Barkley AGACNP ACTUAL EXAM ALL
QUESTIONS AND ANSWERS ALREADY
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UPDATED PER LATEST GUIDELINES |
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Cardiovascular System (Questions 1-15)
Question 1
A 68-year-old male with a history of heart failure with reduced ejection fraction (HFrEF)
presents with worsening dyspnea, orthopnea, and 3+ pitting edema in the lower extremities.
Vital signs: BP 142/88, HR 92, RR 22, SpO2 91% on room air. His current medications include
lisinopril, carvedilol, and furosemide. Which of the following is the most appropriate next step
in management?
A. Increase furosemide dose
B. Start digoxin
C. Add spironolactone
D. Start intravenous inotropic therapy
Correct Answer: A
Rationale: The patient is showing signs of acute decompensated heart failure with fluid
overload. The first-line intervention is diuresis—increasing the loop diuretic dose is appropriate.
Spironolactone is indicated for chronic management in NYHA Class III-IV, not acute
decompensation. Digoxin may be added for symptom control but is not the immediate next
step. Inotropic therapy is reserved for cardiogenic shock or severe end-organ hypoperfusion .
,Question 2
A 72-year-old female presents with acute onset chest pain, diaphoresis, and nausea. ECG shows
ST-segment elevation in leads V1-V4. What is the most appropriate immediate management?
A. Aspirin 324 mg chewed, oxygen, nitroglycerin, and morphine
B. Emergent percutaneous coronary intervention (PCI) if within 90 minutes
C. Administer fibrinolytic therapy if PCI not available within 120 minutes
D. All of the above
Correct Answer: D
Rationale: This is an ST-elevation myocardial infarction (STEMI). Initial management includes
aspirin, oxygen (if SpO2 <90%), nitroglycerin (if no hypotension), and morphine for pain . The
priority is reperfusion: PCI is preferred within 90 minutes of first medical contact; if not
available, fibrinolytics should be given within 30 minutes if within 120 minutes of symptom
onset.
Question 3
A 65-year-old male with hypertension and diabetes is diagnosed with heart failure with
preserved ejection fraction (HFpEF). Which medication class has been shown to reduce
hospitalizations in HFpEF?
A. ACE inhibitors
B. Beta-blockers
C. SGLT2 inhibitors
D. Digoxin
Correct Answer: C
Rationale: SGLT2 inhibitors (empagliflozin, dapagliflozin) have demonstrated benefit in reducing
heart failure hospitalizations in patients with HFpEF regardless of diabetes status. ACE inhibitors
and beta-blockers are primarily beneficial in HFrEF. Digoxin is used for rate control in atrial
fibrillation but does not reduce mortality.
Question 4
A 78-year-old female with atrial fibrillation on warfarin presents with INR of 5.2. She has no
signs of bleeding. What is the appropriate management?
A. Hold warfarin and administer vitamin K 2.5 mg PO
B. Hold warfarin and recheck INR in 24 hours
,C. Hold warfarin and administer prothrombin complex concentrate
D. Continue warfarin; INR is within therapeutic range
Correct Answer: B
Rationale: For an elevated INR >5.0 but <9.0 in a patient without bleeding, the recommendation
is to hold warfarin and recheck INR. Vitamin K is indicated for INR >10 or signs of bleeding.
Prothrombin complex concentrate is reserved for major bleeding.
Question 5
A 62-year-old male with end-stage renal disease on hemodialysis presents with chest pain. ECG
shows peaked T waves and wide QRS complexes. Potassium level is 6.8 mEq/L. What is the
priority intervention?
A. Calcium gluconate IV
B. Insulin with dextrose IV
C. Sodium bicarbonate IV
D. Albuterol nebulized
Correct Answer: A
Rationale: Hyperkalemia with ECG changes (peaked T waves, wide QRS) is a life-threatening
emergency. Calcium gluconate stabilizes the cardiac membrane and should be given first. Insulin
with dextrose, sodium bicarbonate, and albuterol all shift potassium intracellularly but take
longer to work. Hemodialysis is definitive but calcium is the priority .
Question 6
A 70-year-old male with a history of coronary artery disease presents with palpitations. ECG
shows a regular, narrow-complex tachycardia at 180 bpm without visible P waves. What is the
most likely rhythm?
