist with proven cardiovascular benefit (e.g., liraglutide, semaglutide) is
recommended by the ADA guidelines. The LEADER trial demonstrated liraglutide reduces major
adverse cardiovascular events. Glipizide (B) and insulin glargine (D) have neutral cardiovascular
effects but may cause weight gain and hypoglycemia. Sitagliptin (C) is cardiovascular neutral but not
preferred given the need for additional risk reduction.
7. A 40-year-old patient with a history of asthma presents with symptoms of rhinitis, sneezing, and
itchy eyes occurring in the spring. The patient has tried loratadine 10 mg daily with minimal relief.
Which of the following is the most appropriate next step in management?
A. Add montelukast 10 mg daily
B. Switch to fexofenadine 180 mg daily
C. Add fluticasone propionate nasal spray 2 sprays each nostril daily
D. Refer for allergy immunotherapy
Answer: C
Rationale: The patient has moderate-to-severe seasonal allergic rhinitis not controlled with oral
antihistamines. The ARIA guidelines recommend intranasal corticosteroids as first-line therapy for
moderate-to-severe symptoms, especially when nasal congestion is prominent. Adding fluticasone nasal
spray is superior to switching antihistamines (B) or adding montelukast (A), which is less effective.
Immunotherapy (D) is reserved for refractory cases after optimal pharmacotherapy.
Page 3
, 8. A 35-year-old patient with a history of anxiety presents with palpitations, diaphoresis, and
tremor lasting 30 minutes. The patient is afebrile, HR 110 bpm, BP 130/80 mmHg. ECG shows
sinus tachycardia. TSH is 0.1 mIU/L (low), free T4 2.5 ng/dL (high). Which of the following is the
most appropriate initial pharmacotherapy?
A. Propranolol 40 mg orally once
B. Methimazole 20 mg daily
C. Propylthiouracil 100 mg three times daily
D. Hydrocortisone 100 mg intravenously
Answer: A
Rationale: The patient has symptomatic thyrotoxicosis (likely Graves disease) with adrenergic symptoms.
Beta-blockers (propranolol) are the first-line for rapid symptom control (palpitations, tremor, anxiety)
by blocking peripheral effects of thyroid hormone. Propranolol also inhibits peripheral conversion of T4
to T3. Methimazole (B) is antithyroid therapy but takes weeks to reduce hormone levels; it is not for
acute symptom relief. PTU (C) is reserved for first trimester pregnancy or thyroid storm, but not
first-line. Hydrocortisone (D) is used in thyroid storm, not indicated here.
9. A 48-year-old patient with a history of obesity (BMI 34 kg/m²) and hypertension presents with a
4-week history of bilateral knee pain that is worse with activity and improves with rest. On exam,
there is crepitus and bony enlargement of the knees, no warmth or erythema. X-rays show joint
space narrowing and osteophytes. Which of the following is the most appropriate initial
pharmacologic management?
A. Acetaminophen 1000 mg four times daily as needed
B. Ibuprofen 800 mg three times daily scheduled
C. Topical diclofenac gel 1% four times daily to affected knees
D. Intra-articular hyaluronic acid injection
Answer: C
Rationale: The patient has osteoarthritis of the knees. The OARSI guidelines recommend topical NSAIDs
as first-line pharmacotherapy for knee OA, especially in patients with comorbidities (hypertension,
obesity) due to lower systemic absorption and reduced GI/cardiovascular risk compared to oral
NSAIDs. Acetaminophen (A) is less effective and has safety concerns at high doses. Oral ibuprofen (B) is
effective but carries higher systemic risk. Hyaluronic acid (D) is reserved for those who fail conservative
therapy.
10. A 60-year-old patient with a history of chronic kidney disease stage 3b (eGFR 38 mL/min/1.73
m²) and hypertension presents with a blood pressure of 155/95 mmHg. Current medications
include amlodipine 10 mg daily and chlorthalidone 25 mg daily. Laboratory studies show serum
potassium 5.1 mEq/L. Which of the following antihypertensive agents is most appropriate to add?
