Mastering FNP 654: The Definitive 120-
Q&A Midterm Review for Family Primary
Care II
**1. A 62-year-old African American male with a history of type 2
diabetes presents with a BP of 148/90 mmHg on two separate visits.
What is the most appropriate initial pharmacologic therapy?**
A. Hydrochlorothiazide
B. Lisinopril
C. Amlodipine
D. Metoprolol
**Correct Answer: C. Amlodipine**
*Rationale:* The 2020 American College of Cardiology (ACC)
guidelines recommend first-line therapy for African American
patients with hypertension, particularly those with diabetes, to
include a thiazide diuretic or a calcium channel blocker (CCB) like
amlodipine. ACE inhibitors (lisinopril) are less effective as
monotherapy in this population due to lower renin activity. Beta-
blockers are not first-line.
**2. A patient on Lisinopril 20 mg daily develops a dry cough and
angioedema of the lips. Which medication class should be
substituted?**
A. Losartan
,B. Amlodipine
C. Chlorthalidone
D. Carvedilol
**Correct Answer: A. Losartan**
*Rationale:* The dry cough and angioedema are classic side effects
of ACE inhibitors (lisinopril) due to bradykinin accumulation. An
Angiotensin II Receptor Blocker (ARB) like losartan is the preferred
substitute, as it provides similar renal and cardiovascular protection
without affecting bradykinin metabolism.
**3. The JNC 8 guidelines recommend a blood pressure target of
<130/80 mmHg for which patient population?**
A. Healthy 45-year-old female
B. 55-year-old male with gout
C. 68-year-old female with chronic kidney disease (CKD)
D. 72-year-old male with no comorbidities
**Correct Answer: C. 68-year-old female with chronic kidney disease
(CKD)**
*Rationale:* The ACC/AHA 2017 guidelines (which supersede JNC 8
in many contexts) recommend <130/80 mmHg for all adults, but
specifically highlight the benefit for patients with CKD, diabetes, and
those at high ASCVD risk. JNC 8 specifically recommended <140/90
for the general population over 60 but <130/80 for CKD and diabetes.
,**4. Which of the following is a contraindication to the use of
Spironolactone?**
A. Hyperlipidemia
B. Serum potassium of 5.2 mEq/L
C. Left ventricular hypertrophy
D. Gout
**Correct Answer: B. Serum potassium of 5.2 mEq/L**
*Rationale:* Spironolactone is a potassium-sparing diuretic. It is
contraindicated in patients with hyperkalemia (potassium > 5.0
mEq/L). It can be used cautiously in heart failure (including LVH) but
requires close monitoring of potassium and renal function.
**5. A 55-year-old patient with heart failure with reduced ejection
fraction (HFrEF) is on a beta-blocker, ACE inhibitor, and furosemide.
The patient's ejection fraction is 30%. Which medication is guideline-
directed medical therapy (GDMT) for this patient to reduce
mortality?**
A. Digoxin
B. Hydralazine/Isosorbide dinitrate
C. Sacubitril/Valsartan (Entresto)
D. Metolazone
**Correct Answer: C. Sacubitril/Valsartan (Entresto)**
*Rationale:* Sacubitril/Valsartan (ARNI) is a cornerstone of GDMT for
HFrEF. It has been shown to be superior to ACE inhibitors in reducing
mortality and hospitalizations. While hydralazine/nitrate is indicated
, for African Americans with refractory HF, Entresto is a first-line option
for a broader population.
**6. Which ECG finding is most characteristic of hyperkalemia?**
A. Prolonged QT interval
B. Peaked T-waves
C. U-waves
D. ST-segment elevation
**Correct Answer: B. Peaked T-waves**
*Rationale:* Tall, peaked, "tented" T-waves are the earliest and most
characteristic ECG change in hyperkalemia. Prolonged QT is seen with
hypocalcemia, U-waves with hypokalemia, and ST elevation is
associated with myocardial injury or pericarditis.
**7. A 67-year-old male presents with acute onset of severe, tearing
chest pain radiating to the back, with a 20 mmHg blood pressure
difference between arms. What is the most likely diagnosis and
immediate next step?**
A. Myocardial infarction; administer aspirin and nitroglycerin.
B. Pulmonary embolism; obtain a D-dimer.
C. Aortic dissection; obtain emergent CT angiography.
D. Pericarditis; listen for a friction rub.
**Correct Answer: C. Aortic dissection; obtain emergent CT
angiography.**
Q&A Midterm Review for Family Primary
Care II
**1. A 62-year-old African American male with a history of type 2
diabetes presents with a BP of 148/90 mmHg on two separate visits.