A. Atrial fibrillation
B. Atrial flutter with 2:1 conduction
C. AV nodal reentrant tachycardia (AVNRT)
D. Ventricular tachycardia
Correct Answer: C
Rationale: AVNRT presents with regular, narrow-complex tachycardia, typically 150-250 bpm,
with no visible P waves (buried in QRS). Atrial fibrillation is irregularly irregular. Atrial flutter with
, 2:1 conduction often shows flutter waves at 300 bpm with ventricular rate of 150 bpm.
Ventricular tachycardia is wide-complex.
Question 7
A 75-year-old female is started on amiodarone for atrial fibrillation. Which of the following
requires monitoring due to amiodarone's adverse effect profile?
A. Thyroid function tests and liver function tests
B. Pulmonary function tests and chest X-ray
C. Ophthalmic examination
D. All of the above
Correct Answer: D
Rationale: Amiodarone has multiple serious adverse effects requiring monitoring: pulmonary
toxicity (pulmonary fibrosis), thyroid dysfunction (hypo/hyperthyroidism), hepatotoxicity,
corneal microdeposits, and skin discoloration. Baseline and periodic monitoring of thyroid, liver,
and pulmonary function is recommended.
Question 8
A 68-year-old male with hypertension is prescribed a beta-blocker. Which of the following is a
contraindication to beta-blocker therapy?
A. Diabetes mellitus
B. Chronic obstructive pulmonary disease with active bronchospasm
C. Peripheral vascular disease
D. History of myocardial infarction
Correct Answer: B
Rationale: Non-cardioselective beta-blockers are contraindicated in patients with active
bronchospasm due to beta-2 receptor blockade causing bronchoconstriction. Cardioselective
beta-blockers (metoprolol, bisoprolol) may be used cautiously. Diabetes, peripheral vascular
disease, and history of MI are not absolute contraindications.
Question 9
A 72-year-old female with new-onset atrial fibrillation has a CHA₂DS₂-VASc score of 4. Which of
the following is the most appropriate anticoagulation strategy?
QUESTIONS AND ANSWERS ALREADY
GRADED A+. 100% VERIFIED SOLUTIONS |
UPDATED PER LATEST GUIDELINES |
GRADED A+
Cardiovascular System (Questions 1-15)
Question 1
A 68-year-old male with a history of heart failure with reduced ejection fraction (HFrEF)
presents with worsening dyspnea, orthopnea, and 3+ pitting edema in the lower extremities.
Vital signs: BP 142/88, HR 92, RR 22, SpO2 91% on room air. His current medications include
lisinopril, carvedilol, and furosemide. Which of the following is the most appropriate next step
in management?
A. Increase furosemide dose
B. Start digoxin
C. Add spironolactone
D. Start intravenous inotropic therapy
Correct Answer: A
Rationale: The patient is showing signs of acute decompensated heart failure with fluid
overload. The first-line intervention is diuresis—increasing the loop diuretic dose is appropriate.
Spironolactone is indicated for chronic management in NYHA Class III-IV, not acute
decompensation. Digoxin may be added for symptom control but is not the immediate next
step. Inotropic therapy is reserved for cardiogenic shock or severe end-organ hypoperfusion .
,Question 2
A 72-year-old female presents with acute onset chest pain, diaphoresis, and nausea. ECG shows
ST-segment elevation in leads V1-V4. What is the most appropriate immediate management?
A. Aspirin 324 mg chewed, oxygen, nitroglycerin, and morphine
B. Emergent percutaneous coronary intervention (PCI) if within 90 minutes
C. Administer fibrinolytic therapy if PCI not available within 120 minutes
D. All of the above
Correct Answer: D
Rationale: This is an ST-elevation myocardial infarction (STEMI). Initial management includes
aspirin, oxygen (if SpO2 <90%), nitroglycerin (if no hypotension), and morphine for pain . The
priority is reperfusion: PCI is preferred within 90 minutes of first medical contact; if not
available, fibrinolytics should be given within 30 minutes if within 120 minutes of symptom
onset.
Question 3
A 65-year-old male with hypertension and diabetes is diagnosed with heart failure with
preserved ejection fraction (HFpEF). Which medication class has been shown to reduce
hospitalizations in HFpEF?