A. Lisinopril 10 mg daily
B. Losartan 50 mg daily
C. Doxazosin 4 mg daily
D. Metoprolol succinate 50 mg daily
Answer: C
Rationale: This patient has resistant hypertension (on 3 agents including a diuretic) with CKD and
hyperkalemia. Adding an ACE inhibitor or ARB (A, B) would increase the risk of further hyperkalemia
Page 4
Practitioner III (Family III) Test Bank | University of
Texas at Arlington (UTA) - Verified Questions,
Answers & Detailed Rationales
1. A 45-year-old patient with a history of hypertension and type 2 diabetes presents with a blood
pressure of 148/92 mmHg, serum creatinine of 1.3 mg/dL, and urine albumin-to-creatinine ratio of
45 mg/g. Current medications include lisinopril 20 mg daily, metformin 1000 mg twice daily, and
atorvastatin 20 mg daily. Which of the following is the most appropriate modification to the
antihypertensive regimen to optimize renoprotection?
A. Add amlodipine 5 mg daily
B. Increase lisinopril to 40 mg daily
C. Discontinue lisinopril and start losartan 50 mg daily
D. Add hydrochlorothiazide 12.5 mg daily
Answer: B
Rationale: The patient has stage 2 hypertension with albuminuria indicating chronic kidney disease
(CKD) stage 3a. The KDIGO guidelines recommend maximizing the dose of ACE inhibitors (or ARBs) as
first-line renoprotective therapy before adding other agents. Increasing lisinopril to the maximum
tolerated dose (40 mg) is preferred over adding amlodipine or thiazide, which are second-line.
Switching to losartan is not indicated if ACE inhibitor is tolerated.
2. A 30-year-old patient presents with acute onset of unilateral, throbbing headache associated with
nausea, photophobia, and phonophobia, lasting 6 hours. The patient reports similar episodes 2-3
times per month for the past year. Neurological exam is normal. Which of the following is the most
appropriate acute treatment recommendation?
A. Sumatriptan 50 mg oral tablet at onset, may repeat after 2 hours if no response
B. Rizatriptan 10 mg oral disintegrating tablet at onset, may repeat once after 2 hours
C. Ibuprofen 800 mg oral at onset, with metoclopramide 10 mg for nausea
D. Sumatriptan 6 mg subcutaneous injection at onset, may repeat once after 1 hour
Answer: D
Rationale: The presentation is consistent with migraine without aura. Given the severity (throbbing,
nausea, photophobia) and failure to respond to simple analgesics (implied by frequent episodes), a
triptan is indicated. Subcutaneous sumatriptan provides the fastest and most effective relief for acute
migraine, especially when nausea limits oral intake. Oral triptans (A, B) are appropriate for
mild-to-moderate attacks but are less effective with significant nausea. Ibuprofen with metoclopramide
(C) is a reasonable first-line but may be insufficient for this severity.
Page 1
,3. A 55-year-old patient with a 30-pack-year smoking history and a body mass index of 32 kg/m²
presents with a persistent cough and dyspnea on exertion. Spirometry shows FEV/FVC ratio of
0.65 and FEV 55% of predicted. The patient has had two exacerbations in the past year requiring
antibiotics and oral corticosteroids. Which of the following pharmacologic interventions is most
likely to reduce exacerbation frequency?
A. Initiate tiotropium monotherapy
B. Initiate fluticasone/salmeterol combination
C. Initiate budesonide/formoterol as maintenance and reliever therapy
D. Initiate roflumilast 500 mcg daily
Answer: B
Rationale: The patient has GOLD stage 2 COPD (FEV • 50-79%) with frequent exacerbations ("e2/year)
and symptoms. According to GOLD 2024 guidelines, for group E patients (high exacerbation risk),
initial therapy with LABA/LAMA is recommended, but if blood eosinophils 300 cells/µL (likely given
smoking history), ICS/LABA is preferred. Fluticasone/salmeterol (ICS/LABA) reduces exacerbation risk
in patients with eosinophilic phenotype. Tiotropium monotherapy (A) is for group B.