What is the most appropriate initial pharmacologic therapy?**
A. Hydrochlorothiazide
B. Lisinopril
C. Amlodipine
D. Metoprolol
**Correct Answer: C. Amlodipine**
*Rationale:* The 2020 American College of Cardiology (ACC)
guidelines recommend first-line therapy for African American
patients with hypertension, particularly those with diabetes, to
include a thiazide diuretic or a calcium channel blocker (CCB) like
amlodipine. ACE inhibitors (lisinopril) are less effective as
monotherapy in this population due to lower renin activity. Beta-
blockers are not first-line.
**2. A patient on Lisinopril 20 mg daily develops a dry cough and
angioedema of the lips. Which medication class should be
substituted?**
A. Losartan
,B. Amlodipine
C. Chlorthalidone
D. Carvedilol
**Correct Answer: A. Losartan**
*Rationale:* The dry cough and angioedema are classic side effects
of ACE inhibitors (lisinopril) due to bradykinin accumulation. An
Angiotensin II Receptor Blocker (ARB) like losartan is the preferred
substitute, as it provides similar renal and cardiovascular protection
without affecting bradykinin metabolism.
**3. The JNC 8 guidelines recommend a blood pressure target of
<130/80 mmHg for which patient population?**
A. Healthy 45-year-old female
B. 55-year-old male with gout
C. 68-year-old female with chronic kidney disease (CKD)
D. 72-year-old male with no comorbidities
**Correct Answer: C. 68-year-old female with chronic kidney disease
(CKD)**
*Rationale:* The ACC/AHA 2017 guidelines (which supersede JNC 8
in many contexts) recommend <130/80 mmHg for all adults, but
specifically highlight the benefit for patients with CKD, diabetes, and
those at high ASCVD risk. JNC 8 specifically recommended <140/90
for the general population over 60 but <130/80 for CKD and diabetes.
,**4. Which of the following is a contraindication to the use of
Spironolactone?**
A. Hyperlipidemia
B. Serum potassium of 5.2 mEq/L
C. Left ventricular hypertrophy
D. Gout
**Correct Answer: B. Serum potassium of 5.2 mEq/L**
*Rationale:* Spironolactone is a potassium-sparing diuretic. It is
contraindicated in patients with hyperkalemia (potassium > 5.0
mEq/L). It can be used cautiously in heart failure (including LVH) but
requires close monitoring of potassium and renal function.
**5. A 55-year-old patient with heart failure with reduced ejection
fraction (HFrEF) is on a beta-blocker, ACE inhibitor, and furosemide.
The patient's ejection fraction is 30%. Which medication is guideline-
directed medical therapy (GDMT) for this patient to reduce
mortality?**
A. Digoxin
B. Hydralazine/Isosorbide dinitrate
C. Sacubitril/Valsartan (Entresto)
D. Metolazone
**Correct Answer: C. Sacubitril/Valsartan (Entresto)**
*Rationale:* Sacubitril/Valsartan (ARNI) is a cornerstone of GDMT for
HFrEF. It has been shown to be superior to ACE inhibitors in reducing
mortality and hospitalizations. While hydralazine/nitrate is indicated
, for African Americans with refractory HF, Entresto is a first-line option
for a broader population.
**6. Which ECG finding is most characteristic of hyperkalemia?**
A. Prolonged QT interval
B. Peaked T-waves
C. U-waves
D. ST-segment elevation
**Correct Answer: B. Peaked T-waves**
*Rationale:* Tall, peaked, "tented" T-waves are the earliest and most
characteristic ECG change in hyperkalemia. Prolonged QT is seen with
hypocalcemia, U-waves with hypokalemia, and ST elevation is
associated with myocardial injury or pericarditis.
**7. A 67-year-old male presents with acute onset of severe, tearing
chest pain radiating to the back, with a 20 mmHg blood pressure
difference between arms. What is the most likely diagnosis and
immediate next step?**
A. Myocardial infarction; administer aspirin and nitroglycerin.
B. Pulmonary embolism; obtain a D-dimer.
C. Aortic dissection; obtain emergent CT angiography.
D. Pericarditis; listen for a friction rub.
**Correct Answer: C. Aortic dissection; obtain emergent CT
angiography.**