A. ACE inhibitors
B. Beta-blockers
C. SGLT2 inhibitors
D. Digoxin
Correct Answer: C
Rationale: SGLT2 inhibitors (empagliflozin, dapagliflozin) have demonstrated benefit in reducing
heart failure hospitalizations in patients with HFpEF regardless of diabetes status. ACE inhibitors
and beta-blockers are primarily beneficial in HFrEF. Digoxin is used for rate control in atrial
fibrillation but does not reduce mortality.
Question 4
A 78-year-old female with atrial fibrillation on warfarin presents with INR of 5.2. She has no
signs of bleeding. What is the appropriate management?
A. Hold warfarin and administer vitamin K 2.5 mg PO
B. Hold warfarin and recheck INR in 24 hours
,C. Hold warfarin and administer prothrombin complex concentrate
D. Continue warfarin; INR is within therapeutic range
Correct Answer: B
Rationale: For an elevated INR >5.0 but <9.0 in a patient without bleeding, the recommendation
is to hold warfarin and recheck INR. Vitamin K is indicated for INR >10 or signs of bleeding.
Prothrombin complex concentrate is reserved for major bleeding.
Question 5
A 62-year-old male with end-stage renal disease on hemodialysis presents with chest pain. ECG
shows peaked T waves and wide QRS complexes. Potassium level is 6.8 mEq/L. What is the
priority intervention?
A. Calcium gluconate IV
B. Insulin with dextrose IV
C. Sodium bicarbonate IV
D. Albuterol nebulized
Correct Answer: A
Rationale: Hyperkalemia with ECG changes (peaked T waves, wide QRS) is a life-threatening
emergency. Calcium gluconate stabilizes the cardiac membrane and should be given first. Insulin
with dextrose, sodium bicarbonate, and albuterol all shift potassium intracellularly but take
longer to work. Hemodialysis is definitive but calcium is the priority .
Question 6
A 70-year-old male with a history of coronary artery disease presents with palpitations. ECG
shows a regular, narrow-complex tachycardia at 180 bpm without visible P waves. What is the
most likely rhythm?
A. Atrial fibrillation
B. Atrial flutter with 2:1 conduction
C. AV nodal reentrant tachycardia (AVNRT)
D. Ventricular tachycardia
Correct Answer: C
Rationale: AVNRT presents with regular, narrow-complex tachycardia, typically 150-250 bpm,
with no visible P waves (buried in QRS). Atrial fibrillation is irregularly irregular. Atrial flutter with
, 2:1 conduction often shows flutter waves at 300 bpm with ventricular rate of 150 bpm.
Ventricular tachycardia is wide-complex.
Question 7
A 75-year-old female is started on amiodarone for atrial fibrillation. Which of the following
requires monitoring due to amiodarone's adverse effect profile?
A. Thyroid function tests and liver function tests
B. Pulmonary function tests and chest X-ray
C. Ophthalmic examination
D. All of the above
Correct Answer: D
Rationale: Amiodarone has multiple serious adverse effects requiring monitoring: pulmonary
toxicity (pulmonary fibrosis), thyroid dysfunction (hypo/hyperthyroidism), hepatotoxicity,
corneal microdeposits, and skin discoloration. Baseline and periodic monitoring of thyroid, liver,
and pulmonary function is recommended.
Question 8
A 68-year-old male with hypertension is prescribed a beta-blocker. Which of the following is a
contraindication to beta-blocker therapy?
A. Diabetes mellitus
B. Chronic obstructive pulmonary disease with active bronchospasm
C. Peripheral vascular disease
D. History of myocardial infarction
Correct Answer: B
Rationale: Non-cardioselective beta-blockers are contraindicated in patients with active
bronchospasm due to beta-2 receptor blockade causing bronchoconstriction. Cardioselective
beta-blockers (metoprolol, bisoprolol) may be used cautiously. Diabetes, peripheral vascular
disease, and history of MI are not absolute contraindications.
Question 9
A 72-year-old female with new-onset atrial fibrillation has a CHA₂DS₂-VASc score of 4. Which of
the following is the most appropriate anticoagulation strategy?