Budesonide/formoterol SMART (C) is not first-line in COPD. Roflumilast (D) is reserved for severe
COPD with chronic bronchitis and frequent exacerbations despite optimal therapy.
4. A 28-year-old patient with no significant medical history presents with a 3-day history of
dysuria, urinary frequency, and suprapubic discomfort. Urinalysis shows positive nitrites and
leukocyte esterase, with >50 WBCs/hpf and moderate bacteria. The patient is not pregnant and has
no known drug allergies. Which of the following is the most appropriate empiric antibiotic
regimen?
A. Nitrofurantoin 100 mg twice daily for 5 days
B. Ciprofloxacin 250 mg twice daily for 3 days
C. Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days
D. Amoxicillin-clavulanate 875/125 mg twice daily for 7 days
Answer: A
Rationale: The patient has uncomplicated acute cystitis. The IDSA guidelines recommend nitrofurantoin
(5 days), trimethoprim-sulfamethoxazole (3 days if local resistance <20%), or fosfomycin as first-line.
However, given the high prevalence of TMP-SMX resistance in many regions, nitrofurantoin is
preferred. Ciprofloxacin (B) is reserved for complicated UTI or pyelonephritis due to
fluoroquinolone-sparing strategies. Amoxicillin-clavulanate (D) is less effective for E. coli and has
higher resistance rates.
5. A 62-year-old patient with a history of coronary artery disease and heart failure with reduced
ejection fraction (HFrEF, LVEF 35%) is on optimal medical therapy including lisinopril 40 mg,
carvedilol 25 mg twice daily, and spironolactone 25 mg daily. The patient has persistent NYHA
class II symptoms and a heart rate of 72 bpm. Which of the following additional therapies has been
shown to reduce mortality in this population?
A. Ivabradine 5 mg twice daily
B. Sacubitril/valsartan 24/26 mg twice daily
C. Digoxin 0.125 mg daily
Page 2
,D. Dapagliflozin 10 mg daily
Answer: D
Rationale: In HFrEF patients on optimal medical therapy (ACEi/ARB, beta-blocker, MRA), the addition
of an SGLT2 inhibitor (dapagliflozin or empagliflozin) is now a Class I recommendation based on
DAPA-HF and EMPEROR-Reduced trials showing reduced cardiovascular death and HF
hospitalization. Sacubitril/valsartan (B) is indicated if ACEi/ARB is tolerated but patient remains
symptomatic, but it would replace lisinopril, not be added. Ivabradine (A) is for patients with heart rate
70 bpm on beta-blocker; here HR is 72, but dapagliflozin has stronger mortality benefit. Digoxin (C)
reduces hospitalizations but not mortality.
6. A 50-year-old patient with type 2 diabetes (HbA1c 8.2%) and established atherosclerotic
cardiovascular disease (ASCVD) is currently on metformin 1000 mg twice daily and empagliflozin
10 mg daily. The patient has a BMI of 31 kg/m² and eGFR 65 mL/min/1.73 m². Which of the
following agents, when added, has demonstrated cardiovascular benefit in this population?
A. Liraglutide 1.8 mg subcutaneously daily
B. Glipizide 5 mg daily
C. Sitagliptin 100 mg daily
D. Insulin glargine 10 units at bedtime
Answer: A
Rationale: For patients with type 2 diabetes and ASCVD on metformin and an SGLT2 inhibitor, adding a
GLP-1 receptor agonist with proven cardiovascular benefit (e.g., liraglutide, semaglutide) is
recommended by the ADA guidelines. The LEADER trial demonstrated liraglutide reduces major
adverse cardiovascular events. Glipizide (B) and insulin glargine (D) have neutral cardiovascular
effects but may cause weight gain and hypoglycemia. Sitagliptin (C) is cardiovascular neutral but not
preferred given the need for additional risk reduction.
7. A 40-year-old patient with a history of asthma presents with symptoms of rhinitis, sneezing, and
itchy eyes occurring in the spring. The patient has tried loratadine 10 mg daily with minimal relief.
Which of the following is the most appropriate next step in management?
A. Add montelukast 10 mg daily
B. Switch to fexofenadine 180 mg daily
C. Add fluticasone propionate nasal spray 2 sprays each nostril daily
D. Refer for allergy immunotherapy
Answer: C
Rationale: The patient has moderate-to-severe seasonal allergic rhinitis not controlled with oral
antihistamines. The ARIA guidelines recommend intranasal corticosteroids as first-line therapy for
moderate-to-severe symptoms, especially when nasal congestion is prominent. Adding fluticasone nasal
spray is superior to switching antihistamines (B) or adding montelukast (A), which is less effective.
Immunotherapy (D) is reserved for refractory cases after optimal pharmacotherapy.
Page 3
, 8. A 35-year-old patient with a history of anxiety presents with palpitations, diaphoresis, and
tremor lasting 30 minutes. The patient is afebrile, HR 110 bpm, BP 130/80 mmHg. ECG shows
sinus tachycardia. TSH is 0.1 mIU/L (low), free T4 2.5 ng/dL (high). Which of the following is the
most appropriate initial pharmacotherapy?
A. Propranolol 40 mg orally once
B. Methimazole 20 mg daily
C. Propylthiouracil 100 mg three times daily
D. Hydrocortisone 100 mg intravenously
Answer: A
Rationale: The patient has symptomatic thyrotoxicosis (likely Graves disease) with adrenergic symptoms.
Beta-blockers (propranolol) are the first-line for rapid symptom control (palpitations, tremor, anxiety)
by blocking peripheral effects of thyroid hormone. Propranolol also inhibits peripheral conversion of T4
to T3. Methimazole (B) is antithyroid therapy but takes weeks to reduce hormone levels; it is not for
acute symptom relief. PTU (C) is reserved for first trimester pregnancy or thyroid storm, but not
first-line. Hydrocortisone (D) is used in thyroid storm, not indicated here.
9. A 48-year-old patient with a history of obesity (BMI 34 kg/m²) and hypertension presents with a
4-week history of bilateral knee pain that is worse with activity and improves with rest. On exam,
there is crepitus and bony enlargement of the knees, no warmth or erythema. X-rays show joint
space narrowing and osteophytes. Which of the following is the most appropriate initial
pharmacologic management?
A. Acetaminophen 1000 mg four times daily as needed
B. Ibuprofen 800 mg three times daily scheduled
C. Topical diclofenac gel 1% four times daily to affected knees
D. Intra-articular hyaluronic acid injection
Answer: C
Rationale: The patient has osteoarthritis of the knees. The OARSI guidelines recommend topical NSAIDs
as first-line pharmacotherapy for knee OA, especially in patients with comorbidities (hypertension,
obesity) due to lower systemic absorption and reduced GI/cardiovascular risk compared to oral
NSAIDs. Acetaminophen (A) is less effective and has safety concerns at high doses. Oral ibuprofen (B) is
effective but carries higher systemic risk. Hyaluronic acid (D) is reserved for those who fail conservative
therapy.
10. A 60-year-old patient with a history of chronic kidney disease stage 3b (eGFR 38 mL/min/1.73
m²) and hypertension presents with a blood pressure of 155/95 mmHg. Current medications
include amlodipine 10 mg daily and chlorthalidone 25 mg daily. Laboratory studies show serum
potassium 5.1 mEq/L. Which of the following antihypertensive agents is most appropriate to add?
A. Lisinopril 10 mg daily
B. Losartan 50 mg daily
C. Doxazosin 4 mg daily
D. Metoprolol succinate 50 mg daily
Answer: C
Rationale: This patient has resistant hypertension (on 3 agents including a diuretic) with CKD and
hyperkalemia. Adding an ACE inhibitor or ARB (A, B) would increase the risk of further hyperkalemia
Page 4
